Monday, 26 December 2011

Freudian Dream Interpretation (2) - "Irma's Injection"

"Irma's Injection" 
The Specimen Dream of the Psychoanalytical Movement

I will now present Freud’s first self-analytical dream (which he termed his ‘specimen dream’) and some ways in which it has been interpreted, by Freud himself and others. Unfortunately, nearly five years elapsed between Freud’s oneiric experience of “Irma’s Injection” (July 1895) and the publication of his interpretation (November 1899) and so we cannot know of any differences between Freud’s immediate interpretation of the dream upon awakening and that which subsequently appeared in print. For a summary on the history of dream interpretation and a simple background to Freud's psychoanalytic methodology of dream interpretation, please see my earlier post.

“Irma’s Injection” (24 July 1895)
Published in The Interpretation of Dreams (1899) 

A large hall - numerous guests, whom we were receiving.  Among them was Irma. I at once took her to one side, as though to answer her letter and to reproach her for not having accepted my 'solution' yet. I said to her: 'If you still get pains, it's really only your fault'. She replies: 'If you only knew what pains I've got now in my throat and stomach and abdomen - it's choking me'. I was alarmed and looked at her. She looked pale and puffy. I thought to myself that after all I must be missing some organic trouble. I took her to the window and looked down her throat, and she showed signs of recalcitrance, like women with artificial dentures. I thought to myself that there was really no need for her to do that. She then opened her mouth properly and on the right I found a big white patch; at another place I saw extensive whitish grey scabs upon some remarkable curly structures which were evidently modelled on the turbinal bones of the nose. I at once called in Dr M, and he repeated the examination and confirmed it ... Dr M looked quite different from usual; he was very pale, he walked with a limp and his chin was clean-shaven ... My friend Otto was now standing beside her as well, and my friend Leopold was percussing her through her bodice and saying: 'She has a dull area low down on the left’. He also indicated that a portion of the skin on her left shoulder was infiltrated. (I noticed this, just as he did, in spite of her dress) ... M said: 'There's no doubt it's an infection, but no matter; dysentery will supervene and the toxin will be eliminated ... We were directly aware, too, of the origin of the infection. Not long before, when she was feeling unwell, my friend Otto had given her an injection of a preparation of propyl, propyls ... propionic acid ... trimethylamin (and I saw before me the formula for this printed in heavy type) ... Injections of this sort ought not to be given so thoughtlessly ... And probably the syringe had not been clean.

Freud outlined what he perceived to be the personal, professional and family context of this dream as follows:

During the summer of 1895 I had been giving psychoanalytic treatment to a young lady who was on very friendly terms with me and my family. It will be readily understood that a mixed relationship such as this may be a source of many disturbed feelings in a psychotherapist. While the physician's personal interest is greater, his authority is less; any failure would bring a threat to the old-established friendship with the patient's family. This treatment had ended in a partial success; the patient was relieved of her hysterical anxiety but did not lose all her somatic symptoms. At that time I was not yet quite clear in my mind as to the criteria indicating that a hysterical case history was finally closed, and I proposed a solution to the patient which she seemed unwilling to accept. While we were thus at variance, we had broken off the treatment for the summer vacation. 

Manifest/associated content:
Setting: a vacation house, grand reception hall in which Freud's wife's birthday might be celebrated – i.e. the juxtaposition of the personal/family/professional aspects of Freud's life.
Initial mood: ‘reproach’ - initial mutual criticism between Freud and his female patient(s); later between Freud and his male colleagues.
Manifest cast of characters: Irma, a ‘hysterical’ widow (thought to be based on one/two female ‘patients’ Freud knew – see below); Otto (Rie), Freud's friend, medical assistant, and paediatrician to his children;  Dr M. (Dr. Josef Breuer), Freud's elder co-author of Studies on Hysteria (1895); Leopold (Dr. Ludwig Rosenberg), paediatrician colleague and friend of Freud and Rie; and Freud himself.

