My recently completed PhD explored the illness experience of Freud’s patient Anna von Lieben, using a qualitative research methodology – Interpretative Phenomenological Analysis – to analyse her previously undiscovered autopathographical poetry. The analysis, supplemented by a reading of her husband’s diaries and other family documentation, indicated that the patient’s pathology was due primarily to a longstanding gynaecological condition, possibly endometriosis. The overall findings led to the identification of several new avenues of research which I would like to offer for the consideration of researchers in the field of Medical Humanities/Narrative Medicine. My proposals also draw on the work of Nezhat, Nezhat and Nezhat (2012)* who suggest that, throughout history, many of the women diagnosed with hysteria were in fact suffering from endometriosis, or something similar.
On this basis, I have formulated the following ideas:

• a study of ‘hysterical’ patients of the 19th century to identify and further explore those with gynaecological co-morbidities 
• a qualitative analysis comparing the lived experiences of 19th-century ‘hysterical’ patients manifesting gynaecological symptoms and those of present-day endometriosis sufferers  
• a historical investigation over several millennia designed to find evidence in support of the Nezhat theories.

A project based on any of the above might serve as a topic for doctoral or postdoctoral research. It might equally be possible to investigate all three suggestions for an interdisciplinary team-based project. It could also be of interest to language scholars, both modern and classical.
The amount of new primary material which I obtained from the von Lieben family archive would in itself be sufficient for a number of researchers. Added to this is the substantial bank of archival information which I have built up in the course of my own research. I would like therefore to offer the above ideas as a ‘provocation’ to stimulate further investigation. I will not be undertaking any more substantial academic activity myself, but I would be happy to act as a facilitator for others, putting my knowledge and resources at their disposal, and passing the baton on to the next generation of researchers.
My methods and findings are summarised in the Abstract of my doctoral thesis, In her own words: Exploring the subjectivity of Freud’s ‘teacher’ Anna von Lieben (see below). The thesis itself can be accessed at https://theses.gla.ac.uk/82795/
If you would like further information, or to engage in some exploratory discussion, please contact me at hilda.reilly@glasgow.ac.uk
*Nezhat, C., Nezhat, F., & Nezhat, C. (2012). Endometriosis: Ancient disease, ancient treatments. Fertility and Sterility, 98(6), 1-62.
 
ABSTRACT
This project is inspired by the work of Roy Porter (1985), who draws attention to the patient-shaped gap in medical history, and Rita Charon (2006), who emphasises the need to bring the patient’s narrative to the fore in the practice of medicine. The principal aim of the project was to devise a means of accessing the lived experience of a patient who is no longer alive in order to gain an understanding of her narrative.
Anna von Lieben was identified as a suitable subject as she wrote a substantial quantity of autopathographical poetry suitable for analysis and her status as Freud’s patient makes her a person of significant interest to the history of medicine.
The poems were analysed using Interpretative Phenomenological Analysis (IPA), an idiographic and inductive method of qualitative research, based on Heideggerian hermeneutic phenomenology, which explores the lived experience of individuals and is committed to understanding the first-person perspective from the third-person position.
The main findings from the IPA study reveal that Anna experienced a prolonged period of malaise, starting in late adolescence which she believed to result, at least partly, from a traumatic experience which occurred at that time. The analysis also indicates that Anna suffered from deep and lasting feelings of guilt and shame.
The discovery of a significant quantity of additional family documentation enabled me to contextualise and give added substance to the findings of the IPA study. The diaries which Anna’s husband kept throughout their marriage reveal that:

• she had a severe and longstanding gynaecological disorder
• she suffered from severe morphinism
• she did not benefit from Freud’s treatment which seemed neither to ease her symptoms nor identify any cause
• she was treated in Paris, not by Charcot as previously supposed, but by a French hydrotherapist, Theodore Keller, who appears to have become a person of considerable significance in her life.

The above findings led me to investigate Anna’s comorbidities (gynaecological disease and morphinism) and to show how those could be responsible for much of the symptomatology identified by Freud as ‘hysteria’. I then explore the possibility that her psychotic-like experiences could have been iatrogenically induced by her treatment first by Keller and then by Freud. Finally, I propose a fourfold set of hypotheses as an alternative to Freud’s diagnosis of hysteria.
The study overall presents a three-stranded account of the illness and treatment of one of Freud’s patients, combining the narratives of the patient herself, her husband, and Freud. As such, this study is likely to be the first of its kind.

Feminists are keen to claim Bertha Pappenheim as one of their own, and rightly so. She would be happy to consider herself such. After recovering from her illness she was active for the rest of her life in the field of women’s rights – a prolific feminist writer and polemicist, the founder of the League of Jewish Women, and a pioneering social worker, fighting against white slavery and founding a home for Jewish prostitutes and unmarried mothers. As well as all this she even found time to translate Mary Wollstonecraft’s A Vindication of the Rights of Woman into German and to write a play called Women’s Rights.

