Part 12

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 I have often trifled with the expectation that this lady might likewise engage me to relieve her of her symptoms. But even at the time I thought it improbable, for she is of a very shy nature. She resists, as the dream shows. Another explanation might be that she does not need it; in fact, until now she has shown herself strong enough to master her condition without outside help. Now only a few features remain, which I can assign neither to Irma nor to her friend: Pale, bloated, false teeth. The false teeth lead me to the governess; I now feel inclined to be satisfied with bad teeth. Then another person, to whom these features may allude, occurs to me. She is not my patient, and I do not wish her to be my patient, for I have noticed that she is not at her ease with me, and I do not consider her a docile patient. She is generally pale, and once, when she had a particularly good spell, she was bloated. I have thus compared my patient Irma with two others, who would likewise resist treatment. What can it mean that I have exchanged her for her friend in the dream? Perhaps that I wish to exchange her; either the other one arouses in me stronger sympathies or I have a higher opinion of her intelligence. For I consider Irma foolish because she does not accept my solution. The other one would be more sensible, and would thus be more likely to yield. The mouth then really opens without difficulty; she would tell more than Irma.

What I see in the throat; a white spot and scabby nostrils.

The white spot recalls diphtheria, and thus Irma’s friend, but besides this it recalls the grave illness of my eldest daughter two years before and all the anxiety of that unfortunate time. The scab on the nostrils reminds me of a concern about my own health. At that time I often used cocaine in order to suppress annoying swellings in the nose, and had heard a few days before that a lady patient who did likewise had contracted an extensive necrosis of the nasal mucous membrane. The recommendation of cocaine, which I had made in 1885, had also brought grave reproaches upon me. A dear friend, already dead in 1895, had hastened his end through the misuse of this remedy.

I quickly call Dr. M., who repeats the examination.

This would simply correspond to the position which M. occupied among us. But the word “quickly” is striking enough to demand a special explanation. It reminds me of a sad medical experience. By the continued prescription of a remedy (sulfonal) which was still at that time considered harmless, I had once caused the severe intoxication of a woman patient, and I had turned in great haste to an older, more experienced colleague for assistance. The fact that I really had this case in mind is confirmed by an accessory circumstance. The patient, who succumbed to the intoxication, bore the same name as my eldest daughter. I had never thought of this until now; now it seems to me almost like a retribution of fate—as though I ought to continue the replacement of the persons here in another sense; this Matilda for that Matilda; an eye for an eye, a tooth for a tooth. It is as though I were seeking every opportunity to reproach myself with lack of medical conscientiousness.

Dr. M. is pale, without a beard on his chin, and he limps.

Of this so much is correct, that his unhealthy appearance often awakens the concern of his friends. The other two characteristics must belong to another person. A brother living abroad occurs to me, who wears his chin clean-shaven, and to whom, if I remember aright, M. of the dream on the whole bears some resemblance. About him the news arrived some days before that he was lame on account of an arthritic disease in the hip. There must be a reason why I fuse the two persons into one in the dream. I remember that in fact I was on bad terms with both of them for similar reasons. Both of them had rejected a certain proposal which I had recently made to them.

My friend Otto is now standing next to the sick woman, and my friend Leopold examines her and calls attention to a dulness on the left below.

My friend Leopold is also a physician, a relative of Otto. Since the two practise the same specialty, fate has made them competitors, who are continually being compared with each other. Both of them assisted me for years, while I was still directing a public dispensary for nervous children. Scenes like the one reproduced in the dream have often taken place there. While I was debating with Otto about the diagnosis of a case, Leopold had examined the child anew and had made an unexpected contribution towards the decision. For there was a difference of character between the two similar to that between Inspector Brassig and his friend Charles. The one was distinguished for his brightness, the other was slow, thoughtful, but thorough. If I contrast Otto and the careful Leopold in the dream, I do it, apparently, in order to extol Leopold. It is a comparison similar to the one above between the disobedient patient Irma and her friend who is thought to be more sensible. I now become aware of one of the tracks along which the thought association of the dream progresses; from the sick child to the children’s asylum. The dulness to the left, below, recalls a certain case corresponding to it, in every detail in which Leopold astonished me by his thoroughness. Besides this, I have a notion of something like a metastatic affection, but it might rather be a reference to the lady patient whom I should like to have instead of Irma. For this lady, as far as I can gather, resembles a woman suffering from tuberculosis.

An infiltrated portion of skin on the left shoulder.