Images & associations:
Hall: Bellevue, wife's birthday
Irma: female hysterics, marriage, sexual abuse and frustration
Irma's pale and puffy face: pregnancy, puffiness
Irma's throat: diphtheria, tuberculosis, shortness of breath
Irma's throat’s curly structures: nasal reflex neurosis, vagina, masturbation
M's beardless face and limp: contempt
Irma's percussed body: eroticism, shame, Freud's own body
propyl trimethylamin: sexual arousal, frustration 

Latent/associated content:
Reproach 1: conjugal vs. professional duty; challenges and temptations of the couch
Reproach 2: professional (in)competence - of Freud; Otto/Dr M/Leopold and Fliess
Reproach 3: the nasal libido, bisexuality, periodicity/other Fliessian theories
Justification 1: the methods, scientific status, personal/professional perils of psychoanalysis
Justification 2: Sigmund Freud's (auto)biography; Eriksonian ‘generativity’
Justification 3: A (Post)modern hermeneutics 

In respect of “Irma’s Injection”, Freud’s analysis queried why dream ‘Irma’ suffered from ailments of the throat and abdomen; and had a pale complexion in contrast to that of his real-life patient (whom he believed ‘Irma’ represented), leading him to conclude that the dream Irma was a substitute. 

With regard to the suggestion that her disorders may be organic (and therefore not within the remit of Freud’s psychoanalytic cure), Freud questioned whether he was experiencing anxiety at overlooking the possibility of somatic illness (by diagnosing and treating her for hysteria instead), or simply relieved that if this was the case, he cannot be reproached for his failure to find an adequate cure. He noted that he has never had reason to inspect her mouth in real-life. He viewed his dream thought regarding Irma’s lack of need for dentures, as first a compliment to Irma (suggesting youth – when contrasted with his mention of a beautiful ‘Governess’ with false teeth) then suggests that the scene by the window recalled a memory of another experience – a meeting with Irma’s close female friend whom Dr M had diagnosed as having a ‘diphtheric membrane’. 

Dr M and the mention of ‘membrane’ are present in the dream. Further, Freud stated that he also believed Irma’s real-life friend to be suffering from hysteria and was aware that she suffered hysterical choking, like the character of Irma in the dream. He relates the ‘resistance’ demonstrated by the dream Irma to his belief that Irma’s real-life hysterical friend might refuse his offer of therapy due to her reserved personality. He cannot relate the idea of dentures with either the real-life Irma nor her friend and thus settles for associations of ‘bad teeth’ which reminds him of another female ‘patient’ (not one of his own) who also displayed unease in his presence. He concluded that he had compared Irma with two females who he imagined would resist his treatment and this led him to interpret the opening of Irma’s mouth ‘properly’ with his wish of wanting to replace her with her friend who he felt might be of greater intelligent and speak more freely (i.e. submit to Freud’s ‘talking cure’).

As Freud interpreted the dream, he makes attempted to censor himself (most likely to preserve details of extra-marital relationships from his family). In respect of the reference to abdominal pain in the dream, he made a further connection to the anonymous ‘third party’ (Irma’s friend?) and stated that he is measuring both his wife and Irma against the ‘ideal’ of the ‘docile and courageous’ female patient. He then acknowledged that his interpretation of this portion of the dream did not delve deep enough (into the ‘navel’ or abyss of the dream) to elucidate any real meaning or explanation with regard to this particular element. 

For example (this being my own interpretation on this section of Freud’s analysis), Freud associated the reference in the dream to abdominal pain to the third party (i.e. Irma’s friend perhaps? Or the real-life ‘Irma’ herself? The characters in the dream are interchangeable and Freud does not provide enough information for me to make a judgement – although he is clearly referring to a female patient). He expressed confusion early in his analysis, stating that he does not wish to be ‘blamed’ for the ‘unsolved’ stomach pains (he later states they turn out to be the result of gall-stones in the patient). 