Perhaps she would not be so happy, though, with the lengths to which some feminists go in justifying their claim.

In Hysteria Beyond Freud, Elaine Showalter tells us that ‘In her hysterical seizures, Anna became unable to speak her native German, and instead spoke either Yiddish, which she called “the woman’s German,” or a jumble of English, Italian and French.’ While it is true that Bertha’s aphasic disturbances resulted in her being unable to speak German, resorting instead to English, Italian and French, nowhere in the case reports does Breuer mention her speaking Yiddish.

Showalter uses this claim about Bertha’s Yiddish to bolster up a feminist theory about ‘the repression of women’s language or its impossibility within patriarchal discourse’. She quotes psychoanalyst Juliet Mitchell who calls hysteria ‘"the daughter's disease," a syndrome of physical and linguistic protest against the social and symbolic laws of the Father’. Then, in an egregious example of post hoc, ergo propter hoc thinking, she states that in the case of Bertha Pappenheim ‘the connections between hysteria and feminism seemed particularly clear because after her analysis with Breuer in 1882, she went on to become a feminist’.

In Hysteria, Psychoanalysis, And Feminism: The Case Of Anna 0, Dianne Hunter expresses similar views. Although she makes no mention of Yiddish she still puts a feminist gloss on Bertha’s linguistic difficulties. Bertha, she says, refused to speak German because to do so would mean that she accepted ‘integration into a cultural identity [she] wished to reject’ and concludes that her hysteria was a ‘discourse of femininity addressed to patriarchal thought’. Hunter also reads a psychological significance into Bertha’ agrammatism, in particular the fact that she ceased for a while to conjugate verbs, using only infinitives or past participles which, she points out do not specify a person. She seems not to be aware that this is typical of people suffering from Broca’s agrammatic aphasia, often found in people suffering from strokes or other damage in the left cerebral hemisphere. The condition is characterised by, among other things, an inability to inflect verbs or to use subject pronouns.

Hunter goes on to analyse Breuer’s own use of language:  ‘Breuer refers to the pauses in Pap-penheim's speech by the French term absence.’ Not quite. Breuer was not referring to her aphasic symptoms when he used this term, but rather to the petit mal seizures which she experienced (although he did not recognise them as such). For Hunter, however, Breuer’s use of this term ‘suggests that for Breuer as well as for Pappenheim, the abnormal states of consciousness represented foreign parts of the self. Parts of Anna O were alien to signification in her native tongue.’

As for Bertha’s Yiddish, given that this would have been one of the languages with which she, as an Orthodox Jewish woman, must have been familiar, it’s perhaps of significance that she didn’t resort to it in her aphasia. But the explanation is more likely to lie in neural disturbances in the speech centres of her brain than in any kind of gender frustration.  

There is no record of Sigmund Freud ever having met Bertha Pappenheim, certainly not in a professional capacity. However, this has proved no obstacle to the common misapprehension that she was his patient. 

Often when I mention that I’ve written a book about Anna O, people will say something along the lines of: ‘Oh, yes, she was one of Freud’s patients, wasn’t she?’ This isn’t really surprising as she is so intimately connected with the history of psychoanalysis. In a sense, she was, as she is sometimes described, ‘Freud’s Anna O’. Her case is the foundation stone on which Freud started to build his theories; and without Freud, Bertha Pappenheim would be known only for her later success as a pioneering feminist and social worker. 

Some people may think that it doesn’t matter whether or not Freud was her doctor, in the same way that some people think that it doesn’t matter whether Shakespeare or someone else wrote his plays and sonnets. It matters very much, in fact, and this is why it’s surprising that the misconception about Anna O even extends to the psychotherapy community.

A cursory Google search threw up a few interesting items. 

A webpage titled Student Resources in Context has Bertha being treated by both Freud and Breuer simultaneously. In this version the collaboration starts with Breuer telling Freud about Bertha. It goes on to say that ‘during daily visits to Freud and Breuer, the doctors discovered that some of her symptoms were alleviated merely by discussing her memories and the feelings they created in her’. Finally, Freud alone is given credit for the cure with the claim that: ‘When Freud encouraged Anna O to recall a given situation and express the reaction she had earlier repressed, her symptoms vanished.’

Psychotherapist Humair Hashmi goes further. Anna O, he claims, began to express affection for Breuer and tried to put her arms round him. This so alarmed Breuer that he passed the case on to Freud. Nothing daunted, Freud, ‘the fearless pioneer that he was’, regarded this as a challenge and interpreted it as a manifestation of transference which could be used as a means of effecting a cure. Hashmi goes on to say:‘This is what Freud did in Anna’s case.’

