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Epidural blood patch is a standard treatment for obstetric patients experiencing a severe post-dural puncture headache. Patients who sustained an accidental dural puncture during establishment of epidural analgesia during labour or at caesarean delivery were randomly assigned to receive a prophylactic epidural blood patch or conservative treatment with a therapeutic epidural blood patch if required. Eleven of 60 (18.3%) patients in the prophylactic epidural blood patch group developed a post-dural puncture headache compared with 39 of 49 (79.6%) in the therapeutic epidural blood patch group (p < 0.0001). A blood patch was performed in 36 (73.4%) of patients in the therapeutic group. The number of patients who needed a second blood patch did not differ significantly between the two groups: 6 (10.0%) for prophylactic epidural blood patch and 4 (11.1%) for therapeutic epidural blood patch. We conclude that prophylactic epidural blood patch is an effective method to reduce the development of post-dural puncture headache in obstetric patients., (© 2014 The Association of Anaesthetists of Great Britain and Ireland.)

The interpretation of certain dreams, as opposed to the direct examination of behavior, makes it possible to explore the conscience of the dreamer, detect hidden sources of guilt, and interpret them with less likelihood of arousing intractable resistance. Through the recovery of memories and the establishment of an intimate familiarity with one's personal history, it becomes possible to resolve problems of "neurotic" guilt, based ultimately on distortions of repressed childhood memories. The resolution of these conflicts allows a greater role for the operation of "appropriate" guilt, based on genuine transgressions, and the establishment of a more mature ethical structure.

Freud's insistence that "a dream is a (disguised) fulfillment of a (suppressed or repressed) wish" has come under attack repeatedly. This principle, while never widely accepted, was nevertheless expressed, explicitly or otherwise, in the works of Homer, Herodotus, Plato, and other writers of the classical world. A detailed account of a dream of Xenophon's is employed to illustrate the capacity of a psychologically naïve Athenian writer to reject anagogic interpretation in favor of a more soundly based understanding of his own dreams. This is followed with a discussion of "dreams from above," which are most likely to raise this particular issue, one of considerable clinical and theoretical importance.

Secondary revision is a highly provocative concept arising out of Freud's attempts to explain the construction of dreams, but it remains relatively ill-defined. It includes three related, yet by no means identical aspects of the process by which the dream acquires its more or less final form during the experiencing, the remembering, and the telling. It represents one of the most interesting hypotheses dealing with the fluid world between sleeping and waking, a field which still presents us with a host of unanswered questions. Secondary revision not only reflects the higher levels of the dreamer's mental functioning superimposed on his biological substructure, but it also operates as a sensitive indicator of the cultural factors which have helped mold his personality. These factors include both the subculture of the analytic situation and the impact of society in the larger sense. I make reference to individual dreamers in analysis and to the world of dreams recorded in the past from our own and other cultures.

When we make a decision to lecture, or to write for publication, we have begun an activity that will affect every one of our patients. If they attend our lectures, or read our published works, they cannot help being influenced. Even if they do not, they will have some reaction to the focusing of our interest on particular phases of the analysis. This will be true whether or not we intend to present clinical material. These considerations inevitably affect the analyst himself, sometimes inhibiting his writing altogether, sometimes constricting its scope, or worst of all, degrading its quality. The analyst's writing is also almost certain to influence whether and with what success his patient may choose to write. Lest these considerations suggest that we avoid writing altogether, I emphasize that such a sacrifice is by no means desirable or necessary. Problems of discretion will arise, and may in some cases be virtually insoluble; but there are ways of writing that can overcome most such objections. The analyst's interest in writing should be recognized and its effects, if any, brought into the analysis; so long as the writing itself is done with due regard to the conduct of the analysis and the welfare of the patient, it need have no adverse effects on either.

Irony is a more important element of analysis than we generally recognize. First, verbal irony characterizes the discourse of certain patients who employ it as a defense, both adaptively and as a resistance, especially against the expression of intense affect associated with the transference. The frequent employment of irony reflects a significant character trait, an habitual mode of dealing with conflict. It is also a frequent manifestation of a particularly active self-critical faculty. Ironic employment of a "double audience" is also relevant to analytic technique. Second, situational irony is inherent in many aspects of psychoanalysis, as a process and a point of view. It implies the acceptance of the inevitability of conflict, ambiguity and paradox, never quite capable of perfect resolution. It emphasizes critical examination of mixtures of motives of both analysand and analyst, and it requires perpetual questioning of what might otherwise be taken as accepted doctrine, including the principles of psychoanalysis per se. An ironic stance requires some degree of detachment in conjunction with deep commitment, itself an ironic circumstance. Third, the capacity to understand and employ irony can be traced to childhood, relatively early in the course of development of speech and sphincter control; some of its early determinants are to be found in the anal phase of psychosexual development; it reflects as well the capacity to use certain early defenses and mechanisms originally described as characteristic of the dream work. Its later fate as a prominent feature of character is very much a matter of ego and superego development, including such components as intelligence, verbal skills, the capacity for joking and for play, i.e., controlled regression. Sources of identification in the family and the culture are of obvious importance. Finally, an understanding of irony has an important place in the theory of technique, especially with regard to transference and resistance. An ironic stance and understanding on the part of the analyst are valuable, even essential; but irony may become a questionable defense for him as well as for his patient.

This study of analysts' writing consists of two parts. In the following paper, I describe the difficulties facing the practicing analyst who wishes to lecture and publish his findings and ideas, whether or not he intends to cite clinical examples. I make some suggestions directed toward overcoming those (largely internal) obstacles. In a second paper, I shall discuss a special problem, concern over how our lecturing or publishing affects the analytic progress of our patients, especially with respect to analysis of the transference.

It has been difficult to illustrate specific criteria for mental health, largely because of the lack of adequately documented examples. The Diary of Samuel Pepys is a unique soure of data about a man who was not only exceptionally interesting, but was relatively healthy as well.

Even those aspects of transference which initially favor the analytic process and seem to have the least connection with resistance do become integral parts of the transference neurosis and contribute massively to some of the most subtle difficulties in the process, especially in its resolution. These phenomena are, by their very appearance of rationality and cooperation, all the more difficult to bring under analytic scrutiny. They operate as resistances not only to the analysis of preoedipal conflicts, but even more effectively in the case of neurotic disorders centered on inadequate resolution of oedipal conflicts, i.e., in the so-called classical neurosis, "the case of the ideal analytic patient." I suggest, therefore, that the appearance of the "unobjectionable component" be regarded not only as a welcome manifestation of certain conflict-free psychic elements, but also as the manifest resultant of a complex web of unconscious conflicts which must be, and are capable of being, sought for and described. Further, that their analysis may be facilitated by the use of a process analogous to that employed in the analysis of dreams, particularly with respect to secondary revision. Finally, I have emphasized that these aspects of transference, which we are tempted to explain, and in effect dismiss, by reductionist references to early development, be regarded rather as the complex resultant of a prolonged historical experience, and that they be so interpreted.