Thursday, 5 January 2012

Alternative re-interpretations of Freud's "Irma's Injection" dream

For the background to Freud's seminal dream of the psychoanalytic movement - "Irma's Injection", please see my earlier posts which set out the dream narrative and a famous Freudian re-interpretation by the French psychiatrist and philosopher Lacan. Below I have written up some further interpretations of the symbolism and meaning behind "Irma's Injection".

* Griffin’s re-interpretation – expectation fulfilment model
The re-interpretation of Freud’s ‘Irma’s Injection’ dream by Joe Griffin, contains an analysis of factual events and correspondence between Freud and his colleagues which enables a recontextualisation of the meaning. Below is my summarisation of Griffin’s re-interpretation of “Irma’s Injection”. My commentary of Griffin’s analysis is presented after.
Sigmund Freud & Wilhelm Fliess (1858-1928)
Emma Eckstein (1865–1924)
Emma Eckstein (credited as the first female psychoanalyist in 1897) pictured on Freud's infamous couch
Anna Hammerschlagg (1861-1938)
From Freud's discussion of the background to the dream (which on first inspection appears to be about one of his patients, Irma/Emma – see below), it is clear that, on the previous day, he had received a visit from an old friend, the family paediatrician, Dr Oskar Rie. Earlier in his career Rie had been Freud's assistant and collaborated with him on a scientific paper. In the dream of “Irma’s Injection” Freud calls him ‘Otto’. That evening Rie had come directly from ‘Irma’s’ home where he had been staying with her and her family. Freud asked him how ‘Irma’ was and he replied, "she’s better but not quite well". Freud was annoyed by his reply, as he felt that he detected a reproof in it to the effect that he (Freud) had promised the patient too much and not delivered in restoring her to full health. He gave no indication to Rie of his feelings, but that night he worked late, writing out her case history to give to Dr M (subsequently identified as Dr Josef Breuer, a senior colleague and a collaborator with Freud on a book about hysteria).

In The Interpretation of Dreams Freud proceeds to give lengthy associations for each element in the dream and finally concludes that the main instigating force for the dream was a wish to exonerate himself from any blame for the lack of complete success in the treatment of Irma’s condition. This is achieved by (a) blaming Irma herself for not accepting his solution; (b) pointing out that, because the pains were organic in nature, they were not treatable by psychological means; and (c) implying that Otto had caused the pains by giving her an injection with a dirty needle. These reasons are not, however (as Freud himself noted), mutually applicable. The dream also gave him his revenge on Otto, by making Otto responsible for Irma’s condition.

From his contemporaneous correspondence letters, we can see that in March 1895, Freud had treated a young, single woman of 27 years, Emma Eckstein, for hysterical nose bleeds. He had called in his friend Fliess, a nose and throat specialist, to examine her to see if there was a somatic basis to her illness. Fliess had not only operated on Freud himself, but was also at this time, Freud's major confidant and had expressed complete confidence in Freud’s theories. Fliess travelled from Berlin to Vienna to examine Emma and operated on her nose on the 4th March. (Fliess had propounded an unusual theory that the turbinal bones in the nose and the female sexual organs were intimately connected and that somatic symptoms, allegedly arising from masturbation, could be cured through nasal surgery). Freud subsequently wrote to Fliess telling him that the swelling and bleeding hadn’t stopped  and that a foetid odour had set in. He went on to say that he had called in another surgeon, Dr G [Dr Gersuny], who inserted a tube to help the drainage. Four days later he wrote again to Fliess telling him that profuse bleeding had started again and, as Dr G was unavailable, he had called in surgeon Dr R [Dr Rosanes] to examine Emma. While cleaning the area surrounding the opening, Dr R began to pull at a thread and suddenly at least half a metre of gauze came away from the cavity. This was followed by profuse bleeding. It turned out that Fliess had left a piece of iodoform gauze in the cavity some two weeks earlier, which was interfering with the healing process and was the source of the foetid smell. Freud went on to state that leaving in the gauze was an unfortunate accident that could have happened to the most careful surgeon and he reiterated his complete faith in Fliess’ competency. On 28th March 1895, he again wrote to Fliess reassuring him about Emma's condition but, by 11th April, was writing once more telling Fliess that Emma’s condition had deteriorated and that there was a further highly dangerous haemorrhage. On 20th April Freud replied to a letter from Fliess, telling him that Emma would have bled to death quickly had they hesitated in taking action and went on to stress his continued trust in his friend.

These traumatic events occurred just some four months prior to the ‘Irma’s Injection’ dream of the night of 24th July 1895. As we can see from his letters, these were profoundly anxious times for Freud. It is likely that it was because of these traumatic events that Freud was so sensitive to what he felt was an implied rebuke in his old friend Rie's remark about Emma's treatment. No doubt his reaction - to stay up late to write out her case history in order to justify himself - also helped to bring back in full force memories of these events. There are many notable resemblances between the traumatic incidents recounted in the letters concerning Emma and Freud’s dream of “Irma’s Injection” and subsequent interpretations of Freud’s dream have made full structural comparisons between the two, arguing that ‘Irma’s Injection” is a precise analogical restatement of Emma’s case, in a re-enacted metaphorical scenario, with Freud’s introspected views about Fliess’ blame openly expressed.

