Drinan, Francis W.

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The Linacre QuarterlyVolume 21 | Number 2 Article 45-1-1954The Function of the InternistFrancis W. DrinanFollow this and additional works at: https://epublications.marquette.edu/lnqPart of the Ethics and Political Philosophy Commons, and the Medicine and Health SciencesCommonsRecommended CitationDrinan, Francis W. (1954) "The Function of the Internist," The Linacre Quarterly: Vol. 21 : No. 2 , Article 4.Available at: https://epublications.marquette.edu/lnq/vol21/iss2/444 THE LINACRE QUARTERLY ============================-endometrial biopsies should be done, preferably on day one of the eye e. A prettier microscopic picture will be obtained in the premenstr• al phase, but unless the patient has been instructed not to attempt pre J­nancy that month it is best to wait until the first day of the cycle :o avoid interruption of a pregnancy. The endometrium offers an e ,d organ picture of the response of the tissues to both the pituitary a ,cl ovarian hormones, and is simpler and less expensive than extensi -·e hormone assays. The microscopic picture can be improved by the use )f estrogen and progesterone. We prefer O.I mg. stilbestrol daily throug t­out the cycle. When these agents fail, we must suspect failure of del i ·­ery of these hormones to the endometrium. Since the excellent work of the Smiths with stilbestrol in the preve .­tion of repeat abortion has been seriously challenged by Davis ai d Dieckmann's recent large series, we feel that there is a place for a m e physiologic approach. We have proposed the maximal delivery a: d utilization of the patient's own hormones by the surgical elimination ··if autonomic imbalance and vaso-spasm. A more stable blood_ flow w II deliver more hormones to the tissues. We feel . however, that the pr -cedure should be reserved for patients who abort normal fetuses ar :I have evidence of autonomic imbalance by kymographic demonstration , f utero-tubal pressures of high degree. To utilize the endogenous ho -mones of thEi patient in maximal amount by eliminating vasospasm ar :I improving endometrial circulation we suggest the simple procedure ( f paracervical uterine denervation, which can be done either per vagina .1 or at laparotomy. A series of seventeen patients who had this type c f denervation while under fertility studies conceived fourteen times an:! delivered thirteen live children during a two year study. (Jour. Fertiliiv & Sterility, Mar. 1954) These are the simple standard proc�dures which constitute the stu I of the female partner. If we will only till the barren ground, it will I:;� easier for the Author of life to plant the seed. THE LINACRE QUARTERLY 45 The Function of the Internist FRANCIS w. DRINAN, M.D. T HE function of the medical staff in �he op.eration of an InfertilityClinic is primarily to evaluate pat1errts m order to exclude all systemic disorders that may have a bearing on fertility. At times, a relatively simple examination may reveal abnormalities that are signifi­cant, but equally as likely is that exhaustive studies will fail to supply any explanation of infertility.-The causes and factors are many and varied. The internist's interest will be directed towards extra pelvic disorders bf an organic nature. In general, the search entails an evaluation of the general state of health, endocrine systems, toxic or traumatic factors and metabolic disorders. The relationship between general health and ovarian and testicular function has not been clearly defined, and is a source of considerable physiological speculation. General debility, malnutrition, hypoprotein­emia are well known factors th.at are associated with hypofunction of sexual organs. The mechanism of the hypofunction is not clearly under­stood, but most likely involves several factors, as cellular and enzyme activity, primarily hyaluronidase and glucuronidase and hormonal pro-. duction. No medical disease, excluding endocrine disorders, is inevitably associated with infertility. However, spreading tuberculosis, especially involving the Fallopian tubes, and decompensated liver disease are examples of conditions in which conception is unlikely. Endocrine dysfunctions make up the most likely medical reason for sterility. Several conditions that are almost invariably associated with decreased ovarian or testicular activity below the functioning threshold are: Froehlich syndrome, eunuchoidism, Simmond' s disease, arrheno­blastoma, masculinovoblastoma, Stein-Levinthal syndrome and struma ovarii. These situations are usually suspected and diagnosed after appropriate studies. There is a vast field of glandular disorders that may be significant in sexual gland function. Correction of thyroid defi­ciency commonly results in a return to normal of either the general state of health or hormonal balance requisite for pregnancy. In many cases, administration of thyroid to euthyroid patients has been followed by pregnancy in a couple that may have been barren for many years. Hypo­adrenalism is not per se .gufficient