Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Psychologic Management of Infertile Women Linda S. McGuire To cite this article: Linda S. McGuire (1975) Psychologic Management of Infertile Women, Postgraduate Medicine, 57:6, 173-176, DOI: 10.1080/00325481.1975.11714060 To link to this article: https://doi.org/10.1080/00325481.1975.11714060
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 8 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
LINDA S. McGUIRE, PhD
University of Washington School of Medicine Seattle
FAMILY PRACTICE AND The psychologie difficulties associated with treatment of infertility can be minimized by limiting the length of treatment and refraining from suggesting a psychologie cause unless a specifie one can be adduced. If treatment is unsuccessful, referral for supportive therapy may be indicated.
PSYCHOLOGie MANAGEMENT OF INFERTILE WOMEN Infertility is not one of the pressing national or international problems in this overpopulated era, but it is of concern to those who, often without success, treat patients seeking its cure. The complex, often frustrating medical management of these patients can distract and discourage the physician from attending to the emotional concomitants of this disorder. The role of the family physician in the treatment of infertility varies. He may have primary responsibility for diagnosis and treatment. In locales with access ta specialists, he is more likely to decide when a referral is appropriate and follow the patient's course intermittently during her treatment. As a general guideline, before the physician initiates a referral for specifie treatment of infertility, a couple should have attempted to conceive for one year, having intercourse on a regular basis. Depending on the patient's age, the physician may choose to refer in less than a year. My experience in counseling infertile women during and after treatment has convinced me that much could be clone during treatment to alleviate emotional distress and minimize the trauma of an unsuccessful outcome. Timing and Length of Treatment
Because of the many factors involved in diagnosing the cause of infertility, the types of data needed (eg, basal body temperatures, hysterosalpingograms, laparoscopy), and the types of
Vol. 57 • No. 6 • May 1975 • POSTGRADUATE MEDICINE
treatment often necessary (laparotomy, medications), the workup and treatment of infertility are often lengthy. Nevertheless, treatment is sometimes prolonged unnecessarily. Specialists treating women may be tolerant of, or encourage, long delays between appointments or procedures with the hope that time will prove curative. Frequently, the nature of the problem is poorly defined. This, plus the knowledge that infertility clinics do not produce much better results than would occur by chance alone, has made many clinicians fee! it is worthwhite ta take breathers in treatment or to give a specifie form of treatment severa! months to work. Like many other aspects of treating infertile women, duration of therapy must be decided by weighing many factors, sorne not exclusively medical. A candid discussion of probable time involvement at the start of treatment and intermittent talks about progress and future types and lengths of treatment could give patients a more realistic time framework. Patients may schedule visits far apart, attempting ta put off the day when medical resourcefulness is exhausted. The four, five, and occasionally, ten years of treatment in individual cases can be detrimental to the infertile woman, principally because while undergoing treatment for her infertility, and seemingly obsessed by it, she is rarely dealing with it effectively. That is, as long as she is re-
173
LINDA S. McGUIRE Dr. McGuire is assistant professer, departments of obstetrics and gynecology and of psychiatry and behavioral sciences, University of Washington Scheel of Medicine, Seattle.
