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O Anna: Being Bertha Pappenheim – Historiography and Biography HISTORY HISTORY O Anna: being Bertha Pappenheim – historiography and biography Robert Kaplan Objective: To review the famous case of Anna O. (the index case of psy- choanalysis) as seen by each generation, in the light of current knowledge and thinking. Conclusions: The case was neither a catharsis nor a cure as described. Historical research has revealed a significantly different outcome, shedding new light on the motives of the chief protagonists, Breuer and Freud. No less interesting but greatly neglected is the life of Bertha Pappenheim, the real identity of Anna O. Key words: Anna O., Bertha Pappenheim, Breuer, Freud, psychoanalysis. ell over a century ago in fin-de-siècle Vienna, a 21-year-old woman had one of the strangest episodes known in medicine. W In the prim surroundings of a comfortable middle-class home, she shrieked, had visions of black snakes, spurned water, threw fits, shuddered in agony and cried. She developed a squint, disturbances in hearing and vision and prolonged absences. She became paralysed down one side and lost the ability to speak her native German, using English instead. Her personality oscillated between one living in the present and one living 365 days earlier. Her father fell ill with a subphrenic tubercular abscess while the family were staying at their holiday home in the spa of Isle (today Bad Isle). A surgeon attempted to drain the abscess; the illness ran a progressively relapsing course. The patient, who had a ‘passionate love for the father who pampered her’, nursed him at night. For the 2 months before he died, she was not allowed to see him and lied to about his condition. Consequently, his death came as a shock and she felt ‘robbed’. She fell ill herself. From December 1880 to June 1882, she was attended by Josef Breuer, the family physician. A dedicated physician and brilliant researcher, he discovered the role of the vagus nerve in breathing (Hering–Breuer reflex) and the semicircular canals in balance. Described by physicians in Vienna as ‘the doctor’s doctor’, he had a keen interest in the fashionable specialty of neuropathology. Breuer’s patient, the bright, charming and beloved daughter of a man she devotedly nursed till his death from tuberculosis, was a surprising candidate for an illness that continues to baffle, intrigue and raise March 2004 questions to each new generation of followers. The psychoanalytic historian Ellenberger described the story as ‘a unique case of which no other instance is known, either before or after her’.1 From these beginnings came psychoanalysis, Freud’s vision of the unconscious world. • Vol 12, No 1 Breuer described her personality, noting that ‘the sexual element was astonishingly undeveloped’. Despite early reservations and doubts – at Robert Kaplan one time, he wondered whether she had tuberculous meningitis – he Consultant Psychiatrist, The Liaison Clinic, Wollongong, NSW, diagnosed hysteria. Australia. Correspondence: Dr Robert Kaplan, The Liaison Clinic, Inexorably drawn into the case, Breuer spent 2 hours a day with his Wollongong, NSW 2500, Australia. patient. She in turn became dependent on his care and would invariably Email: [email protected] Australasian Psychiatry relapse when he was away for a few days. 62 At a loss, Breuer suggested hypnosis; intuitively, his reference to his tendency to dispense morphine to his patient took the lead. Each afternoon she fell into a patients.4 somnolent state; in the evening they did ‘chimney- To ensure anonymity – a dubious enterprise consider- sweeping’ sessions, discussing the symptoms of the ing the close-knit circles of middle-class Jewish day to make them disappear. She called this her Vienna – the patient’s name was given as Fraülein talking cure. Anna O. Treatment was brought to a close when she repro- Breuer’s case history was written from ‘incomplete duced a frightening hallucination of a black snake. notes’.4 In the discussion he used the term ‘repress’, After this, reported to have ‘regained her mental the first documented mention of the central tenet of health entirely’, she remained well. psychoanalysis.5 Breuer discussed the case on numerous occasions The book received a less than modest response. Freud, with his brilliant young protégé, Sigmund Freud. anticipating the legend of the prophet in the wilder- Freud had visited Jean-Martin Charcot (the ‘Napoleon ness, accused colleagues of being too timid to accept of neurologists’) in Paris. Establishing a school and his shocking findings. The truth was less exciting. inspiring a generation of neurologists, Charcot In the Vienna of Krafft-Ebing, sexual perversion was devoted the last years of his career to studying nothing new, nor the idea that neurosis stemmed hysteria, a condition he believed could be cured by from childhood abuse. hypnosis. Freud