An even more surprising misrepresentation is one I discovered when I came across a Wall Street Journal review of a show called Dr Freud’s Cabaret in which Freud takes to the boards with a number of his most famous patients. The show starts with an Anna O number called Chimney Sweeping (Bertha Pappenheim’s term for the talking she did with Breuer) and the review describes how ‘Anna O would hold Freud’s hand while she told him fairy stories and dark fantasies that helped alleviate her psychosis.’ Investigating this further I found that the idea for the show had germinated when the writer was readingStudies in Hysteria as research for a novel. So far so good, but the fact that she had done this research makes it even more puzzling that she could then flout the truth by portraying Anna O’s treatment as being with  Freud rather than with Breuer. Artistic licence, you might say. Perhaps. But what really takes the biscuit is that the show was put on at the Freud Museum in London which seems to have been quite comfortable with helping to perpetuate the myth that Freud was Anna O’s patient. It would all be so much neater if she had been, after all. The fact that she was not is possibly, for them, what Al Gore might term ‘an inconvenient truth’. 

Medical historian Roy Porter* draws attention to what he calls a 'patient-shaped gap' in the history of the case study, with accounts of illness being written invariably by doctors rather than patients. In discussing a research agenda to remedy this imbalance, he claims that ‘its real challenges lie in reconstructing patterns of consciousness and action’. For the historical novelist, this involves trying to think oneself into the mindset of the character. 

One of the cultural sources I turned to in trying to 'reconstruct the consciousness' of Bertha Pappenheim was The Girl's Own Paper, a magazine first published in 1880, the year in which Bertha's story began. Reading it brings one to the inescapable conclusion that the past is indeed a foreign country. I feel that I could more easily understand a present-day Zulu or Maori than any young 19th-century woman whose mind was formed by the principles governing those moralising texts.


Feminism was still only a speck on a distant horizon, at least as far the GOP was concerned. An article titled The Girls of Today, written by 'One of Them', while advocating a degree of working activity for women, concluded: '…. there is plenty of work to do, not only for our fathers and brothers but for us girls also. Out of this work we will select that which we can do best, whether it be nursing, teaching, book-keeping, mending, lamp-cleaning, dressmaking, or anything else. At the same time we will endeavour to hold fast by those attributes of modesty, gentleness and patience which belong to good women, and while we enrich the home with our earnings, we will try to be its sunlight and its ornament.' As for a career in journalism, anyone considering it was advised that the job might require her to be out and about late at night, which would not be seemly, and that she would need 'a bold mien' to work with male reporters 'on whose province she is encroaching'. As a final word of warning GOP cautioned that 'it is not an occupation that tends to the development of feminine graces.' On a more positive note, the newly invented typewriter was promoted as a solution to the problem of finding employment for ladies, it being 'peculiarly fitted for their nimble fingers'. 

Beauty, just as much as health, was considered to be a matter of mens sana in corpore sano. 'Health can make the plainest girl pleasant to behold, if her mind be pure and innocent,' exhorted Medicus in 1884. Readers were encouraged to believe that a good head of hair could be obtained by cultivating 'a calm and unruffled frame of mind'. A daily bath, 'as cold as can be borne', and exercise were judged ideal beauty aids. Powder and 'paint' were anathema, a sign of loose morals. 

Overall the texts were saturated with religiosity. An article titled What Shall We Do With Our Sundays? was accompanied by a poem by Yeats suggesting that the answer was church attendance: 'She prays for father, mother dear, To Him with thunder shod. She prays for every falling tear, In the holy church of God. 'Middle-class girls were encouraged to procure copies of 'the Holy Gospels' and other 'nice little books' and to leave them in appropriate places, such as under the seat cushion in a hired vehicle, where they could be found by 'the lower orders'. Acting was disapproved of. 'Once on the stage, those wishing to leave it and live religious lives find much prejudice from prospective employers.' The writer wasn't thinking of women wanting to enter a convent, but simply leading a life that wasn't immoral. 

Replies to readers' letters were tart and bracing. A reader with academic aspirations was advised: 'The subjects to be avoided, save in an elementary manner, are mathematics, and possibly science - certainly, however, the former.' A young woman enquiring about a career as a governess in 1884 was told: 'You seem to think that we keep a registry office. You are not sufficiently educated to take a place as nursery governess. You cannot write; and do not express yourself properly.' But this was nothing to the scolding doled out to a correspondent from Canada: 'This is the last notice that we shall take of your silly letters. Learn your lessons, read your Bible, and make and mend your own clothes and waste no more time in writing such rubbish.'

It's difficult to believe that only 130 years separates this kind of thing from the tweets of Paris Brown, the seventeen-year-old who has just had to resign from her police job after it was discovered that she had posted homophobic and racist rants and boasted about her binge drinking, drug taking and sex life on Twitter.  But then, much as I said at the beginning, I might find it easier to understand a Zulu or a Maori than Paris Brown. 

*Porter, Roy, ‘The Patient’s View: Doing Medical History from Below’, Theory and Society, 14 (March, 1985), 175-198