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Since Freud's (1916) classic paper on the 'exceptions', and Jacobson's (1959) elaboration of it, detailed descriptions of clinical material from the analysis or analytic psychotherapy of individuals suffering from the results of congenital deformity have been taken almost entirely from the therapy of children or adolescents, whose subsequent development may be expected to show the influence of that treatment. None of the patients reported by Lussier (1960), Blos (1960) or Furman (1968) had defects affecting the function of internal organs, and to date there has been no published follow-up of the case of Monica (Engel & Reichsman, 1956), whose congenital oesophageal atresia and surgically created fistulae were repaired before she was two. Niederland's (1965) work on patients with early physical malformations was derived from a study of eight adult patients treated in analysis or analytic therapy, who had minor non-visible defects, important largely by virtue of the fact that they were kept secret. However, certain of his clinical observations are applicable to individuals with any form of congenital deformity, and can be illustrated by the following case.
In the first part of this paper, I shall describe the character and personality of a 29-year-old woman born with a congenital defect, and show how this defect was reflected in her adult psyche at all levels of consciousness. A discussion of her developmental history will concentrate on defining the role played by the congenital deformity in moulding her personality structure, and on the factors which mitigated its traumatic effects at various psychosexual stages.
The patient, who will be called Julie, was born with spina bifida in the lumbo-sacral region, accompanied by a sizable meningocoele which was not removed until she was in her early 20s, and which affected sphincter function throughout her formative years.1 Observations are based on material from 350 hours of essentially analytic treatment, extending over