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Vera's deliria followed a toxic infection. But for this circumstance it seems justifiable to assume that there would have been no psychosis. She had adapted herself successfully to the ordinary conditions of life, and had moreover taken a university degree.

In conjunction with the toxic infection, however, there were earlier predisposing factors. Her health seems to have been weakened by earlier repressions. Since the resistances to which I attribute the fact that much of her libido remained unconscious or 'inaccessible' have been broken down during analysis, many environmental handicaps have been destroyed, thus lessening her susceptibility to future disturbances. Before proceeding to the analysis of the deliria a brief outline of the nature of three alternating phases of personality is necessary.

Vera's adolescence will first be considered. Certain partial dissociations found to be present during adolescence will be traced through analysis, to infancy. Lastly the mental synthesis eventually made will be briefly sketched.

Vera's personality at the age of 17, as it appeared to someone else, is suggested by a passage written by K. in 1914, two years later.

He writes that Vera is different from any other girl he has ever known, because in her there seem to meet two apparently irreconcilable elements-the eternal feminine love and wonder of woman, with the clear thinking coolness supposed to be man's great adjunct, and that Vera seems to have this and the feminine nature both unspoilt....On the third side Vera appeared to K. as one of nature's own wild things.

Allowing for the over-valuation apparent in this passage, it remains clear that to an outside observer there appeared to be a partial dissociation into three incompatible trends of character. This division was accepted by Vera, who also accepted the names 'Lilith' and 'Eve' given by K. to two of them.

Lilith represented the clear thinking side of Vera's personality which came to be regarded as the 'male' side, known as 'B' for purposes of analysis. It co-existed with the womanly side Eve, known as 'A.' The third side 'C' simply burst its way up to consciousness from time to time, sweeping all before it in the sheer irresponsible joy of living. In 1913 Vera writes in her diary mentioning her 'dual' personality, but referring to all three phases. She speaks of herself as Lilith, thus accepting that phase as the dominant one:

"For some time past I have been steadily casting my dredger into Lilith's heart, but I have not sounded it completely yet. Her curious dual personality baffles me. The person who suffers so much (4) seems. almost a totally different being from the one who experiences such a joy in living (C) and again the person whom the world at large sees, is a rather phlegmatic commonplace girl (B)....I think her real personality is pretty well masked, and I think it is as well, though sometimes it is hard to find which is her and which is what you might expect her to be."

Two years later her diary again refers to the three irreconcilables, but by that time C has to some extent replaced B as dominating her attitude, as is shown by the following quotation:

"I am quite mad, I believe, yet would not be different. In some things I am a woman, a woman who wishes in all things to be true to her sex, to be a womanly woman. In others I am a wild tomboy, doing things against my woman's nature, shocking and outraging it, yet rejoicing1. There are two irreconcilable parts in me, each is real and sincere, and they alternate rapidly, and I would not give up either. It would not be me if I were tamed as one man suggested I needed. Tamed! no, by Jove, imagine a meek and mild colourless image supposed to be me. I'm too much alive to be tamed as he meant it...I want to remain wild, I would not give up my love for, and enjoyment of, the clean simple things of nature for anything. I would not be sober and sedate. Yet I want learning, I want to study, to prove I can do as well as a man, to do a man's work. Yet too, more than anything, I want to be a woman, and a woman wants love...a man to love and be loved by, to care for and by whom to be cared for; and most of all I want a little child. How reconcile these three parts? I don't know. They all exist, yet which will in the end swallow up the other two. I do not know. Yet I'm not ill content as I am. Their continual clashing affords some interest even to myself."

In these notes Vera shows that she realises the impossibility of developing all three sides adequately, feeling she can be any of them, but not all at once, and that some day one will 'swallow up' the others. In the following notes she indicates that she does not know which it will be.

"I am perfectly sincere in what I say and do at any particular time, the difficulty is there are so many different sides to my character that I lay myself open to the charge of being fickle, since one part of me thinks one thing and another part the opposite, and what I say depends on which part predominates at any instant. My head and my heart, colloquially speaking, are in continual conflict and being fairly well 1 Cp. this with Sally in the Beauchamp case, described by Morton Prince in The Dissociation of a Personality.

Med. Psych. IV


matched, the struggle is often a keen one. In other words my reason and my feminine feelings or emotions are always at loggerheads. I have no idea which will eventually come out top dog. I suppose it depends on a man. It is hateful to think so, but I do. If I meet someone I think is the exception that proves the rule, I believe I'm fool enough to throw all reason to the winds and in spite of my ravings against men, marry him."

All through Vera's diary the same recognition of conflicting systems, and the acceptance of all as herself, coupled with ignorance as to which will dominate at any time is shown. In 1915, however, the third party of the trio was more explicitly recognised than it had been in 1913.

In 1914, the time of acutest conflict, a 'nervous breakdown' had occurred. Owing to the fact that the male' intellectual B was the dominant partner of the trio until then, the libido stimulated by K. was repressed as incompatible with B's outlook. I attribute the breakdown to this reinforcement of dissociated libido. So complete was the dissociation of the physical aspect of love that only the psychical was experienced in connection with K., though, as will be shown later, the repressed physical aspect expressed itself in the delirium of 1919. The conflict in 1914 produced nervous disorders, which seem to me to be the result of tying up so much mental energy. After the breakdown, which was then attributed to overstudy, the intellectual side was suppressed for a time. Vera determined to develop 'Eve' rather than 'Lilith' for some time to come. This, however, led to the predominance of C later on, owing, so far as I can see, to Vera passing through an agnostic stage, which led to a partial repression of Eve as well as Lilith, and to the fact that the sexual nature of C was less known to Vera then.