returned to Vienna singing the praises of his new mentor – and named his first son The drama of the case enveloped its protagonists. after him – convinced the cause of hysteria lay in While Breuer accepted there could be a sexual ele- hidden psychological trauma. ment in hysteria, he doubted whether this was the only cause. He cautioned Freud against being too Although his heart was in research, Freud had gone dogmatic but did not get a warm response. Freud into private practice as a neurologist to enable him to drew away and later rejected Breuer.6 In Freud’s view, finally marry his fiancé Martha Bernays. Freud did Breuer was not Faustian enough to accept the truth of not find private practice easy and it took a while to the daring hypothesis that became the leitmotif of get established. He saw a series of female patients psychoanalysis: that hysteria was caused by repressed with hysteria. He used the conventional cures of the sexual trauma. day: faradism (electrotherapy), warm baths, magnetic Freud began to gather around him the circle of cures, but had little success. In desperation, he tried disciples to launch the enterprise of psychoanalysis hypnotism. He was not a natural hypnotist, patients into the world. As psychoanalysis developed, the refused to go under and he began to eliminate the Anna O. case was read and re-read, repeatedly cited as rituals of the practice, getting them to talk about the a reference and recognized as the first case to be first thing on their mind. treated with psychoanalytic methods. Peter Gay From there, he had developed the ‘talking cure’, described it as ‘the founding case of psychoanalysis’.6 convinced the cause of hysteria lay deep in the Yet Anna O. was never destined to rest in a museum unconscious: the repressed memory of sexual abuse. for long. Freud discussed the undisclosed ending to But all this was to come later. the case with people around him, including Jung, the Freud collected four cases of hysteria and persuaded destined crown prince. At a conference in 1925, by a reluctant Breuer to write up the case that had made which time the two had gone their own way and he such an impact on him 12 years earlier; this became had few reasons to keep silent, Jung stated that the the centrepiece of their book Studies on Hysteria. case had been far from the success the authors Freud’s rush to get Studies on Hysteria into print in claimed and could by no means be regarded as a cure. Australasian Psychiatry 1895 was to ensure that Pierre Janet did not get In 1932 Freud told Stephan Zweig that Breuer had not credit for discovering the psychological treatment of brought the case to a successful conclusion as claimed hysteria.2 in the book. Some time after he ended his active involvement with her, he was called round to the Breuer had reservations about publishing the case. house, where Anna lay on the bed, writhing in pain. His commitment to the case played havoc with his ‘Now comes Dr B’s child’, she cried. Recognizing a • Vol 12, No 1 working and home life and he swore never again to pseudocyesis (hysterical pregnancy), Breuer hastily subject himself to such an ordeal.3 As subsequently hypnotized her to remove the symptoms and fled the became evident, the case had turned out far from house. He took his wife on a hastily arranged second successfully and the patient was admitted to a psychi- honeymoon to Venice, as a result of which his atric hospital where a significant amount of effort March 2004 daughter Dora was born. went into curing her of morphine and chloral hydrate addiction. This may have led to criticism from col- This story was emblematic: Breuer, lacking the steel leagues that his conduct was ‘less than exemplary’ – a of the true conquistador, blinked at the crucial 63 moment, refusing to recognize the erotic element in that Freud had picked up ideas that had been around the transference. Freud, by contrast, had held his gaze since ancient times. In the 18th century the rise of and had gone on to discover the truth at the basis of ‘magnetic cures’ rekindled interest in the uncon- psychoanalysis. scious, and further developments occurred after Charcot became interested in hypnosis. Almost The sniping did not end either. Freud, perhaps suffer- singlehandedly, Ellenberger resurrected the neglected ing from a guilty conscience, made reference in a career of Pierre Janet and showed that many of his footnote to a ‘reconstruction’ of a memory in which ideas preceded Freud. Breuer had confirmed the hysterical pregnancy, communicated by his daughter after he died. Freud’s Ellenberger had good reason to question the official ‘reconstruction’ was no more valid than any other version of the case, stating that Jones’ version ‘is recovered memory and has been firmly discounted by fraught with impossibilities … based on hearsay and researchers.7 should be considered with caution’.
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