The setting for the dream is a party that was to be held the following day to celebrate Freud’s wife’s birthday. Among the guests is Irma, who Freud takes aside to rebuke for not having accepted his solution. Freud tells us that Irma (a name used by Freud to protect the patient's identity) was a young widow and a friend of the family. Subsequent evidence has identified ‘Irma’ as Anna Hammerschlag, a young widow and family friend, who was the godmother of Freud’s daughter Anna. She was briefly treated by Freud at this time. This has led to the conclusion that the manifest dream character of Irma/Anna was an analogical replacement for Emma Eckstein. Both Irma/Anna and Emma were referred by Freud to Fliess for nasal examination. Fliess, as we have learned, recommended and carried out nasal surgery on Emma Eckstein to remove the turbinate bone in her nose, with near fatal consequences. Fliess, who was at that time an inexperienced surgeon, advocated this entirely unnecessary operation on the grounds that it would help her recover from what his theory said were the harmful effects of masturbation (Fliess’s theory had rightly been dismissed by the scientific community of the day, but nevertheless, Freud believed for several years that it was a fundamental biological discovery). After the operation, Fliess returned to Berlin and no doubt Freud was irritated, as in the dream, by the persistence of Emma’s somatic illness. When he examined Irma in the dream, she showed signs of ‘recalcitrance’ - in his letter to Fliess of the 4th March 1895, he told him that he had encountered resistance from Emma.

The throat in the dream is an analogy for the nose. This is made quite clear in the dream when Freud looked down Irma’s throat and saw structures similar to the turbinal bones of the nose. Freud then reveals the sight of patches/scabs upon these structures, i.e. the operation site. He at once called in Dr M [Dr Breuer], a senior colleague of his, who confirmed his examination. This parallels the events recounted to Fliess in his letter of 4th March 1895, where he said that, because of the pain and swelling, he had let himself be persuaded to call in Dr G, who conducted further treatment.
Freud & Dr Oskar Rie (1863-1931)
Dr Ludwig Rosenberg (1858-1928)
Dr Josef Breuer (1842-1925)
Freud notes that, in the dream, Dr M did not have his usual appearance, but possessed the physical characteristics of Freud’s elder half-brother. In his letter of 8th March, Freud told Fliess that Dr G had behaved in a rather rejecting way towards him during his visit. This explains why the character in the dream standing for Dr G is a composite of Dr M and Freud’s brother – both of them, Freud tells us in his associations to the dream, had recently rejected a suggestion that he had put to them. Freud then recalled that Otto was standing beside the patient. Otto [Rie] is the analogical replacement for Fliess in the dream. It’s not surprising that Otto should have been Fliess’s analogical substitute, as both men were friends of Freud; both were doctors; both had a professional relationship with him and his family; and both had been involved in Freud’s theoretical work. After the visit of Dr G — represented by Dr M in the dream — Freud wrote a series of letters to Fliess, making him aware of each step in the developing crisis. Thus, in a metaphorical sense, Fliess was standing beside the patient. It is entirely in keeping with this view that Otto in the dream doesn’t do anything from this point, except observe what is going on.

Next in the dream sequence, Freud’s friend Leopold is examining Irma. In Freud’s letter of 8th March 1895 we learn that he had to call in a Dr R to examine the patient because Dr G wasn’t available - therefore the structure of the dream is working out exactly as it did in real-life. In the dream, his friend Leopold’s examination indicated that a portion of the skin on the left shoulder was ‘infiltrated’. Freud could see the infiltration in spite of Irma’s dress. In the real life situation, Dr R had pulled at something like a thread, an accordingly, a piece of gauze (left from Fliess’s surgery) was removed — an ‘infiltration’.

Next, Dr M intervenes again and gives the opinion that "There’s no doubt it’s an infection …" etc. We have already shown that Dr M (perceived by Freud in the dream as a combination of Dr Breuer and Freud’s brother) is the analogical substitute for Dr G and (in real-life), we see from Freud’s own letter of 8th March to Fliess, that Dr G did indeed come the next day and assist Dr R in attending to the patient.

Next we come to perhaps the most important element of the dream sequence, when Freud says:

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 made so thoughtlessly … and probably the syringe had not been clean.”

Freud refers to events that have happened “not long before" — in other words, before the sequence of visits analogically represented in the dream. This corresponds exactly to the sequence in real-life i.e. Fliess had carried out his abortive operation before the sequence of other doctors’ visits were set in train. Everybody in the dream, including Otto (i.e. Fliess), is aware that Otto is to blame, that he had been thoughtless and probably negligent in that the syringe wasn’t clean. Freud may have felt protective towards his close friend Fliess, after the discovery of Fliess’s mistake (as indicated in his correspondence), but the dream makes clear that -  by the time of the dream - Freud had come to see that Fliess had been professionally negligent, and that the other doctors who were subsequently called in were also fully aware of Fliess’s professional incompetence. It would have been natural for Freud to have reviewed those events as he considered a defence of his own professional conduct in the case of another patient, whom he had also referred to Fliess for treatment. The injection of "propionic acid… trimethylamin" is again an analogy. Propionic acid is described in pharmacological reference books as having a putrid/rancid odour. Freud referred to Emma's lesion as having a 'foetid' odour and it is known that gauze left overly long in a wound causes a foul smell of rotting flesh. Fliess had told Freud that trimethylamin was one of the products of sexual metabolism. Fliess’s operation removed the turbinate bone in Emma's nose to alleviate the deleterious effects of masturbation, which he claimed gave rise to a 'nasal reflex neurosis'. We can see that by this metaphorical means Freud was pointing the finger of blame at Fliess for the foul smelling lesion in Emma's nose, which had resulted from his negligent surgery.