Whilst the concept of blameworthiness in the analysis tends to point towards that of a professional nature i.e. Freud’s competence in recommending and carrying out certain forms of medical treatment – I think Freud’s twice mentioning of the fact he did not wish to be associated with or blamed for the stomach pains of another reveals more than he himself is willing to disclose in background detail. I think this is a hint that he has engaged in sexual intercourse and fears a resultant pregnancy outside of marriage. His own wife, Martha, was pregnant with their sixth child, Anna Freud around this time. He mentioned in annotation to the text that the dream did not turn out to be prophetic - which might also implicate him in unethical professional behaviour and the need to exonerate himself, albeit ambiguously. 

Further, Freud’s ‘replacement’ of Irma with her more docile, favourable friend at the point in the dream where Irma is encouraged to open her mouth properly signifies his desire to exchange the resistant and withdrawn female for her more forthcoming rival – something I choose to view in a sexual sense. My interpretation is credible – Freud’s paradigm of dream analysis places emphasis on sexual symbolism and the wishful fulfilment of the sexual urges of the ‘id’. The opening of the mouth relates to a submission to the ‘talking cure’ but also to the possibility of oral penetration (i.e. she is making her mouth available for Freud’s penis). 

Taking this association further – the mouth is a cavity and thus, an archetypal Freudian symbol for the female sex organs (see below – Freud relates the structures he sees in Irma’s nasal/cavity to the vagina in his own interpretation of “Irma’s Injection”) and thus, generally, Irma’s substitute is shown to be more readily available to her therapist, both psychiatrically and sexually. Even if no physical acts took place between Freud and  a female patient in real-life, my interpretation remains wholly operational within Freud’s ‘wish fulfilment’ model of dream analysis – he is unconsciously satisfying his desire to penetrate the mind and body (mouth/vagina) of a willing female analysand and thus achieving domination on two counts.

The white spots in Irma’s throat are associated with diphtheria (and therefore Irma’s friend); a serious illness previously suffered by Freud’s eldest daughter, Mathilda (Mathilde); and his concerns about his own health, in particular his prior ‘medicinal’ use of cocaine, which had caused the untimely death of a friend. The presence of Dr M in the dream is linked, not only with Dr M’s real position in their professional circle (i.e. someone of respected opinion), but recalls a memory of a previous patient of Freud whom he had ‘poisoned’ by prescribing sulphonal and had subsequently been treated by Dr M. 

The dream allegedly reminded Freud that his poisoned patient shared the same name as his elder daughter - Matilda. He saw this as him seeking every opportunity to reproach himself for his lack of medical conscientiousness, referring to ‘an eye for an eye, a tooth for a tooth’ – i.e. that his daughter’s illness might be retribution for her patient namesake’s  earlier suffering as a result of Freud’s negligence.

Freud acknowledged that the character of Dr M in the dream appears to be a fusing of the real-life ‘Dr M’ (Dr Josef Breuer) and Freud’s elder brother – due to their similar physical characteristics (shaved chin; walking with a limp) – and concluded that this fusion might be due to a real-life disagreement he had with his brother and Dr M regarding a certain proposal of his which both had rejected. The appearance of Otto (Rie)/Leopold (Rosenberg) is explained by Freud in terms of the two real-life persons these dream characters were thought to represent – both relatives; competitors in the same profession; and previous assistants of Freud. He stated that the dream sequence recalled real-life situations when the three men were examining child patients. He compared the nature of the two men (Otto/Leopold), identifying Otto as prompt/alert and Leopold as cautious – then drew analogies between Irma and her friend. 

The dream associations took Freud from the notion of the sick child to a children’s clinic. The ‘dullness’ low on the left side of the dream Irma, enabled Freud to once again make a connection to her more favourable friend who had actual symptoms imitating tuberculosis. The ‘infiltrated’ skin on the shoulder is also associated with Freud’s own body – the rheumatism he suffered in his left shoulder at night. 

