Freud — "The dream of Irma's injection"

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Emma’s condition had deteriorated, that there was a further highly dangerous haemorrhage, that these were "gloomy times, unbelievably gloomy ... the demoralization resulting from the obvious medical helplessness, and the whole air of danger", and that he was "really quite shaken that such a misfortune can have arisen from this operation, which was depicted as harmless."

On 20th April Freud replied to a letter from Fliess, telling him that his (Fliess’s) suggestion that they could have waited was completely impractical. Indeed, if the surgeon had sat around and waited, Emma would have “bled to death in half a minute”. However, he goes on to reassure Fliess that he remains for him "the prototype of the man in whose hands one confidently entrusts one’s life and that of one’s family".

These traumatic events occurred just some four months prior to the Irma dream of the night of 23rd July 1895. As we can see from his letters, these were profoundly anxious times for Freud. A patient was in danger of losing her life as a result of a mistake made by a surgeon he had recommended, who also happened to be (at that time) his closest friend. Freud's confidence was badly shaken.

Indeed, we may well suspect that it was because of these traumatic events that he was so sensitive to what he felt was an implied rebuke in his old friend Rie's remark about Irma'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 to his mind these traumatic events. In fact, as Schur noted when he published Freud’s letters to Fliess, there were many resemblances between the traumatic events recounted in the letters and Freud’s dream of 'Irma’s injection'. However, without the benefit of the theory Griffin has now put forward, he was, perhaps, unlikely to make the full structural comparison necessary to show that the dream of 'Irma's injection' is actually a precise analogical restatement of the traumatic events of Emma’s treatment. It is a re-enacted metaphorical scenario of those events, with Freud’s introspected views about Fliess’s blame made abundantly clear to everyone, including Fliess.

The setting for the dream is a party that was to be held the following day to celebrate his 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. In 1984 Jeffrey Masson produced evidence from a number of sources which identify Irma as Anna Hammerschlag, a young widow whose husband had died a year after their marriage, and who was the godmother of Freud’s daughter Anna.[2] She was briefly treated by Freud at this time. This manifest dream character of Irma-Anna was an analogical replacement for Emma Eckstein, as will become clear.

Both Irma-Anna and Emma were referred by Freud to Fliess for nasal examination. Fliess, as we have seen, 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 as "disgusting gobbledygook".[3] Nevertheless, Freud believed for several years that it was "a fundamental biological discovery".[4] After the operation, Fliess returned to Berlin. No doubt Freud was irritated, as in the dream, when even after the operation she still complained of somatic symptoms. 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 from Emma “resistance to irrigation”.

The throat in the dream is, of course, 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 goes on to tell us that, in the dream, his examination revealed “a big white patch” and “whitish grey 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 [Dr Gersuny], who said that access to the cavity was restricted and inserted a rubber tube to help drainage.

Freud notes that, in the dream, Dr M did not have his usual appearance but possessed the physical characteristics of Freud’s older 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 half brother – both of them, Freud tells us in his associations to the dream, had recently rejected a suggestion that he had put to them.

We are next told that Otto was standing beside the patient. Otto [Dr Oskar 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. We can see therefore, how, 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, we learn that 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. We can see that 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 and a piece of gauze was removed — an "infiltration" as it was a "foreign body" (the phrase Freud used in his letter) that should not have been left there from Fliess’s operation.

The next incident in the dream is that 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 half brother) is the analogical substitute for Dr G [Dr Gersuny] and, in real life, we again know from Freud’s own letter of 8th March to Fliess, that Dr Gersuny did 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. 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, of course, corresponds exactly to the sequence in real life. 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 letters to him), but the dream makes clear that, by the evening before 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 aware of Fliess’s professional incompetence. It would have been natural, on the evening before his dream, for Freud to have reviewed those events, and who was to blame, as he sat writing 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 and rancid odour'. Freud in his letter to Fliess described Emma's lesion as having a 'foetid' odour. Gauze left overly long in a wound, as medical friends have told us, gives rise to a 'particularly 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 abortive operation.

Freud's dream of 'Irma's injection' is, therefore, a metaphorical simulation of the traumatic events of the 'Emma affair', which must have been distressing for everyone involved, and in which everybody is metaphorically made aware of where the blame really lies — with Fliess. 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 affair'. This patient nearly lost her life after Freud referred her to his friend Fliess for surgery that was both unnecessary and unorthodox (to say the least). Just as he wrote up the case history of Irma [Anna] that night to make clear that he was not responsible for her continuing symptoms (as mentioned, he had referred her to Fliess too), so the dream also makes clear that it is Fliess and not he himself who was responsible for the mistreatment of Emma. (In fairness to Freud it should be noted that he had complete faith, at the time of his referral, in what he thought was Fliess's unrecognised genius and that his referral of patients to Fliess was done in good faith.)

Clearly, Freud's introspections about the nearly fatal case of Emma, as he wrote up his notes about Irma’s case for his mentor Dr Breuer, are metaphorically expressed in his dream exactly as Joe’s expectation fulfilment theory would predict.

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References
1] Schur, M. (1966) Some additional 'day residues' of the specimen dream of psychoanalysis. Lowenstein, R. M., Newman, L.M.,Schur, M. & Solnit A.J., (Eds.), Psychoanalysis: A General Psychology — Essays in Honour of Hartmann, H. International Universities Press, 45-85

2] Masson, J. M (1984) Freud: The Assalt on Truth. Faber & Faber

3] Ry, B. (1897) in a review of Fleiss's book, The Relationship between the Nose and the Female Sexual Organs, Published in Wiener Klinische Rundschau. Dr Benjamin Ry's words are quoted in a footnote in Masson's The Complete Letters of Sigmund Freud to Wilhelm Fleiss (see ref. 2 above)

4] Sulloway, F. J. (1979) Freud, Biologist of the Mind: Beyond the Psychoanalytic Legend. Andre Deutsch

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