Freud's dream of “Irma's Injection” can therefore be seen as a metaphorical simulation of the traumatic events of the Emma case. It is also apparent that Freud's sensitivity to the assumed criticism of his professional conduct, implied by Otto's remarks of the night before, reawakened the trauma of his recent involvement in the Emma case. This patient nearly lost her life after Freud referred her to his friend Fliess for surgery that was both unnecessary and unorthodox . Just as he wrote up the case history of ‘Irma’ [Anna] for his mentor, Dr Breuer that night to make clear that he was not responsible for her continuing symptoms, Freud's introspections about the nearly fatal case of Emma were brought to the surface of his mind and were metaphorically expressed in his dream .

Griffins, who propounds this particular interpretation of the “Irma’s Injection” dream, refers to his analytical theory of dream interpretation as ‘expectation fulfilment’, placing it in contrast with Freud’s paradigm of ‘wish fulfilment’. Griffin’s theory suggests that under his model, Freud’s dream can be reinterpreted in a way which shatters the foundations upon which the psychoanalytic theory was established.

Under Griffin’s theory, all dreams are expressed in the form of sensory metaphors and the reason for this is found in the biology of the rapid eye movement (REM) state - a special brain activation experienced by all mammals. Research by Michel Jouvet had already indicated that instinctive behaviours are programmed during the REM state in the foetus/neonate, but Griffin took this suggestion further, arguing that this programming is necessarily in the form of incomplete instinct templates, for which the animal later identifies analogous sensory components in the real world. These analogical templates give animals the ability to respond to the environment in a flexible way and generate the ability to learn, rather than just react. Once an instinct-driven pattern is activated and becomes an expectation, it can normally only be deactivated by the actual carrying out of the programmed behaviour by the central nervous system. Although instincts are 'hard-wired' in us, this process alone clearly would not enable the flexibility we need for survival, because if we acted out every experienced arousal there would be chaos. All emotions derive from expectations - when an expectation is 'set up' the autonomic arousal system raises an emotion to provide the necessary energy to assist the expectation in being met. Only once the expectation is fulfilled is the autonomic nervous system de-aroused. If this complete ‘arousal/de-arousal’ process does not happen whilst we are awake, it is 'deactivated' metaphorically in a dream. This has to happen otherwise our instincts would be conditioned out of us. Griffins argues that dreaming evolved because animals needed to the ability to inhibit arousals when necessary, leaving them to be deactivated later when they could do no harm.

The brain is constantly matching patterns, comparing and contrasting the incoming data it receives for similarities with innate instincts or memories so appropriate responses can be formulated. This is known in Griffin’s theorem as 'metaphorical pattern matching' and the reason why the unfulfilled emotional expectations ‘left over’ from the day are run out in the form of metaphors in dreams during REM sleep. Without this happening, the brain would not be freed up to deal with any new emotionally arousing events the following day.

Griffin provides reasoning for the metaphorical nature of dream content. Firstly, he avers that the brain cannot generate ‘real world’ reality without feedback from the environment and since all our senses are switched off whilst we are dreaming. Therefore, instead of the brain seeking to fulfil the patterns of arousal externally, it does so internally, drawing on memories that have emotional and metaphorical resonances with the unresolved arousal patterns in the autonomic nervous system.  This accounts for the bizarre nature of dreams - they draw on memories and images from your entire life, even though they are only about un-acted out arousals from the previous day. So every person you see in a dream is metaphorically representative of someone else in real-life. Secondly, without using metaphorical translations, the brain would either be forced to create false emotional memories or be left with massively significant gaps in memory. In the first example, if the brain acted out unexpressed waking expectations and committed that experience to memory, it would have created false memories. It could be argued that we have the ability to distinguish dreams from waking reality, but Griffin argues that this would be missing the point. The emotional conditioning of our reactions would have still taken place even if we were subsequently able to separate dreams from real memories. On the other hand, if the brain chooses to forget the dream (which is what happens) it would create gaps in memory for what actually happened since the dream will involve both real and fantasy experiences. This would be equally disastrous because a memory system with significant memories missing would be next to useless as a basis for predicting the future.  Under Griffin’s model, by using analogy or metaphor whilst dreaming, the brain can discharge the arousal, safely forget the metaphorical dream material and keep the original record of what really happened filed away in memory.

Griffin’s expectation fulfilment theory
  1. Dreams are the deepest ‘trance states’ experienced on a regular basis.
  2. Dreams are metaphorical translations of waking expectations.
  3. Only expectations that cause emotional arousals that are not acted upon during the day become dreams during sleep.
Dreaming deactivates that emotional arousal by completing the expectation pattern metaphorically, freeing the brain to respond afresh to each new day.