Health was gradually recovered after this breakdown as the feminine, pleasure loving, emotional side became more stably organised. During the years 1918-19 it seemed as if Lilith's long suppression (1914–18) had brought her to an end. She showed no signs of life, the conflict seemed to be over in favour of C. Nevertheless B was only dissociated, not destroyed, as her later resurrection demonstrated.

Thus when in 1919, disease and drugs together caused a toxic disturbance of the central nervous system, there was already conflict and dissociation sufficient to bring about much more severe mental disturbances. The ten dissociated pseudo-personalities which appeared in the delirium knew nothing of each other. They are believed to be the result of ego-regression of the three main synthesis A, B, and C respectively, with projections from different libido levels. The delirious progression from the feminine, pleasure loving ego, through the 'male'

intellectual ego, to the womanly one which was felt to be her real self, brought about a more complete readjustment, a more stable balance, than when either male B or female C had been on top. On tracing these out analytically, it was found that the dissociation into B and C had occurred quite definitely at the age of two. B was an introvert, C an extravert. A, the main personality, combined some of the characteristics of both B and C, possibly through co-existing in consciousness with each alternately. It also seemed as if when B was in consciousness, C developed unconsciously, and vice versa. What appears to be a split between introvert and extravert had occurred, so that each went its own way independently, but could not gain control of the whole organism on account of the other. A reversal of the unstable equilibrium was invariably brought about by external circumstances. Only after the delirium, when A reappeared with more of C in her than before, owing to the long spell C had had in control, was more stable equilibrium established. The complete synthesis, however, only occurred later through analysis. A finally combined B and C in a working unity.

Development of the Dissociation

As a result of analysis dealing with the earlier years of Vera's life it seems as if at the age of two, self-assertion, acquisition and curiosity combined with infantile clitoris libido (auto-erotic) in the formation of the wish to be a man, and that this clitoris libido retained its more active masculine characteristics even when detached from the physical plane through sublimation. For a year this wish expressed itself in dreams and phantasies which became progressively more elaborate. Then Vera contracted pneumonia, during which time the birth of a brother occurred, and after which the memory of the wish to be a man was forgotten and was replaced by the wish to have a baby of her own. Though the maternal instinct developed in consciousness, the results of analysis support the belief that the repressed wish remained dynamic in the unconscious, forming the nucleus of the male introvert B. Further that at the same time that the wish to be a man developed in consciousness, the tender emotion focussed on the father became associated with the sexual libido and was repressed. Presumably this libido formed the mainspring of C, the extravert side, in which heterosexual feeling predominated.

At the same time the third side A was developing psychically. Apparently libido and interest alike were drawn off from the ego through love and interaction with the environment, and were sublimated or

'socialised' by acting through the channels of the herd instincts1, incompatible components being repressed. In A both self-abasement and self-assertion seem to have combined in the self-regarding sentiment forming the basis of the more stable personality. The self was recognised as in relation with others, chiefly the parents. The instinct of curiosity was found to have played a large part in this synthesis, together with the psychical aspect of love or tender emotion which was the forerunner of the maternal libido. The sexual aspect, owing to its association with the physical expression, had been repressed and thus dissociated.

At the age of three, the maternal libido was strongly developed through the birth of a brother, and apparently sufficiently so to cause the repression of the wish to be a man. The wish to have a baby of her own, recognised as a woman's prerogative, proving stronger, the incompatible wish was forced into the unconscious. There it appears to have developed out of touch with reality. A held the field temporarily, B and C being repressed, but independently.

In A the constructive instinct was closely associated with the maternal libido. The emphasis was on the conational side of the mode of reaction typical of 4. Pleasure lay in doing. In B pleasure lay in thinking, the cognitive aspect being most developed, whereas in C the pleasure lay in being, the affective aspect predominating. Very soon the forces which had synthesised to form B were too strong to be repressed. The wish to be a man did not reach consciousness in its earliest physical form, but the active intellectual introvert tendency had to find expression through sublimation.

By the age of five, Vera had developed enough to be able to read the New Testament. Keen pleasure was taken in reading and in being read to. The world of thought was already becoming important, and most of the simple Bible stories were familiar. The self-regarding sentiment was being built up in A as a self in relation to God, whose loving presence was very real to A-B. This possibly prevented the complete introversion that B alone would have developed. Pleasure in reading grew and in it sympathy and admiration were always for the man. The reader

1 I have suggested the use of the term altroversion for the socialisation of either the introverted or the extraverted types, which gives rise to a social self, with balance between the self and the environment, neither being over-estimated as in introversion or extraversion. The personality which thus combines introvert and extravert reactions in a working unity, synthesising interest and libido in a well balanced sentiment, can be conveniently called an 'altrovert' in the same way that the personality resulting from a onesided synthesis of interest and libido, with over emphasis on ego and object respectively, is called an introvert or an extravert.

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