to depress the factors necessary for conception. However, Addison's disease is rarely seen in pregnancy. Cessation of cortisone therapy is known to be followed by a decrease 46 THE LJNACRE QUARTERLY in adrenal cortical activity, and thus may be a temporary factor sterility. The pituitary activities are so inter-related with each other ar with other glands, that alm.ost anything causing a derangement of i function will be reflected elsewhere. The Sheehan syndrome has to l considered in cases of secondary sterility. Pituitary neoplasms ar non-sexual gland over-stimulation may adversely affect estrogen ar. 1 androgen production. Search must be made into other disorders that may directly t indirectly depress sexual gland activity. Excessive radiation in x-r workers and those exposed to radio-active substances is an accepte etiological factor in sterility. Disturbances of hormonal metabolism seen in liver disease and the chronic congestion of organs with th inadequate arterial circulation of congestive heart failure are frequent! associated with amenorrhea and inadequate sperm counts. Many othe pathological conditions with deranged body physiology are at time associated with sterility-whether as a coincident or causative agent i difficult to determine. The diagnostic studies for medical evaluation of sterility cases ar, multiple. However, no set of screening tests can be established. Routin< laboratory procedures, as blood counts, sedimentation rate, urinalysi, are a part of any complete examination. Basal metabolic studies, proteir bound iodine determination, blood sugar, glucose tolerance curves, live1 function tests will be required in some cases. Bio-assays of hormones, it more feasible, would add greatly to our knowledge of the subject, but from the practical point of view will seldom be mandatory tests. Enzyme determination may perhaps in future years be very important, but at the present time adds relatively little to the workup. The internist must be aware of all factors and the inter-relationship of factors if he is to contribute to the individual's problem of sterility. A very complete and exhaustive workup may reveal no significant abnor­malities, but the discovery of obscure conditions may make the time consumed a very fruitful experience. The discovery of many of the abnormal conditions will not produce fertility but will obviate further diagnostic procedures and perhaps add to our ever-growing knowledge of sterility. THE LINACRE QUARTERLY 47 Urological Aspects RICHARD E. STILES, M.D. The function of the Catholic urologist in the management of appar­ently infertile marriages is two-fold. He is concerned primarily with t�e diagnosis of infertility or sterility in the male partner, and secondanl_Y with the treatment of such abnormalities. In both these concerns, his medical enthusiasm is tempered by Catholic principles of morality. It is the purpose of this paper to describe how these objectives are achieved within the framework of a hospital out-patient clinic. Patients are usually referred by the obstetrical clinic or family physician, after at least superficial studies of the wife have been made and no obvious cause of infertility found. At this point it is frequently desirable to investigate the male partner, in an effort to determine his role, if any, in the etiology of the problem. When he is first seen, the husband's attitude may vary from genuine interest and enthusiasm, to polite skepticism, or ill-concealed antago­nism. A little time spent in establishing rapport at this point pays dividends later, not only to the- urologist and referring physician, but also to the patient's wife. whose repeated urging has frequently been necessary to get the patient to the clinic. For this reason, an effort is made to personalize each original interview at the clinic to avoid any · impression of assembly-line tactics. At the same time, for consistency inrecord maintenance, a printed blank form is used, which has adequatespace for entering the necessary historical, physical, and laboratory data.In addition to establishing the usual details of medical history, thepatient is questioned concerning previous marriages or pregnancies,episodes of genital infection, especially gonorrhea, mumps orchitis, orepididymitis. Inquiry is also made concerning previous operations forhernia, cryptorchidism, hydrocele, or varicocele, or allied conditions.Detailed information concerning the use of tobacco, alcohol. and otherdrugs is sought, as well as facts concerning the patient's occupation,with particular reference to his exposure to industrial poisons, x-ray, orother noxious agents. Finally, detailed information pertaining to thepatient's marital life is worth eliciting. It is surprising how much vari­ance there may be in the history obtained from the two partners on suchfundamentals as potency and libido, frequency of intercourse, contra­ception, premature ejaculation, and so forth.General physical examination is then carried out, with particular 

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