ce1vmg medication or undergoing laboratory tests or surgical procedures, she is usually putting aside crucial decisions about career, life plans, and adoption, and persona! confrontation with her childlessness. Few women request assistance for infertility until their late 20s, and if treatment is protracted until the early or middle 30s, many find certain options less open to them after treatment than if they had not delayed seeking help. For example, sorne patients will not make even tentative steps toward adoption, such as requesting a screening interview, until treatment is ended. Since adoption agency waiting periods currently are one to two years, such delays may affect the couple's desirability as candidates and their ease in adaptation and effectiveness as parents. Further, overlong treatment creates an exaggerated emphasis on the infertility, heightening the difficulties with self-esteem and sexuality that can accompany this disorder. Decisions about length of treatment are highly individualized. A duration damaging to one patient may be easily tolerated by another. Only by an awareness of other aspects of a patient's life can a decision be made integrating the social and emotional factors with the medical. Emotional Effects of lnfertility
Handling the emotional side effects of infertility can be difficult, and care must be taken to refrain from casting slurs as to psychogenesis. Unless words are chosen carefully, even in answering a patient's queries about psychologie factors ("Is it all in my head?") one can sorne-
174
times inadvertently confirm the patient's fears that she is somehow causing her infertility. Unless a ~pecific psychologie cause can be adduced for the infertility, and this is difficult, it can be harmful to assume that the absence of a known organic cause means that psychologie factors are dominant. The infertile patient often experiences such guilt and self-deprecation about her inability to conceive that chance remarks or musings about psychologie factors tend to be magnified and distorted. There are historical reasons for women's sensitivity to this issue. It has only been in the last 15 years that the male partner of infertile couples has been included in the workup for infertility, and to date, knowledge of male factors lags far behind know ledge of female factors in this disorder. Browne and Browne1 report that "in approximately 25 per cent of cases the husband is responsible for his wife's failure to conceive." They stress that "in considering treatment it is necessary again to emphasize that in relatively few cases of sterile marriage is either the husband or wife absolutely sterile, and that the failure to conceive is due in most instances to a summation of unfavorable factors in both partners. In most cases successful treatment will depend on the cure of as many of these unfavorable factors as possible." Furthermore, if language reflects attitudes and attitudes shape emotional responses, a look at the infertility literature over the last three decades is helpful in understanding the cultural environment within which the infertile woman exists. Of interest, for example, are the changes in terminology used to describe women unable to conceive and deliver children. "Barren," with its biblical sense of cursedness, was used in the 1940s. The ultraclinical term "sterile" was used in the 1950s and early 1960s. Currently, the more biologie term "infertile" is used. Clearly, as the state of the diagnostic art has improved, the number of women found to be "functionally, psychogenically or psychosomatically infertile" has correspondingly decreased. In 1957, Weiss and English2 wrote, "It is safe to say that about one third of all cases have no
POSTGRADUATE MEDICINE • May 1975 • Vol. 57 • No. 6
evidence of organic disease ta account for the sterility. Mental and emotional strain seem ta be the chief factors in producing it." In 1964, Browne and Browné reported that "in about 10 per cent of cases of sterility the cause is unknown and no fault can be discovered either in wife or husband by any method of investigation available at this present time." Karahasanoglu, Barglow, and Growe 3 cite four criteria that should be met before one can determine if a state of infertility is psychologically induced: (1) the presence of sperm at the cervical os in adequate numbers and with sufficient motility, (2) the exclusion of known organic causes through complete gynecologie study, (3) the presence of specifie emotions or character traits that possibly relate meaningfully ta infertility, and (4) an explanation of how psychic factors produce short-term somatic effects. This degree of rigorousness in making a diagnosis of "psychogenic infertility" is, in practice, rarely met. Moreover, the research literature which bas attempted ta delineate psychologie factors in infertile women reinforces caution in making this diagnosis. Although various writers 4 •6 have characterized infertile women as aggressive, dependent, or infantile, results of studies comparing the emotional stability, marital relationships, and family background of fertile and infertile women continue ta be highly inconclusive. Seward and associates 7 found virtually no differences between these groups in a large well-controlled comparison of relevant variables. A more recent study by Mai, Munday, and Rump 8 of psychiatrie interview comparisons also failed ta show substantial differences between infertile and fertile couples, although the authors noted that sorne infertile wives tended ta have disturbed "sexual raies and feelings." In virtually ali of this research, however, it is impossible ta determine whether these personality factors are a cause or a result of the infertility, as no prospective studies are reported. Conclusion
It is important ta pay attention ta the infertile woman's sexual functioning and marital rela-
•Physician ·Nurse •Biomedical Engineer · Administrator ·Medical Technician
THE PHYSICIAN demands diag· nostic accuracy, definition, de· pendability; no time-consuming retakes; mistake· free lead coding -and that's what the solid· state EK/5A de· 1ive rs. Exceeds AHA frequency response recom· mendations.
THE NURSE DR MEDICAL TECHNICIAN wants the ease of operation that results in time saving- from featu res 1ike the EK/5A automat· ic lead marking activated by a fast-switching lead selector, and easy porta· bility.