The noticing of Irma’s skin (at the same time as Leopold) ‘despite’ her wearing a dress is said by Freud to be ambiguous and intending to mean ‘feel on my own body’ i.e. relate to his own body. He noted the unusual phrasing of  ‘infiltrated portion of skin’, contrasting it with similar, yet differently worded medical terminology which related to symptoms associated with tuberculosis – again leading to further associations with Irma’s friend. The phrase “despite the dress” is held by Freud to be an interpolation. He contrasted the usual method of examining children (undressed) with that of an adult female patient – often examined over their clothes.

Dr M’s comments about dysentery, infection and poison are thought bizarre by Freud, but nonetheless he viewed this section of the dream as having significant latent meaning. He stated that he found local diphtheritic symptoms in his patient and had, on a separate occasion, discussed the condition around the time of his daughter Matilda’s illness (diphtheria). In the dream, Leopold demonstrates the existence of this illness in Irma, pointing out the dull patch which would indicate a metastatic cause of her continued pain. To Freud, the symptoms in the dream are more consistent with pyaemia. 

Freud saw the comment “but no matter” as a consolation – Irma’s suffering stemmed from an organic cause and Freud recognised this aspect of the dream as  an attempt to shift blame from himself – as a psychiatrist he is not responsible for physical illness. However he expressed anxiety that he had created such a serious illness for his dream Irma, with the sole purpose of exculpating himself as it seemed ‘cruel’. Therefore in seeking consolation, he believed he made the right (dream) choice in placing the consolatory words in the mouth of Dr M. 

Yet he saw the fact that he placed himself as a figure of superiority in the dream as requiring further explanation and felt that the content of the dream, when analysed, rendered the Dr M’s consolation nonsensical. For example, Dr M’s theory that the toxins of dysentery might be eliminated via the intestine is far-fetched and therefore Freud saw himself as ‘mocking’ Dr M’s habit of curious diagnosis. 

The mention of dysentery also reminded Freud of a male patient suffering intestinal problems, diagnosed by another doctor as anaemia with malnutrition, but appearing to Freud to be a case of hysteria. Unwilling to treat him with psychoanalysis, Freud sent him on a sea-voyage, latterly receiving a letter from the patient (who was then in Egypt) reporting a fresh onset of illness, which was diagnosed by a doctor as dysentery. Freud thought this to be a misdiagnosis by an ignorant peer, fooled by the patient’s hysteria, but also felt concerned he had placed a patient at risk of organic illness in addition to his hysterical condition. He likened the word ‘dysentery’ to ‘diphtheria’ – a word which does not itself occur in the dream. The comment made by Dr M -  “dysentery will develop” -  is perceived as a further mocking of Dr M, as Freud is reminded of story told to him by Dr M of a real-life patient who was seriously ill. When Dr M’s colleague was informed that albumen had been found in the patient’s urine, he appeared unconcerned and said “that does not matter, my dear sir, the albumen will soon be excreted!” 

It is worth noting that Freud himself, viewed all strongly-smelling body fluids (including menstruation; sweat; faeces) as being an excretion by the sexual metabolic system. Influenced by Darwinian thought, he even propounded the theory that man evolved into upright stature to distance himself from his sexual organs and the smell created by the body through sexual metabolism.

Freud concluded that the part of the dream relating to his examination of Irma and Dr M’s consolation clearly expressed derision for those of his colleagues who were ignorant of the condition hysteria. He is led to wonder whether Dr M (who diagnosed tuberculosis in Irma’s friend) had considered the possibility of hysterical illness or allowed himself to merely be fooled by her psychosomatic  symptoms. The fact that, within the dream, both Irma and Dr M accept Freud’s solution, is perceived as a revenge on both these characters – Irma, in the words “if you still have pains it is your own fault” and Dr M, in the nonsensical consolation placed in his mouth.