In terms of Griffin’s reinterpretation of “Irma’s Injection”, I think his theory runs into problems. Whilst his actual theory of dreaming and explanation of dream function is credible (taking its grassroots from the theory of renowned French dream scientist Jouvet), the analysis of Freud’s dream does little but attempt to discredit the psychoanalytic movement. Griffin sets out his theory and counter-interpretation of Freud’s dream (stripping away the need for ‘associative content’ and symbolic analysis by framing his interpretation as an analogous account of biographical fact with added introspective devices which serve to reveal the true emotions and thoughts of the dreamer) without reconciling the two. His reinterpretation simply ignores much of Freud’s express recognition of, and anxiety regarding, the possibility of his own professional misconduct and admitted need to ‘avenge’ himself of Rie’s dismissive remark on the night of the dream and the real-life ‘Irma’s’ resistance to his psychoanalytic therapy. Further, Fliess’ work complimented that of Freud and many of their theories were mutually supportive of each other’s. Freud associated the ‘Otto’ character with Rie – a perceived ‘detractor’ of psychoanalysis (i.e. a doctor of physiological disease), whereas he experiences professional support from Fliess – who shared Freud’s beliefs in the hysterical or sexual basis for somatic illness. Whereas Freud’s interpretation focuses substantially upon his own feelings of guilt/anxiety about what he refers to as his ‘professional conscience’ and analyses the latent content as a form of wish fulfilment where he can be absolved for any blame regarding the real-life ‘Irma’ (assumed to be Emma in Griffin’s interpretation) and avenge himself; Griffin elects to analyse Freud’s dream in terms of a (metaphorical) accusatory finger being pointed at Fliess, yet without sufficiently deconstructing it within the expectation fulfilment paradigm. Freud interpreted his dream in terms of his own subconscious anxieties regarding two issues: professional conscience (as referred to above) and the health of himself and his loved ones. He analysed the latent content of “Irma’s Injection” as relating to the fulfilment of a wish that he be found blameless and thus, for Griffin to interpret the dream within the context of a ‘recognition’ of Fliess’ guilt in Emma’s ordeal – completely overrides any notion of Freud’s own personal anxiety (as expressed in Freud’s own interpretation, within which he associates imagery from the “Irma’s Injection” dream to several real-life incidents which had led him to question his professional judgment i.e. Matilda/his friend who died from cocaine poisoning – both incidents involving an injection) and repositions it upon Fliess - as represented by ‘Otto’ – which would be nonsensical, as this would suggest that what Freud perceived to be anxiety/fear regarding his own professional conscience (a rational explanation) was in actual fact (within Griffin’s interpretative framework) merely a recognition of his friend’s gross malpractice, with Freud’s anxiety regarding his own professional conscience being ignited by Otto’s remark that evening, but not becoming the main thematic focus of the dream itself. Freud saw his dream as a subconscious recognition of his own possible blame (due to the associations linked with the dream symbolism, discussed above) and the fulfilment that such blame be shouldered by others – which does not cancel out the fact that Fliess might indeed have been responsible for the real-life ‘Irma’s’ suffering; Griffin discounts Freud’s personal account of his ‘identified’ unconscious thoughts and how they manifested themselves in the dream content in order to reconceptualise ‘wish fulfilment’ as ‘expectation fulfilment’ without elucidating further on what expectation had been created and how the processes of arousal and de-arousal operate in relation to the particular dream content.

* Peter Gay’s interpretation
In his text, Freud: A Life for our Time (2006), Gay argues that the Irma character in the dream is certainly a composite of more than one person – most likely a merging of Emma Eckstein and Anna Hammerschlag, although this is not expressly confirmed in Freud’s own interpretation, rather alluded vaguely.

Gay argues that in fact ‘Irma’s Injection’, unbeknownst to both Fliess (for whom Freud expressed homosexual feelings – both he and Fliess of the belief that humans are bisexual by nature) and his wider audience, was actually a intricately constructed scenario, designed in part to rescue Freud’s idealised image of Fliess, in defiance of damning evidence. Fliess’ theory of ‘nasal reflex neurosis’ was criticised by commentators at the time and referred to as ‘the sexual nose’ theory and, as correspondence between he and Freud bears out, Fliess’ diagnosis and negligent operation upon Freud’s ‘hysterical’ patient, Emma and the disastrous consequences which followed provided material upon which an interpretation of ‘Irma’s Injection’ may be based.

 * Structural interpretations
Structural interpretations provide an alternative to psychoanalytic interpretation, focusing on the internal dialect of the dream – i.e. the movement from the initial premise to the resolution with an emphasis on the internal coherence and structured development of the dream narrative (in contrast to Freud’s piecemeal decoding of dream symbolism). Structural analysis of Freud’s “Irma’s Injection” dream suggest a movement away from an interpretation based on psychosexual fixations, arguing that the content of the dream appears to relate to Freud’s theoretical ideas – i.e. psychoanalysis itself.

* Theme polyphony
Academics such as Strunz (1990), claim that Freud’s interpretation of the “Irma’s Injection” dream provides an accurate picture of Freud's knowledge on transference and counter-transference in 1895 and informs us on a series of psychological problems of the dreamer himself: his feelings of guilt; his latent homosexual tendencies; his aggressiveness toward colleagues and women; as well as the state of his marital relation. A problem-solving interpretation of the “Irma’s Injection” dream reveals the still defective state of his new ‘talking cure’ as illustrated by the many therapeutic errors committed in the therapy of his patient Irma and the other incidents recounted by Freud in his dream analysis. The polyphony of themes that can be seen in the initial, or ‘specimen’ dream of the psychoanalytic theory, warns of monothematic interpretive proposals by therapists that are likely to be ill-understood or frankly rejected in favour of open-ended interpretations.

Other scholars, such as Sulloway (1980) and Lupton (1993) focus on Freud’s fascination with menstruation – a theme which can be connected to the ‘Irma’s Injection’ dream through the nasal references (i.e. nasal reflex neurosis; the physiology of the turbinal bones which swell during menstruation; and smell). Freud made several associations between menstruation and hysteria in various research papers, yet the subject of menstruation was absent from psychoanalytic theory.
In 1923, Freud underwent a series of operations to treat his cancer – which led to a ‘union’ between his nasal and oral cavities – the same affliction suffered by ‘Irma’ in his earlier dream. This has led to some academics questioning whether this supports the theory that dreams serve as an indicator of physical illness. I will post more on this theory later.