THE BIDMED ENGINEER looks for multi· pie use in the hospital; patient· isolated circuitry lleakage is less th an 1 D microamperesl; solid·state sim· plicity; multiple circuit boards for easier, faster service; computer compatibility; sound ECG de· sign.
BURDICN Vol. 57 • No. 6 • May 1975 • POSTGAADUATE MEDICINE
THE ADMINIS· TRATDR AND PURCHASING AGENT like (ll the savings that result from dependable performance; (2) medical staff sat· isfaction, and (3) Burdick dealer service and main· tenance availa· bility.
THE BURDICK CORPORATION Milton, Wls.
535&3
tionship in the course of treatment. The distortion in a couple's sexual relationship caused by ovulation-determined intercourse can be reduced. It is necessary to take a detailed sexual history initially and then periodically compare the patient's sexual activity leve! and satisfaction with the pretreatment period. If she achieves orgasm with greater difficulty or less frequency than before or if she is becoming increasingly nonresponsive, a one- or two-month respite from treatment may be helpful. Acknowledgment of the stresses associated with this treatment and assurance that normal responsiveness will retuen after treatment can provide emotional support. Finally, with many patients a referral for short-term counseling at the termination of
lengthy, unsuccessful treatment of infertility is appropriate. This period represents a crisis to many women in which their self-image, sexuality, and !ife plans must be reassessed and integrated with their childless state. Sponsored by family planning and education grant RS 68003 from the Rockefeller Foundation. Address reprint requests to Linda S. McGuire, PhD, University Hospital RH-20, University of Washington, Seattle, WA 98195. ACKNOWLEDGMENT 1 wish to thank Dr. Carol Wallace of the department of obstetrics and gynecology, University of Washington School of Medicine, for her incisive comments and suggestions.
REFERENCES 1. Browne FJ, Browne JC: McClure Postgraduate Obsterrics and Gynecology. Ed 3. London, Butterworth, 1964 2. Weiss E, English OS: Psychosomatic Medicine. Philadelphia, WB Saunders Co, 195 7, p 117 3. Karahasanoglu A, Barglow P, Growe G: Psychological aspects of infertility. J Reprod Med 9:241-247, 1972 4. Cooper H: Psychogenic infertility and adoption. S Afr Med J 45:719-722, 1971 5. Rommer JJ, Rommer CS: Sexual tones in marriage
of the sterile and once-sterile female. Fertil Steril 9:309-320, 1958 6. Ford ES, Forman 1, Wilson J Jr, et al: A psychodynamic approach to the study of infertility. Fertil Steril 4:456-464, 1953 7. Seward GH, Wagner PS, Heinrich JF, et al: The question of psychophysiologie infertility: Sorne negative answers. Psychosom Med 27:533-545, 1965 8. Mai FM, Munday RN, Rump EE: Psychiatrie interview comparisons between infertile and fertile couples. Psychosom Med 34:431-440, 1972
O O O ReadySource DON TEXTBOOKS Clinical Gynecologie Endocrinology and lnfertility (Speroff, Glass, Kasel Baltimore: The Williams & Wilkins Co, 1973 Gynecology, Principles and Practice (Kistnerl Chicago: Year Book Medical Publishers, lnc, 1969 Progress in lnfertility (Behrman, Kistner, editorsl Boston: Little, Brown & Co, 1968
COURSES Office Management of the Infertile Couple (8 hrs; continuousl Atlanta Accredited for continuing medical education (AMAl Contact: The American Fertil ity Society, 1801 9th Ave S, Suite 101, Birmingham, AL 35205 Cast: $75
176
INFERTILITY
lnfertility (intermittent, arrangedl Englewood, Flemington, or Jersey City, NJ Accredited for continuing medical education (AMAl Contact: Academy of Medicine of New Jersey, 2424 Morris Ave, Union, NJ 07083
AUDIOVISUALS Evaluation of the Infertile Couple (7:10-min tape, catalog #470l (Tagatzl Source: Wisconsin Dial Access Tapes, Department of Continuing Medical Education, 610 Walnut St, Madison, Wl 53706 Cast: $4 audio tape (114-inl; $10 Echomatic cassette
For details on how ta use ReadySource, see page 11.