Freud referred to his sudden realisation as to the cause of Irma’s infection in the dream as ‘remarkable’. Otto (Rie)  had recounted a real-life story of visiting a nearby hotel to administer an injection to an unwell patient, during his recent stay with  the real-life ‘Irma’s’ family. The thought of ‘injection’ again reminded Freud of his friend, who had died as a result of cocaine use. Freud had recommended the use of cocaine, for internal use, during withdrawal from ‘morphia’ (morphine) only i.e. not recreationally, but his friend had chosen to inject the drug himself, against Freud’s advice, and died as a result.

The associations drawn from the dream preparation of “propyl... propyls...propionic acid” are complex.  The chemical equation propyl->trimethylamin [(CH3)3CNH2] reflects the ‘triadic’ structure of the dream construction itself, whereby figures appear in sets of three – i.e. Freud associates to ‘Widows’ (Irma, her friend, Martha); to ‘Elders’ (Dr M/Breuer, Fleischl, Emanuel); and to ‘Equals’(Otto/Rie, Leopold/Rosenberg, Fliess). The number three in a dream was thought by Freud to be symbolic of the male phallus.

Freud referred to the writing up of his patient case study the evening before the dream, after which his wife had opened a bottle of liqueur, named ‘Ananas’ which was a gift from Rie (with whom the ‘Otto’ character is substituted). The drink smelled so strong of fusel oil that Freud refused to drink it and joked that his wife should not poison their servants with it by passing the unwanted gift onto them. The smell of fusel oil (amyl) awakened Freud’s memory of the whole sequence – (propyl, methyl etc) which appeared in the formula for the dream preparation which appeared in heavy-type before his eyes. He recognised that he has effected a substitution in smelling amyl and dreaming of propyl  and further linked the name ‘Ananas’ to the real-life ‘Irma’s’ own name (Anna) although he referred to her ‘family name’ which may have been an attempt to add a shield of semi-anonymity. 

The fact that trimethylamin, appeared in this heavy typeface in the dream, was thought to be of some significance. Freud associated it with a conversation he had had with a close friend (Fliess) who had disclosed to him a ‘groundbreaking’ theory regarding the presence of trimethylamin in sexual metabolism. This friend was currently suffering from rhinitis.

These thoughts led Freud onto the subjects of sexuality - which he believed to be the basis of the neurotic condition suffered by the widowed Irma - and Irma’s friend, whom  also happens to be a young widow. Thus, the importance of the word ‘trimethylamin’ is an allusion for the all-important factor of sexuality. Freud stated that his friend (Fliess) had developed remarkable theories linking the turbinal bones in the nose with the female sex organs and in fact he had referred the real-life ‘Irma’ to his friend for diagnosis/treatment. The three curly structures in Irma’s throat are linked to the turbinal bones in the nose, and thus, the vagina. Freud also believed that the images in the dream were ‘oral’ in the psychodynamic sense – and hence pre-Oedipal. At the time of this dream, Freud had a concurrent interest in the connection between neurosis and oral sex acts; his interest in the sexuality of the nose formed the ‘prototype’ for his later theories on orality and obsession. 

Within the dream, reproach is directed towards Otto, being the person who rashly administered the injection to Irma. Freud referred to an incident the afternoon prior to dream where the real-life Otto (Rie) had made a comment to Freud which Freud took to be a veiled insult about his professional conduct and a sign Rie was taking sides against him. He then connected this remark with thoughts of his deceased friend, who died from injecting cocaine. Freud is keen to point out that he did not intend his friend to continue injecting himself with the drug and had merely wanted to help him overcome his morphine addiction. In identifying his reproach of Otto in the dream, Freud  is then reminded once again of the patient Matilda – the pretext for which similar criticism was levelled at Freud following his negligent administration of intravenous sulphonal.