I see at once that this is my own rheumatism of the shoulder, which I always feel when I have remained awake until late at night. The turn of phrase in the dream also sounds ambiguous; something which I feel ... in spite of the dress. “Feel on my own body” is intended. Moreover, I am struck with the unusual sound of the term “infiltrated portion of skin.” “An infiltration behind on the upper left” is what we are accustomed to; this would refer to the lung, and thus again to tuberculosis patients.

In spite of the dress.

This, to be sure, is only an interpolation. We, of course, examine the children in the clinic undressed; it is some sort of contradiction to the manner in which grown-up female patients must be examined. The story used to be told of a prominent clinician that he always examined his patients physically only through the clothes. The rest is obscure to me; I have, frankly, no inclination to follow the matter further.

Dr. M. says: “It is an infection, but it does not matter. Dysentery will develop, and the poison will he excreted.”

This at first seems ridiculous to me; still it must be carefully analysed like everything else. Observed more closely, it seems, however, to have a kind of meaning. What I had found in the patient was local diphtheritis. I remember the discussion about diphtheritis and diphtheria at the time of my daughter’s illness. The latter is the general infection which proceeds from local diphtheritis. Leopold proves the existence of such general infection by means of the dulness, which thus suggests a metastatic lesion. I believe, however, that just this kind of metastasis does not occur in the case of diphtheria. It rather recalls pyæmia.

It does not matter, is a consolation. I believe it fits in as follows: The last part of the dream has yielded a content to the effect that the pains of the patient are the result of a serious organic affection. I begin to suspect that with this I am only trying to shift the blame from myself. Psychic treatment cannot be held responsible for the continued presence of diphtheritic affection. But now, in turn, I am disturbed at inventing such serious suffering for Irma for the sole purpose of exculpating myself. It seems cruel. I need (accordingly) the assurance that the result will be happy, and it does not seem ill-advised that I should put the words of consolation into the mouth of Dr. M. But here I consider myself superior to the dream, a fact which needs explanation.

But why is this consolation so nonsensical?

Dysentery:

Some sort of far-fetched theoretical notion that pathological material may be removed through the intestines. Am I in this way trying to make fun of Dr. M.’s great store of far-fetched explanations, his habit of finding curious pathological relationships? Dysentery suggests something else. A few months ago I had in charge a young man suffering from remarkable pains during evacuation of the bowels, a case which colleagues had treated as “anæmia with malnutrition.” I realised that it was a question of hysteria; I was unwilling to use my psychotherapy on him, and sent him off on a sea voyage. Now a few days before I had received a despairing letter from him from Egypt, saying that while there he had suffered a new attack, which the physician had declared to be dysentery. I suspect, indeed, that the diagnosis was only an error of my ignorant colleague, who allows hysteria to make a fool of him; but still I cannot avoid reproaching myself for putting the invalid in a position where he might contract an organic affection of the bowels in addition to his hysteria. Furthermore, dysentery sounds like diphtheria, a word which does not occur in the dream.

Indeed it must be that, with the consoling prognosis: “Dysentery will develop, &c.,” I am making fun of Dr. M., for I recollect that years ago he once jokingly told a very similar story of another colleague. He had been called to consult with this colleague in the case of a woman who was very seriously ill and had felt obliged to confront the other physician, who seemed very hopeful, with the fact that he found albumen in the patient’s urine. The colleague, however, did not let this worry him, but answered calmly: “That does not matter, doctor; the albumen will without doubt be excreted.” Thus I can no longer doubt that derision for those colleagues who are ignorant of hysteria is contained in this part of the dream. As though in confirmation, this question now arises in my mind: “Does Dr. M. know that the symptoms of his patient, of our friend Irma, which give cause for fearing tuberculosis, are also based on hysteria? Has he recognised this hysteria, or has he stupidly ignored it?”

But what can be my motive in treating this friend so badly? This is very simple: Dr. M. agrees with my solution as little as Irma herself. I have thus already in this dream taken revenge on two persons, on Irma in the words, “If you still have pains, it is your own fault,” and on Dr. M. in the wording of the nonsensical consolation which has been put into his mouth.

We have immediate knowledge of the origin of the infection.

This immediate knowledge in the dream is very remarkable. Just before we did not know it, since the infection was first demonstrated by Leopold.

My friend Otto has recently given her an injection when she felt ill.

Otto had actually related that in the short time of his visit to Irma’s family, he had been called to a neighbouring hotel in order to give an injection to some one who fell suddenly ill. Injections again recall the unfortunate friend who has poisoned himself with cocaine. I had recommended the remedy to him merely for internal use during the withdrawal of morphine, but he once gave himself injections of cocaine.