X jrUCH accumulated knowledge exists concern-J -V J . » n g the pathophysiology and histology of Graves' disease, and the presence and precipitating role of psychologic factors are well established. The ultimate etiology and, in particular, the nature of the psychologic influences are still unknown.The emotional concomitants of thyrotoxicosis are discussed in detail in the clinical literature, and there are a large number of well-documented observations on the precipitation of the thyrotoxic state by emotional trauma: a phenomenon expressed most succinctly by the term "shock Basedow." Only a few investigators, including Nolan Lewis (33), Agnes Conrad (11), Brown and Gildea (8), Lidz and Whitehorn (34, 35) have studied patients from a psychodynamic point of view. These workers have demonstrated the presence of certain personality features in this disease. Our study consisted of the analysis of material from anamnestic interviews of 23 patients and multiple psychoanalytic interviews of one patient.Our first aim was to determine the psychodynamic constellations in which the characteristic psychologic factors appear. As a result of these studies, it has been possible to propose a psychologic gestalt which includes both our own results and the physiologic and psychologic findings of previous observers. This presents a comprehensive picture which throws light on the development of the disease, upon spontaneous remissions as well as the response to treatment. We propose to demonstrate that the disease symptoms can be understood as the organism's responses to the early experiences of development which are characteristic for these patients. In this response the thyroid gland is only one effector link in a chain of physiologic events. More specifically, the physiologic response can be well understood
FUNCTIONAL STERILITY as a diagnosis refers to the somatic effects of psychodynamic factors resulting in a more or less persistent inhibition of the propagative function in individuals whose functional capacity for sexual intercourse is adequate. 6 Psychoanalytical studies of women often reveal data in regard to childbearing. Psychoanalytical studies of men, however, hardly touch on the problem of fertility, as if it were tacitly assumed that man's fertility, belonging to the realm of organic physiology, lies outside of the territory of psychological investigation. Even in this project, in which at the onset we assumed that the subjects of our investigation were fertile women whose husbands are sterile, we did not plan an investigation of the emotional motivations of the infertility of these men. Our aim was to investigate the emotional factors which inhibit conception by artificial insemination at the time of ovulation in women whose wish for pregnancy and motherhood appears obvious. We hoped in this way to secure more concrete data about emotional factors which might inhibit or facilitate conception.successful procedure in animals, resulting in pregnancy in more than 99 per cent of single inseminations. The successful impregnation of women by artificial insemination, however, occurs only after three to twenty inseminations, or in from 4 per cent to 30 per cent of the attempts; the average number of such procedures before pregnancy is eight. These data include only those instances of artificial inseminations which were attempted during the presumptive fertile periods as determined by basal body temperatures, vaginal smears, changes in the cervical mucus, and in hormone excretion. Artificial insemination is not attempted until after three months of observation of the patient to determine whether or not she ovulates and develops a secretory endometrium premenstrually. It has been observed that following artificial insemination the first few times, women, who had previously ovulated regularly, failed to ovulate for varying lengths of time. To the psychoanalyst, it cannot be surprising that artificial insemination, a mechanized, "unnatural" technique, as a substitute for an action of intimacy and highly emotional gratification, is a traumatizing procedure; that it naturally leads to the inhibition of its own aim.This study is limited to six cases; all of them were in treatment by one of the investigators* for varying lengths of time for the purpose of achieving pregnancy by artificial insemination. After several unsuccessful attempts, psychotherapy was recommended. There was no further selection of the cases in regard to indication and suitability for psychotherapy; no pre-* Boris B. Rubenstein, M.D.
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