The notion of the dirty syringe is associated, by Freud, with an incident the previous day, when he met an elderly patient to whom he administered two daily injections of ‘morphia’. He heard the patient was suffering phlebitis and had wondered if the cause might by infiltration by a dirty syringe. He was at pains to state he had never infected her, nor any other patient, with an unclean syringe. The phlebitis is then associated with Freud’s wife who suffered from a bout of thrombosis during pregnancy and Freud concluded that this brought to mind three related incidents which justified the linking of his wife; Irma and the patient Matilda in his unconscious. He does not elaborate on what real-life incidents he was referring to – another attempt to censor what might be ‘sensitive’ material from his audience.

It is at this point that Freud declared he was certain he had interpreted his dream, stating that he had been careful to avoid all comparisons between the dream-content (manifest content) and the dream-meaning (latent content) hidden beneath. He identified his intentions or motivation for having the ‘Irma’s Injection’ dream as the fulfilment of several wishes awakened within him by the events of the previous day (Rie’s visit/the writing of the patient’s case history). Following Rie’s disparaging comment about Irma’s imperfect cure, Freud’s dream fulfilled the function of absolving from him all blame, and redirecting reproach towards ‘Otto’. The dream acquits Freud of the cause of Irma’s pain and provides an organic explanation, presenting a certain state of affairs as Freud wished them to exist. The motive of the dream is thus a wish; and its content, wish fulfilment. 

Freud’s ‘revenge’ against Otto takes place for three reasons: (i) too readily taking sides against him, professionally; (ii) the injection given to Irma; (iii) the bad liqueur. The avenging of Freud continues, in the comparison of Otto with his more reliable colleague (Leopold), demonstrating Freud’s contempt towards his friend. Freud, similarly, takes revenge on Irma, his disobedient patient, exchanging her for her friend whom he perceived to be more sensible and docile. With regard to Dr M – Freud viewed his appearance within the dream as an allusion for Freud’s view that he was an ‘ignoramus’ and thus within the dream ‘replaces’ him with his friend (Fliess) who in real-life, supported Freud’s psychoanalytic cure. Freud is therefore identifying the characters represented by Otto, Irma and Dr M – and replacing them with three favourable persons.

Irma’s pains are not attributable to Freud – they are organic and thus outside the remit of psychic treatment and in any event, her own fault as she has refused to accept his solution. He suggested that Irma’s suffering was satisfactorily explained by her widowhood, a state he cannot alter. Additionally, Irma’s suffering is also the result of the negligent injection given by Otto. All these aspects of the dream unite to, in effect, acquit Freud by absolving him of any possibility of blame regarding Irma’s condition. He pointed out in the text that the absolving elements of the dream do not ‘agree’ with one another and even work to exclude each other conclusion – i.e. they are contradictory and provided an analogy by way of explanation:

The whole plea - for this dream is nothing else - recalls vividly the defence offered by a man who was accused by his neighbour of having returned a kettle in a damaged condition. In the first place, he had returned the kettle undamaged; in the second place it already had holes in it when he borrowed it; and in the third place, he had never borrowed it at all. A complicated defence, but so much the better; if only one of these three lines of defence is recognised as valid, the man must be acquitted.

Freud examined the other themes present in the dream – some of which, the connection to his non-responsibility for Irma, is not instantly apparent. These themes included: his daughter’s illness; his patient Matilda; the dangers of cocaine; the male patient in Egypt; concern about the health of his wife, brother and Dr M; his own physical troubles; anxiety for his friend Fliess, suffering rhinitis. These themes were combined into a single train of thought, labelled as ‘concern for the health of myself and others; professional conscientiousness’.

Freud warned that his interpretation should not be considered entirely complete nor flawless (having also previously admitted attempts to censor himself with regard to personal facts relevant to the background of the dream, yet alluded to in his analysis). Therefore I have taken time to analyse subsequent alternative interpretations of Freud’s dream, which I shall post separately.

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