Friday, August 9, 2019

The dream diagnosis Dr Freud missed

The most famous of all the dreams Freud analyzed was one of his own, the Irma Dream. In The Interpretation of Dreams he gives a lengthy account of this 1895 dream and his work with it. In the dream, he inspects the mouth of a patient called Irma and discusses her condition with several doctors.
     His work with this dream, by Freud’s own account, led him to invent psychoanalysis. He wanted a “marble tablet” to be placed at the house where he analyzed the Irma Dream, with the following inscription:

IN THIS HOUSE, ON JULY 24th, 1895,

 The tragic irony is that in all his work on this dream, Freud may have missed a health warning that could have saved his life. Dr. José Schavelzon, a cancer surgeon who is also a psychoanalyst has concluded, after careful review of Freud’s personal medical records, that the Irma Dream contained an amazingly exact preview of precise symptoms of the oral cancer that killed Freud 28 years later.
The night before the dream, Freud received a visit from a junior colleague, “Otto”, with whom he was in the habit of sitting up playing tarok (a card game related to Tarot) and smoking cigars. They discussed the case of “Irma”, whom Freud had been treating for hysteria. Freud was irritated when Otto reported, “She’s better, but not quite well.” He spent part of his evening writing up Irma’s case history.
He then dreamed that Irma arrived in a large hall where he was receiving guests. He immediately took her aside and told her. “If you still get pains, it’s really only your fault.” She was pale and puffy, and told Freud she was suffering dreadful pains, especially in her throat: “It’s choking me”. Freud was alarmed, and began to fear he had been missing “some organic trouble” in his approach. He took Irma to a window and peered into her mouth. He had a hard time getting it open because “she showed signs of recalcitrance, like women with artificial dentures.” When he got a good look inside, he found very disturbing symptoms – “a big white patch” inside the mouth on the right side, and also “extensive whitish grey scabs.” Freud gave an oddly specific description of these scabs; they reminded him of “the turbinal bones of the nose.”
He called for a second opinion on his patient. His senior colleague Dr. M. appeared looking pale and clean-shaven, repeated Freud’s examination, and gave a positive prognosis; there was certainly an “infection” but “the toxin will be eliminated.” Another medical colleague, Leopold, was less confident; he found infection had spread to the patient’s left shoulder and that there was “a dull area low down on the left.”
The dream scene became a medical gathering. Freud’s associate Otto was there too. All four doctors – including Freud himself – had no doubt of the origin of the patient’s illness. Otto had given her an injection of “a preparation of propyl, propyis…propionic acid…trimethylamin”. Freud saw the formula for the last chemical printed in heavy type, underscoring its importance. He concluded his dream report: “Injections of that sort ought not to be made so thoughtlessly…And probably the syringe had not been clean.”
In commenting on his dream, Freud began by noting that he had been thinking and writing about his patient the night before. Yet this left the content of dream totally mysterious to him, since his actual patient did not have symptoms anything like the ones that concerned him in the dream. “Constriction of the throat played scarcely any part in her illness. I wondered why I decided upon this choice of symptoms in the dream but could not think of any explanation at the moment.”
Freud wondered whether Irma, in his dream, was actually a stand-in for another patient, who had experiences of choking. Freud’s analysis wandered off through many other associations. When he pondered the names of the chemicals in his dream, he recalled a conversation in which a colleague suggested that trimethylamin might be an element in sexual arousal. This carried him away into “Freudian” thoughts about the probable source of hysteria in sexual frustration.
He wrapped up his interpretation of his Irma dream by declaring that it was a text-book example of wish fulfillment in dreams. He had been jarred the night before by Otto’s suggestion that his patient had not been fully cured. In his dream he got his “revenge” on Otto by establishing that her pains were Otto’s fault, not his own.