POSTGRADUATE MEDICINE • May 1975 • Vol. 57 • No. 6
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Psychologic Management of Infertile Women Linda S. McGuire To cite this article: Linda S. McGuire (1975) Psychologic Management of Infertile Women, Postgraduate Medicine, 57:6, 173-176, DOI: 10.1080/00325481.1975.11714060 To link to this article: https://doi.org/10.1080/00325481.1975.11714060
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 8 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20
LINDA S. McGUIRE, PhD
University of Washington School of Medicine Seattle
FAMILY PRACTICE AND The psychologie difficulties associated with treatment of infertility can be minimized by limiting the length of treatment and refraining from suggesting a psychologie cause unless a specifie one can be adduced. If treatment is unsuccessful, referral for supportive therapy may be indicated.
PSYCHOLOGie MANAGEMENT OF INFERTILE WOMEN Infertility is not one of the pressing national or international problems in this overpopulated era, but it is of concern to those who, often without success, treat patients seeking its cure. The complex, often frustrating medical management of these patients can distract and discourage the physician from attending to the emotional concomitants of this disorder. The role of the family physician in the treatment of infertility varies. He may have primary responsibility for diagnosis and treatment. In locales with access ta specialists, he is more likely to decide when a referral is appropriate and follow the patient's course intermittently during her treatment. As a general guideline, before the physician initiates a referral for specifie treatment of infertility, a couple should have attempted to conceive for one year, having intercourse on a regular basis. Depending on the patient's age, the physician may choose to refer in less than a year. My experience in counseling infertile women during and after treatment has convinced me that much could be clone during treatment to alleviate emotional distress and minimize the trauma of an unsuccessful outcome. Timing and Length of Treatment
Because of the many factors involved in diagnosing the cause of infertility, the types of data needed (eg, basal body temperatures, hysterosalpingograms, laparoscopy), and the types of
Vol. 57 • No. 6 • May 1975 • POSTGRADUATE MEDICINE
treatment often necessary (laparotomy, medications), the workup and treatment of infertility are often lengthy. Nevertheless, treatment is sometimes prolonged unnecessarily. Specialists treating women may be tolerant of, or encourage, long delays between appointments or procedures with the hope that time will prove curative. Frequently, the nature of the problem is poorly defined. This, plus the knowledge that infertility clinics do not produce much better results than would occur by chance alone, has made many clinicians fee! it is worthwhite ta take breathers in treatment or to give a specifie form of treatment severa! months to work. Like many other aspects of treating infertile women, duration of therapy must be decided by weighing many factors, sorne not exclusively medical. A candid discussion of probable time involvement at the start of treatment and intermittent talks about progress and future types and lengths of treatment could give patients a more realistic time framework. Patients may schedule visits far apart, attempting ta put off the day when medical resourcefulness is exhausted. The four, five, and occasionally, ten years of treatment in individual cases can be detrimental to the infertile woman, principally because while undergoing treatment for her infertility, and seemingly obsessed by it, she is rarely dealing with it effectively. That is, as long as she is re-
173
LINDA S. McGUIRE Dr. McGuire is assistant professer, departments of obstetrics and gynecology and of psychiatry and behavioral sciences, University of Washington Scheel of Medicine, Seattle.