* The dream as a debate on psychoanalysis
“Irma’s Injection” can also be read as a debate on psychoanalytic theory - all the symptoms presented by Irma in the dream fall within the ambit of Fliess’ ‘nasal reflex neurosis’ and when Freud inspects Irma’s mouth (i.e. psychoanalysis ad the ‘talking cure’) he discovers the turbinal bones of her nose (Fliess’ alternative, physiology-based theory). On one level, “Irma’s Injection” is concerned with a theoretical debate between the two men over the nature of neurosis and perhaps also between them (as proponents of ‘subversive’ theories) and the rest of the medical community, from whom their unorthodox practices isolated them.

However, Freud looks in the mouth and also discovers the symbolic ‘vagina’ (turbinal bones/female genitals) -  behind the resistance (symbolised as the imagined false teeth; and the phrase ‘heard’ in the dream “despite her dress”). Furthermore, scholars have argued that a natural medical diagnosis of the white spots and the scabs would be syphilis, which Freud also hypothesised at one point as a cause of neurosis (note for example, the reference to a dirty syringe – i.e. an infected penis).The dream, on a deeper level, is conflating all such theories of neurosis, demonstrating that they lead to the same conclusion. The causes of neuroses which Freud correlates in his dream are all libidinally-charged – and it must be noted, originally identified by Freud in attempts to explain his own neurosis. Interpreted in terms of Freud’s real-life involvement in the treatment of Emma – which has been described as a gross act of intellectual violence against a woman, in defence of psychoanalysis and patriarchy - the dream might indeed reflect Freud’s anxieties and shame regarding intellectual rejection and professional failure.

By this interpretation, we may surmise that Irma’s disease-ridden body represents the body of psychoanalysis itself, subjected to interpretation and disagreement by doctors.

If the “Irma’s Injection” dream be taken as a archetypal revelation of psychoanalysis, revealing the whole programme of its consciousness (i.e. not simply an expression of the person Sigmund Freud), then the images portray a ‘preview’ of the psychoanalytic domain – it is the initial dream, or genetic blueprint, of the psychoanalytic movement and thus psychoanalysis would be an endless variation on the “Irma’s Injection” dream.

* Re-interpretation of the “Irma’s Injection” symbolism

Birthday celebration
In his associations to the dream, Freud stated that the reception is for the birthday of his wife. The creation myth starts out in a great hall where many figures are received to celebrate a day of birth - the day of birth of the spouse of  First Analyst, his feminine partner for life (psychoanalysis, Freud's spouse for life, in statu nascendi). As we witness the creation of psychoanalysis, the day of birth of the spouse, we meet the dramatis personae - the characters in this myth: Freud (First Analyst, Arch-analyst); Irma (Psyche-in-Analysis); and later, three other Doctor figures. Among them the drama of psychoanalysis is conceived.

The relatives
In the background of “Irma’s Injection” (visible only in the preamble to the dream), are Irma’s relatives who are described as the ones who don't approve of the treatment. The natural solution in which Psyche-in-Analysis exists, her close kin, resists analysis. Therefore, the initial movement  the First Analyst makes with Psyche-in-Analysis is one of separation ("Irma, whom I immediately take aside"). The exterior light First Analyst has shed on Psyche-in-Analysis ("I take her to the window") is resisted, not only by Psyche herself ("she offers some resistance to this"), but by her natural intimi as well. This illustrates Jung's image of the opus contra naturam.

Medical quaternion
The creation myth shows four patriarchal medical figures grouped around Psyche. Of course, there is First Analyst, who says in his associations to the dream: "It is as if I looked for each occasion to reproach myself for a lack of medical conscientiousness." Below, when we discuss the images of inferiority, we'll see why. Then there is Dr. M whom is described in the interpretation preamble as a figure of authority. This figure is Joseph Breuer, the authoritative voice in matters of pathology and prognosis ("There's no doubt that it's an infection...dysentery will follow and the poison will be eliminated"). In the case of psychoanalysis, however, this diagnostic and prognostic authority is limp and his chin shaven of the beard of virility. The authoritative judgment in analysis is weak, uneven, and not penetrating, lacking phallic dignity. Leopold is the conscientious, observant perspective, the one who looks carefully at the phenomena. He is the one attitude who, through careful observation of Psyche-in-Analysis, discovers the nature of the pain. Finally there is Otto, our healer who causes the iatrogenic disease. If we take the “Irma’s Injection” dream as the initiation dream or ‘creation myth’, then we must see how each of these four attitudes is active in our therapy with Psyche - the one who feels he's done something wrong; the one who limply diagnoses the matter and where it’s likely consequence; the one who carefully observes; and most of all our therapist, who makes Psyche sick. Each of them seems to be a necessary component in our drama.

