The Collected Works of Sigmund Freud. Sigmund Freud
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statement: In the summer of 1895 I had psychoanalytically treated a young lady who stood in close friendship to me and those near to me. It is to be understood that such a complication of relations may be the source of manifold feelings for the physician, especially for the psychotherapist. The personal interest of the physician is greater, his authority is less. A failure threatens to undermine the friendship with the relatives of the patient. The cure ended with partial success, the patient got rid of her hysterical fear, but not of all her somatic symptoms. I was at that time not yet sure of the criteria marking the final settlement of a hysterical case, and expected her to accept a solution which did not seem acceptable to her. In this disagreement, we cut short the treatment on account of the summer season. One day a younger colleague, one of my best friends, who had visited the patient—Irma—and her family in their country resort, came to see me. I asked him how he found her, and received the answer: "She is better, but not altogether well." I realise that those words of my friend Otto, or the tone of voice in which they were spoken, made me angry. I thought I heard a reproach in the words, perhaps to the effect that I had promised the patient too much, and rightly or wrongly I traced Otto's supposed siding against me to the influence of the relatives of the patient, who, I assume, had never approved of my treatment. Moreover, my disagreeable impression did not become clear to me, nor did I give it expression. The very same evening, I wrote down the history of Irma's case, in order to hand it, as though for my justification, to Dr. M., a mutual friend, who was at that time a leading figure in our circle. During the night following this evening (perhaps rather in the morning) I had the following dream, which was registered immediately after waking:—
Dream of July 23–24, 1895
A great hall—many guests whom we are receiving—among them Irma, whom I immediately take aside, as though to answer her letter, to reproach her for not yet accepting the "solution." I say to her: "If you still have pains, it is really only your own fault." She answers: "If you only knew what pains I now have in the neck, stomach, and abdomen; I am drawn together." I am frightened and look at her. She looks pale and bloated; I think that after all I must be overlooking some organic affection. I take her to the window and look into her throat. She shows some resistance to this, like a woman who has a false set of teeth. I think anyway she does not need them. The mouth then really opens without difficulty and I find a large white spot to the right, and at another place I see extended grayish-white scabs attached to curious curling formations, which have obviously been formed like the turbinated bone—I quickly call Dr. M., who repeats the examination and confirms it.... Dr. M.'s looks are altogether unusual; he is very pale, limps, and has no beard on his chin.... My friend Otto is now also standing next to her, and my friend Leopold percusses her small body and says: "She has some dulness on the left below," and also calls attention to an infiltrated portion of the skin on the left shoulder (something which I feel as he does, in spite of the dress).... M. says: "No doubt it is an infection, but it does not matter; dysentery will develop too, and the poison will be excreted.... We also have immediate knowledge of the origin of the infection. My friend Otto has recently given her an injection with a propyl preparation when she felt ill, propyls.... Propionic acid... Trimethylamine (the formula of which I see printed before me in heavy type).... Such injections are not made so rashly.... Probably also the syringe was not clean.
This dream has an advantage over many others. It is at once clear with what events of the preceding day it is connected, and what subject it treats. The preliminary statement gives information on these points. The news about Irma's health which I have received from Otto, the history of the illness upon which I have written until late at night, have occupied my psychic activity even during sleep. In spite of all this, no one, who has read the preliminary report and has knowledge of the content of the dream, has been able to guess what the dream signifies. Nor do I myself know. I wonder about the morbid symptoms, of which Irma complains in the dream, for they are not the same ones for which I have treated her. I smile about the consultation with Dr. M. I smile at the nonsensical idea of an injection with propionic acid, and at the consolation attempted by Dr. M. Towards the end the dream seems more obscure and more terse than at the beginning. In order to learn the significance of all this, I am compelled to undertake a thorough analysis.
Analysis
The hall—many guests, whom we are receiving. We were living this summer at the Bellevue, in an isolated house on one of the hills which he close to the Kahlenberg. This house was once intended as a place of amusement, and on this account has unusually high, hall-like rooms. The dream also occurred at the Bellevue, a few days before the birthday of my wife. During the day, my wife had expressed the expectation that several friends, among them Irma, would come to us as guests for her birthday. My dream, then, anticipates this situation: It is the birthday of my wife, and many people, among them Irma, are received by us as guests in the great hall of the Bellevue.
I reproach Irma for not having accepted the solution. I say: "If you still have pains, it is your own fault."
I might have said this also, or did say it, while awake. At that time I had the opinion (recognised later to be incorrect) that my task was limited to informing patients of the hidden meaning of their symptoms. Whether they then accepted or did not accept the solution upon which success depended—for that I was not responsible. I am thankful to this error, which fortunately has now been overcome, for making life easier for me at a time when, with all my unavoidable ignorance, I was to produce successful cures. But I see in the speech which I make to Irma in the dream, that above all things I do not want to be to blame for the pains which she still feels. If it is Irma's own fault, it cannot be mine. Should the purpose of the dream be looked for in this quarter?
Irma's complaints; pains in the neck, abdomen, and stomach; she is drawn together. Pains in the stomach belonged to the symptom-complex of my patient, but they were not very prominent; she complained rather of sensations of nausea and disgust. Pains in the neck and abdomen and constriction of the throat hardly played a part in her case. I wonder why I decided upon this choice of symptoms, nor can I for the moment find the reason.
She looks pale and bloated. My patient was always ruddy. I suspect that another person is here being substituted for her.
I am frightened at the thought that I must have overlooked some organic affection. This, as the reader will readily believe, is a constant fear with the specialist, who sees neurotics almost exclusively, and who is accustomed to ascribe so many manifestations, which other physicians treat as organic, to hysteria. On the other hand, I am haunted by a faint doubt—I know not whence it comes—as to whether my fear is altogether honest. If Irma's pains are indeed of organic origin, I am not bound to cure them. My treatment, of course, removes only hysterical pains. It seems to me, in fact, that I wish to find an error in the diagnosis; in that case the reproach of being unsuccessful would be removed.
I take her to the window in order to look into her throat. She resists a little, like a woman who has false teeth. I think she does not need them anyway.
I had never had occasion to inspect Irma's aural cavity. The incident in the dream reminds me of an examination, made some time before, of a governess who at first gave an impression of youthful beauty, but who upon opening her mouth took certain measures for concealing her teeth. Other memories of medical examinations and of little secrets which are discovered by them, unpleasantly for both examiner and examined, connect themselves with this case. "She does not need them anyway," is at first perhaps a compliment for Irma; but I suspect a different meaning. In careful analysis one feels whether or not the "background thoughts" which are to be expected have been exhausted. The way in which Irma stands at the window suddenly reminds me of another experience. Irma possesses an intimate woman friend, of whom I think very highly. One evening on paying her a visit I found her in the position at the window reproduced in the dream, and her physician, the same Dr. M., declared that she had a diphtheritic membrane. The person of Dr. M. and the membrane return in the course of the dream. Now it occurs to me that during the last few months, I have been given every reason to suppose that this lady is also hysterical. Yes, Irma herself has betrayed this to me. But what do I know about her condition? Only the one thing, that like Irma she suffers from hysterical choking in dreams. Thus in the dream I have replaced my patient by her friend. Now I remember that