ce1vmg medication or undergoing laboratory tests or surgical procedures, she is usually putting aside crucial decisions about career, life plans, and adoption, and persona! confrontation with her childlessness. Few women request assistance for infertility until their late 20s, and if treatment is protracted until the early or middle 30s, many find certain options less open to them after treatment than if they had not delayed seeking help. For example, sorne patients will not make even tentative steps toward adoption, such as requesting a screening interview, until treatment is ended. Since adoption agency waiting periods currently are one to two years, such delays may affect the couple's desirability as candidates and their ease in adaptation and effectiveness as parents. Further, overlong treatment creates an exaggerated emphasis on the infertility, heightening the difficulties with self-esteem and sexuality that can accompany this disorder. Decisions about length of treatment are highly individualized. A duration damaging to one patient may be easily tolerated by another. Only by an awareness of other aspects of a patient's life can a decision be made integrating the social and emotional factors with the medical. Emotional Effects of lnfertility
Handling the emotional side effects of infertility can be difficult, and care must be taken to refrain from casting slurs as to psychogenesis. Unless words are chosen carefully, even in answering a patient's queries about psychologie factors ("Is it all in my head?") one can sorne-
174
times inadvertently confirm the patient's fears that she is somehow causing her infertility. Unless a ~pecific psychologie cause can be adduced for the infertility, and this is difficult, it can be harmful to assume that the absence of a known organic cause means that psychologie factors are dominant. The infertile patient often experiences such guilt and self-deprecation about her inability to conceive that chance remarks or musings about psychologie factors tend to be magnified and distorted. There are historical reasons for women's sensitivity to this issue. It has only been in the last 15 years that the male partner of infertile couples has been included in the workup for infertility, and to date, knowledge of male factors lags far behind know ledge of female factors in this disorder. Browne and Browne1 report that "in approximately 25 per cent of cases the husband is responsible for his wife's failure to conceive." They stress that "in considering treatment it is necessary again to emphasize that in relatively few cases of sterile marriage is either the husband or wife absolutely sterile, and that the failure to conceive is due in most instances to a summation of unfavorable factors in both partners. In most cases successful treatment will depend on the cure of as many of these unfavorable factors as possible." Furthermore, if language reflects attitudes and attitudes shape emotional responses, a look at the infertility literature over the last three decades is helpful in understanding the cultural environment within which the infertile woman exists. Of interest, for example, are the changes in terminology used to describe women unable to conceive and deliver children. "Barren," with its biblical sense of cursedness, was used in the 1940s. The ultraclinical term "sterile" was used in the 1950s and early 1960s. Currently, the more biologie term "infertile" is used. Clearly, as the state of the diagnostic art has improved, the number of women found to be "functionally, psychogenically or psychosomatically infertile" has correspondingly decreased. In 1957, Weiss and English2 wrote, "It is safe to say that about one third of all cases have no
POSTGRADUATE MEDICINE • May 1975 • Vol. 57 • No. 6
evidence of organic disease ta account for the sterility. Mental and emotional strain seem ta be the chief factors in producing it." In 1964, Browne and Browné reported that "in about 10 per cent of cases of sterility the cause is unknown and no fault can be discovered either in wife or husband by any method of investigation available at this present time." Karahasanoglu, Barglow, and Growe 3 cite four criteria that should be met before one can determine if a state of infertility is psychologically induced: (1) the presence of sperm at the cervical os in adequate numbers and with sufficient motility, (2) the exclusion of known organic causes through complete gynecologie study, (3) the presence of specifie emotions or character traits that possibly relate meaningfully ta infertility, and (4) an explanation of how psychic factors produce short-term somatic effects. This degree of rigorousness in making a diagnosis of "psychogenic infertility" is, in practice, rarely met. Moreover, the research literature which bas attempted ta delineate psychologie factors in infertile women reinforces caution in making this diagnosis. Although various writers 4 •6 have characterized infertile women as aggressive, dependent, or infantile, results of studies comparing the emotional stability, marital relationships, and family background of fertile and infertile women continue ta be highly inconclusive. Seward and associates 7 found virtually no differences between these groups in a large well-controlled comparison of relevant variables. A more recent study by Mai, Munday, and Rump 8 of psychiatrie interview comparisons also failed ta show substantial differences between infertile and fertile couples, although the authors noted that sorne infertile wives tended ta have disturbed "sexual raies and feelings." In virtually ali of this research, however, it is impossible ta determine whether these personality factors are a cause or a result of the infertility, as no prospective studies are reported. Conclusion
It is important ta pay attention ta the infertile woman's sexual functioning and marital rela-
•Physician ·Nurse •Biomedical Engineer · Administrator ·Medical Technician
THE PHYSICIAN demands diag· nostic accuracy, definition, de· pendability; no time-consuming retakes; mistake· free lead coding -and that's what the solid· state EK/5A de· 1ive rs. Exceeds AHA frequency response recom· mendations.
THE NURSE DR MEDICAL TECHNICIAN wants the ease of operation that results in time saving- from featu res 1ike the EK/5A automat· ic lead marking activated by a fast-switching lead selector, and easy porta· bility.