Psyche Uncovered
"Leopold percusses her covered chest" (literally meaning that he examined her over the bodice of her dress). Of course, Freud lived in Victorian Vienna, but here we should disregard history and look at mythical image – corresponding to associations made by the unconscious mind. Two implications arise from Irma’s bodice - first, Psyche-in-Analysis is always under cover. We never see her unveiled;  she is a dance of endless veils. This ends the hope that we will see what is really going on and therefore we must sense it underneath the cover-up. Our language must cover what it tries to reveal and all clear descriptions as to the true nature of psychic reality are dubious; a bodice of myth is woven around Psyche. Second, there is material between Psyche and the First Analyst. The work of analysis goes through the material which is formed by the sexual taboo between Psyche and Analyst. This taboo is necessary since (as we will see below) the nature of their relationship is one of dirty sexuality. The taboo leads this pornographic-cross-over from the literal naked enactment to the vivid sexual imagination of the transference, most clearly described by Jung in Psychology of the Transference. This taboo on naked touch -  direct sexual contact in the creation myth - indicts against naked sexuality as therapy.

In the dream, Freud reproaches Irma for not yet accepting the "solution." When Oedipus (Freud's central hero), is asked a riddle by the Sphinx, he knows the solution, and knowing the solution to the riddle is the doorway to the incest. Riddle and solution belong to mother and incest. Psyche-in-Analysis does not accept the solution the First Analyst has found for the riddle of her illness and he fails to unlock her doors or lift her veil. It is the First Analyst who does not understand the meaning of the word ‘solution’ in the mysteries of Psyche. Mother poses riddles; Psyche is mysterious. For Psyche-in-Analysis ‘solution’ means turning into water, the stinking waters of dysenteric diarrhoea that will discharge what poisons her. In the chapter of Psychology of the Transference  entitled "Diving into the Bath",  Jung states: "this diving into the 'sea' means solutio. Dissolution in the physical sense and ... at the same time the solution to a problem. It is to be placed back into the dark initial state....This stinking water contains all in itself, of which it has need." With the problem of solutio we have re-entered the original Greek meaning of the word "analysis": the process of dissolution. Dissolution into stinking water; dysentery. And, as Jung stresses in the same paragraph, it is the waters from below that cause the process of dissolution. The waters from below rise and dissolve the fixed positions, the fixed boundaries; clear distinctions. This intimates that we are dealing, not with a distant and clean process of clear vision and detached treatment, but with a dirty one where the distinctions between Psyche and First Analyst dissolve. Both are drenched in the stench of stinking water, the experience of the low. Being dissolved in the feelings of lowly stench is the experience of the inferior. This feeling of inferiority is the experiential counterpart to the initiation from below.

Images of the inferior Analyst
In this section are collected those moments in our story of genesis in which First Analyst, or one of his colleagues, is shown as inferior. One of these images we already referred to: the limping, beardless Dr. M. As the authoritative analyst is not of strong posture and masculine beard, but limps, devoid of virile regalia (as a beard in 1895 would allude to), so the analytical authority is not firm and of masculine superiority, but drags its feet and is of inferior dignity. This image is repeated in the Freud’s  preamble, where he states: “The personal interest of the doctor is greater, his authority less." The First Analyst and Psyche-in-Analysis are intimate already before the onset of analysis. They are familiar to each other, calling each other du, before becoming the constituents of psychoanalysis. They are involved in a mixture of relationships, as in alchemy: a massa confusa. There is no clear single relationship but an unnerving mix-up and any attempt to remain disengaged and exclusively professional seems doomed from the outset. Personal involvement is intrinsic to analysis as there is no objective persona to hide behind. Between analyst and analysand there is not the relationship of the disinfected syringe administered detachedly by a white-coated doctor, but a dirty needle, laden with personal infection. Also, this mixture of relationships refers to the fact that there is an internal psychic relationship between Psyche and the First Analyst before any analysis takes place. Psychoanalysis is an intimate, familiar process that goes on constantly in the depth of soul as one of the archetypal processes. It is only socially formalised and structured by the literal psychoanalysis. It is this primordial psychoanalysis that forms the basis for literal psychoanalysis and it may therefore be important to establish in the beginning of literal, artificial analysis how the primordial analysis has been conducted in order to have a notion of which elements get mixed when primordial analysis and artificial analysis interpenetrate. In the preamble,  the First Analyst fears professional reproach for having promised too much. Psychoanalysis is related to the Promise - the archetypal intimation of a ‘better world to come’. Since it is the nature of the Promise never to be fulfilled, psychoanalysis is always a "partial success" ( see Freud’s preamble, where he states: "the treatment ended in a partial success. . . ."). Since the necessary relationship to the Promise is the failure to live up to it, there will be a constant, gnawing sense in the First Analyst of not living up to what was promised. This is the basis for the sense of charlatanism plaguing  the First Analyst: the con-man who promises more than he delivers.

Irma has been shown to coincide with or correspond to the victim of one of the most negligently conducted cases in the written history of psychotherapy. The following information is based on an article by Max Schur, Freud's personal physician and the correspondence between Freud and Fliess (March – April 1985). Freud bases his theory of the wish-fulfilment nature of dreams on his dream of “Irma’s Injection”.  He stated that the dream acquitted him of all wrong-doing, by blaming Otto, the doctor who had reproached Freud for promising too much. Otto gave the injection with the dirty needle, causing all of Irma's pain. From the letters written by Freud and Fliess, it is evident that Freud felt there was another reason why blame for Emma’s condition should be displaced onto ‘Otto’. Rie was the person who had uncovered Fliess' malpractice. Schur remarks that this episode also marks the beginning of the end of the powerful transference Freud had to Fliess. At this time, as can be seen very clearly in the correspondence, Freud was by no means consciously ready to blame Fliess for any wrongdoing, so the displacement of the guilt onto Otto has a double purpose - to disculpate both himself and Fliess. Freud stresses how helpless he felt during all this to the extent of a deterioration of his heart condition. The inferiority Freud experiences is thus ‘heartfelt’.

