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?”