In all his discussion of “substitution” – how a dream character may stand in for another person, or several other people – he paused for only a heartbeat to consider the possibility that the real patient might be the dreamer himself. He wondered whether the “scabs” that resembled nasal structures could be a warning to him about the possible effects of his excessive use of cocaine – but moved briskly on from that thought without considering other substances and their possible effects.
Twenty-eight years after the Irma dream, Freud’s oral surgeons were looking at the precise symptoms he had dreamed – in Freud’s own mouth.
Early in 1923, a surgeon performed an excision of a cancerous growth resembling the “big white patch” on the right side of Irma’s mouth “at the right anterior palate.”
In a series of surgeries and treatments over the next fifteen years, Freud’s doctors worked to excise “proliferative papillary leukoplakia” inside his mouth resembling the unusual “scabs” in the 1885 dream. His many surgeries produced further scabs.
     In the Irma dream, the patient had difficulty opening her mouth. After Dr Pichler performed radical surgeries on Freud late in 1923, Freud - like the patient in his dream - had to wear "dentures", actually a removable prosthesis. Because Freud developed lockjaw during his multiple surgeries there was often difficulty inserting the prosthesis. Towards the end of his life, there were times when he “could not open his mouth.” 
     The reference to structures of the nose in the 1895 dream report may have been a preview of Freud's condition after surgery left the nasal cavity visible from the oral cavity.
     What about all the doctors who figure in the Irma dream? Stripped of their pseudonyms, they were medical colleagues who gave Freud differing advice on his smoking habit.  “Dr  M”, who gives a cheerful but wrong prognosis for the patient, was  actually Dr Joseph Breuer, a friend and mentor who was persuaded by Freud - despite misgivings - to drop his opposition to Freud's heavy cigar smoking.
   “Leopold” was a “slow but sure” medical colleague who had cautioned that smoking could contribute to serious diseases.
   “Otto” was Oskar Rie, a friend who shared Freud’s taste for cigars and may have brought him a gift of cigars the night before the dream.
    Whether Freud’s dream doctors represented aspects of himself – or their actual personalities and positions – their role in the dream held up a mirror to the dreamer’s behavior and attitude. Unfortunately, he was able to see in that glass only darkly.
   Freud thought the syringe (the German word also means “squirter”) was a penis and that the cure for the patient's symptoms was sexual intercourse. But a “dirty syringe” could also be a nicotine delivery system - one of the cigars Freud was almost certainly smoking the night before. All the chemicals named in the Irma Dream are found in cigar smoke. Though trimethylamin is not regarded as a carcinogen, when mixed with nitrites in an acidic environment (such as the smoker's mouth) it can be “nitrosated” into a very toxic carcinogen, dimethylnitrosamine (DMNA).
     The evidence suggests that Freud’s dream gave him a rather exact picture of both the origin and the histology of the oral cancer that subjected him to a painful and protracted death. Although Freud became interested in the idea that dreams can contain messages from the body, he missed this one - unlike Jung, who gave up smoking because of a dream.
     An important question for our understanding of the nature of diagnostic dreams is whether the Irma Dream may have contained a warning message from inside Freud’s cellular system, as it was at the time of the dream. In other words, could the Irma dream have been a “tumor marker”? It is possible that a single affected cell could trigger a dream, sending a distress signal out via neighboring cells, or via the endocrine system, that was shaped into a dream by the production company in the brain.
Freud may have paid an enormous penalty for forcing his own dreams to run along narrow-gauge rails of interpretation. Since the bigger story of the Irma Dream has such large resonance for dream interpretation, it seems appropriate that the pseudonym Freud chose for his patient means “universal”.
Somehow this tragic episode has escaped most of the legion of students and biographers of Freud. It suggests that Freud may have paid a terrible price for ignoring both the premonitory and the somatic aspects of dreams, and it offers a cautionary message for all of us as dreamers: let’s remember to check for diagnostic content in dreams.

Adapted from The Secret History of Dreaming by Robert Moss. Published by New World Library. All rights reserved.

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