From Freud's personal perspective and from the wish-fulfilment aspects of the dream, which move the inferiority complex away from ego , his interpretation is clear. But what does this Emma story add to the mythical reading of the dream as creation myth of psychoanalysis? From this perspective the movement of the guilt from First Analyst to Colleague is not a displacement, but a further specification of the imagery surrounding  the First Analyst. Otto is Arch- analyst in his dark and dirty aspect. The added material also introduces a new figure: Fliess. The word ‘Fliess’ means ‘flow’  and Freud says that he "was overflowing with ideas and projects as long as [Fliess was] within reach." Fliess was Freud's ardently admired lover with whom he corresponded for years and then broke off completely. The intercourse of this love affair was nasal; they constantly treated and worried over the state of each other's noses which they both acknowledged as intimate sexual organs – note Freud’s concern for Fliess (suffering from rhinitis) in his analysis of “Irma’s Injection”.  Fliess is the healer who will cure the suffering of Irma by removing the fundamental cause of the disease, the nasal dysfunction. Thus the figure of Fliess embodies the elevated, magical healer at the source of the flow of ideation, who promises the simple cure through the removal of the sexual dysfunction, thereby leading Psyche-in-Analysis to a moment where "within half a minute she would have bled to death." It is this cherished healer aspect of Arch-analyst who leads Psyche-in-Analysis to her dreadful confrontation with death. The magical healer, the wellspring of ideas, makes Psyche suffer the proximity of death gruesomely while intending a simple erotic cure. He is an unconscious, dark Eros who loves to play with ideas and fantasise about causes and whose unconscious aim leads toward a betrayal of Psyche-in-Analysis that drains her toward death.

According to Freud’s preamble, Irma was suffering from "hysterical dread." Through information about the real-life Emma, we see how this hysterical dread is transformed into realistic dread in a process that looks like a sacrifice of Psyche-in-Analysis by the healer shadow of First Analyst. If we take the “Irma’s Injection” dream as an embodiment of psychoanalysis and a description of what psychoanalysis is, then the foundation of that profession is the tragic and the dark mission of our healer shadow - a necessary and repulsive element of the psychoanalytic drama. The ugly way down is led by an inferior figure and the unravelling of Psyche-in-Analysis is a violation all the way, like the murderous tale of Hades and Kore.

The Dirty Needle
One of the great dreams of modern medicine is that of sterility. The sterile, disinfected whiteness is able (through clean injections) to cure disease. In the initial  dream of psychoanalysis, the needle is dirty with inferior motives, personal involvement and infectious filth for which the cure is dysentery and diarrhoea.  Through feelings of inferiority, there is a dissolution to water – the treatment is a debacle. Inept surgeons are little more than ‘butchers of soul’ and the incompetence of the medical cure is seen to be sticking in Psyche's throat. The love of healing magic all but kills Psyche; and the  love of ideas leads, not to the missing piece of a puzzle, but to dissolute excretion. Our exalted purpose leads to the misery from below. The’ dirty needle’ is filled with trimethylamin – a chemical recognised by Freud to be a sexual stimulant. That is shown in the dream to be the italicized cause of the iatrogenic disease from which Psyche-in-Analysis suffers - she was penetrated by the unclean ‘Spritze’, which could also be translated as ‘squirter’. The Latin word for ‘unclean’ in the sense of unchaste is incastius from which we derive the word ‘incest’.  In order to stimulate her sexually, the dirty ‘squirt’ enters Psyche-in- Analysis incestuously and it is this violation and contamination which brings about both the iatrogenic disease and the cure - the dysenteric dissolution. Another aspect of the ‘dirty needle’ producing infection metaphor points to venereal disease. What is this incestuous, sexually stimulating, sickening process that leads to venereal infection and cure in psychoanalysis? It could be said to be a form of ‘transference’: the sick bond between First Analyst and Psyche-in-Analysis, sealed by the penetration of the dirty needle. Not a clean patient-doctor relationship, but a sickening, unchaste, highly personally involved and confused erotic bind - transference. It should be remembered that the first  ‘talking cure’, the case of Anna O (who incidentally coined the phrase following her treatment by Freud), ended in a hysterical (‘phantom’) pregnancy. Here again, it is the inferior venereal ministrations that pervade psychoanalysis throughout. This leads to an interpretation of Freud’s “Irma’s Injection” dream as a story of sickening love -  and the excreting lovesickness in the stench outpouring of toxins.

* Erotic impulses & sexuality in “Irma’s Injection”
It is commonly noted that, despite Freud’s psychoanalytic model which frequently linked dreams to  erotic impulses and sexual drives (and the fact that he referred to “Irma’s Injection” as the seminal dream of the psychoanalysis movement), he neglects to engage in an analysis of the sexual symbolism in the dream. Firstly, analogy can be undoubtedly drawn between the oral and vaginal cavities, leading some scholars, such as Murray Lionel Wax (1999) to conclude that the specks of white which Freud observes in Irma’s throat may symbolise semen. As Anna Hammerschlag was recently widowed – and it is evident that she and Freud were on familiar terms, as opposed to merely doctor and patient – it may not be implausible that the symbolism present in the “Irma’s Injection” dream hints towards sexual relations. Wax refers to Freud’s correspondence with Fliess which discussed trimethylamin and the biochemistry of sexuality and the fact that whilst ‘die Spritze’ may translate as ‘hypodermic syringe’ it is also an overt reference to the male phallus and ejaculation.