THE BIDMED ENGINEER looks for multi· pie use in the hospital; patient· isolated circuitry lleakage is less th an 1 D microamperesl; solid·state sim· plicity; multiple circuit boards for easier, faster service; computer compatibility; sound ECG de· sign.
BURDICN Vol. 57 • No. 6 • May 1975 • POSTGAADUATE MEDICINE
THE ADMINIS· TRATDR AND PURCHASING AGENT like (ll the savings that result from dependable performance; (2) medical staff sat· isfaction, and (3) Burdick dealer service and main· tenance availa· bility.
THE BURDICK CORPORATION Milton, Wls.
535&3
tionship in the course of treatment. The distortion in a couple's sexual relationship caused by ovulation-determined intercourse can be reduced. It is necessary to take a detailed sexual history initially and then periodically compare the patient's sexual activity leve! and satisfaction with the pretreatment period. If she achieves orgasm with greater difficulty or less frequency than before or if she is becoming increasingly nonresponsive, a one- or two-month respite from treatment may be helpful. Acknowledgment of the stresses associated with this treatment and assurance that normal responsiveness will retuen after treatment can provide emotional support. Finally, with many patients a referral for short-term counseling at the termination of
lengthy, unsuccessful treatment of infertility is appropriate. This period represents a crisis to many women in which their self-image, sexuality, and !ife plans must be reassessed and integrated with their childless state. Sponsored by family planning and education grant RS 68003 from the Rockefeller Foundation. Address reprint requests to Linda S. McGuire, PhD, University Hospital RH-20, University of Washington, Seattle, WA 98195. ACKNOWLEDGMENT 1 wish to thank Dr. Carol Wallace of the department of obstetrics and gynecology, University of Washington School of Medicine, for her incisive comments and suggestions.
REFERENCES 1. Browne FJ, Browne JC: McClure Postgraduate Obsterrics and Gynecology. Ed 3. London, Butterworth, 1964 2. Weiss E, English OS: Psychosomatic Medicine. Philadelphia, WB Saunders Co, 195 7, p 117 3. Karahasanoglu A, Barglow P, Growe G: Psychological aspects of infertility. J Reprod Med 9:241-247, 1972 4. Cooper H: Psychogenic infertility and adoption. S Afr Med J 45:719-722, 1971 5. Rommer JJ, Rommer CS: Sexual tones in marriage
of the sterile and once-sterile female. Fertil Steril 9:309-320, 1958 6. Ford ES, Forman 1, Wilson J Jr, et al: A psychodynamic approach to the study of infertility. Fertil Steril 4:456-464, 1953 7. Seward GH, Wagner PS, Heinrich JF, et al: The question of psychophysiologie infertility: Sorne negative answers. Psychosom Med 27:533-545, 1965 8. Mai FM, Munday RN, Rump EE: Psychiatrie interview comparisons between infertile and fertile couples. Psychosom Med 34:431-440, 1972
O O O ReadySource DON TEXTBOOKS Clinical Gynecologie Endocrinology and lnfertility (Speroff, Glass, Kasel Baltimore: The Williams & Wilkins Co, 1973 Gynecology, Principles and Practice (Kistnerl Chicago: Year Book Medical Publishers, lnc, 1969 Progress in lnfertility (Behrman, Kistner, editorsl Boston: Little, Brown & Co, 1968
COURSES Office Management of the Infertile Couple (8 hrs; continuousl Atlanta Accredited for continuing medical education (AMAl Contact: The American Fertil ity Society, 1801 9th Ave S, Suite 101, Birmingham, AL 35205 Cast: $75
176
INFERTILITY
lnfertility (intermittent, arrangedl Englewood, Flemington, or Jersey City, NJ Accredited for continuing medical education (AMAl Contact: Academy of Medicine of New Jersey, 2424 Morris Ave, Union, NJ 07083
AUDIOVISUALS Evaluation of the Infertile Couple (7:10-min tape, catalog #470l (Tagatzl Source: Wisconsin Dial Access Tapes, Department of Continuing Medical Education, 610 Walnut St, Madison, Wl 53706 Cast: $4 audio tape (114-inl; $10 Echomatic cassette
For details on how ta use ReadySource, see page 11.
POSTGRADUATE MEDICINE • May 1975 • Vol. 57 • No. 6