Wax takes his interpretation further – linking the concept of ‘die Spritze’ or the ‘dirty squirter’ or ‘syringe’ with the idea of fateful consequences of sexuality – in other words, unwanted pregnancy. At the time of Freud’s “Irma’s Injection” dream, Freud’s wife Martha was pregnant with their sixth child (Anna), having already suffered numerous health complaints as a result of child-bearing. There was also evidence that at this time, the Freud family were battling financial problems and slow progress in building a steady and profitable client base for Freud’s clinical practice. Wax suggests that Freud may have regretted initiating sexual intercourse with a (resistant?) spouse, which resulting in conception and thus “Irma’s Injection” represented his subconscious desire that “dysentery would follow and the poison eliminated”. This re-interpretation for the “Irma’s Injection” dream remains consistent with Freud’s ‘wish fulfilment’ paradigm and would account for his censoring of background material in his own analysis.

Wax suggests that, as a result of his communication with Fliess, on the subject of menstruation and sexual metabolism Freud may have timed the act of intercourse with Martha believing there to be no risk of conception. He further states that Oskar Rie, Freud’s family physician, may have visited Freud on the evening of his dream for the purposes of examining Martha, thus triggering the dream. Wax argues that ‘Irma’ was a compound figure, made up of several different women, ostensibly Anna Hammerschlag; Sophie Schwab-Panath; Mathilde Breuer; his daughter Mathilde Freud; the children being treated at the Kassowitz Clinic – and most notably, his wife, Martha Freud.
Sigmund & Martha Freud (1861-1951)
Wax does not rely on one interpretation of “Irma’s Injection”, instead arguing that a polyphony of multi-layered readings is possible (although cf. with Freud’s own view that there could only be one correct interpretation or meaning for a dream). He also argues that the “Irma’s Injection” dream may have projected Freud’s unconscious feelings of moral failure with regard to his friendship with Fliess. Freud’s feelings of guilt may also relate to his treatment of two real-life females in particular – Anna Hammerschlag and Martha Freud, and Wax questions whether “Irma’s Injection” may have been a communication of how these women felt about him and his conduct towards them – which Freud had not allowed himself to consciously acknowledge and confront. The dream may also be viewed as a reflection of Freud’s views regarding femininity generally (see below for a further version of this re-interpretation) – his impatience with and dismissal of female suffering, which he chose to class as ‘hysteria’ despite the presence of somatic symptoms (as in the case of Emma Eckstein).

* Homosexuality & misogyny in “Irma’s Injection”
David Lotto (2001) suggests that Freud’s dream of “Irma’s Injection” can be re-interpreted as symbolic of his struggles with homosexuality (his feelings towards Fliess); misogyny and guilt. He argues that the highly condensed dream element trimethylamin is central to the dream of “Irma's Injection” and following a  review of the medical literature on timethylamine (TMA), provides evidence in support of his thesis that two important meanings of this chemical and its properties lie in its disguised reference to disparaging views of women, as well as to Freud's homosexual connection to Fliess. Freud's misogynistic and homosexual impulses were stimulated by Fliess's recent surgical error committed while operating on Freud's patient Emma Eckstein. Evidence is presented that the collaboration between Freud and Fliess in performing an aggressive act toward a woman was for Freud an enactment of a childhood situation in which he and his nephew John had ganged up on John's sister Pauline. The later relationship between Freud, Jung, and Sabina Spielrein is seen as an additional re-enactment of this childhood triangle. An examination of Freud's associations to and analysis of the Irma dream, as well as some of his later relationships with women, indicates that guilt and the wish to make reparation were also prominent themes in Freud's inner life.

The notion of a ‘triangular’ or tripartite theme within the “Irma’s Injection” dream is central to many interpretations. Douglas Davis (1997) refers to this model as an ‘eternal triangle’ and states that throughout Freud’s life he experienced competitive feelings for a woman with whom he shared an intimate male friend. The resultant male-female-male triangles, typically brought Freud’s relationship with the other male into crisis. The prototype – as proposed by Freud himself - was Freud's infantile lust for his mother, which he perceived to be threatened when he was displaced from her breast by the birth of baby brother Julius, and eventuating in prototypical guilt when Julius seemed to succumb to Sigmund's hatred by dying (Krüll, 1986). The second instance, recovered by Freud in his analysis of the screen memory of playing in a meadow (Freud, 1899), involved his half-brother Emmanuel's children, John and Pauline Freud. In this memory the aggressive and sexual elements were merged, as three-year-old Sigmund and four-year-old John threw Pauline to the ground and took her dandelions – ‘deflowered’ her.  Thus, the Freudian triangle represented by Freud, Emma Eckstein (or ‘Irma’) and Fliess may be compared to those of Freud, his mother and Julius; Freud, Pauline and John; and further, Freud, Jung and Sabina Spielrein. It may therefore be argued that the act of sexually-charged violence against Pauline, by two males she trusted with her physical well-being (i.e. her uncle and brother) were mirrored by the act of misogynistic violence carried out upon Emma Eckstein by Freud and Fliess – as symbolised in “Irma’s Injection” – a dream reflecting the triangular nature of Freud’s inner conflict and his residual guilt regarding both Pauline and Emma. 

Indeed, the presence of an aggressive sexual element to the “Irma’s Injection” dream was also recognised by Stephen Frosh who states that on first appearance the dream appears to be about paradigmically masculine account of penetration and domination (and I add, contamination – or loss of purity).

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