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

"Hysterical a[phasia]…. is characterized by its completeness or, rather, by its absolute character. It is not that the patients are restricted to the use of individual words, but that they are completely speechless, indeed voiceless; not a sound, not a cry comes about."
        Sigmund Freud, Aphasie 1888

In my post of 5 March I quoted Josef Breuer's description of Bertha's aphasia. It was of a complex nature and varied over the course of her illness, ranging from the typical telegrammatic speech of Broca's aphasia to the complete loss of her mother tongue, at which stage she could only express herself in other languages, mainly English. How then, in view of Freud's already published view about hysterical aphasia, could he and Breuer be subscribing to the idea that her aphasia was hysterically induced?

Freud was clearly enchanted by his own theories about hysteria, so much so that it seems almost to have constituted a default diagnosis for him. Once convinced that a patient suffered from hysteria nothing would budge him from that conclusion.

In the case of Frau Emmy von N (the second of the cases reported in Studies on Hysteria) the patient displayed, in addition to depression and insomnia, a set of symptoms which would nowadays be recognised as associated with Tourette's syndrome: random interjections and clacking sounds, agitated finger movements, convulsive facial tics and neck spasms. Freud, treating her with the cathartic method developed in discussion with Breuer, elicited from his patient a number of traumatic childhood memories, after which, he claimed, her vocal tics 'were strikingly improved' although they 'were not completely relieved'. This limited success turned out to be 'not a lasting one'.

There is nothing surprising in this. Tourette's symptoms are known to wax and wane, quite independently of any treatment.What is surprising is that Freud didn't even consider the possibility of a neurological cause as he had known Gilles de Tourette while working with Charcot in Paris, at the very time when de la Tourette first published a paper on the disorder which was to bear his name.

A later, and much more serious, misdiagnosis was made in the case of a fourteen-year-old girl, known only as M-l, who suffered from abdominal pains. Freud diagnosed her as an 'unmistakable' case of hysteria, which he claimed cleared up 'quickly and radically' under his care. The girl died two months later of sarcoma of the abdominal glands.

Freud was still loath to relinquish the hysteria diagnosis. The girl had indeed been a hysteric, he maintained. The hysteria, instead of creating its own symptoms, had simply appropriated for itself the existing pains produced by the sarcoma.

This 'mixed aetiology' explanation has served on other occasions as a get-out clause in the history of hysteria. We see it too in the above case of Frau Emmy von N. Finding that the neck spasms were continuing unabated Freud declared that they did not form part of the hysterical picture but were a form of migraine, therefore of organic origin and not susceptible to the cathartic treatment.

It's difficult to see how the mixed-aetiology explanation could be applied to solve the question I started this post with but given Freud's belief in his ability to wriggle Houdini-like out of any diagnostic bind he found himself in he would surely have come up with some rationale. 

"Mrs Pappenheim stopped in the doorway. She saw Bertha’s features crease into fretful petulance, her finger pointing to the untouched breakfast tray lying beside the bed.
‘No voglio petit-déjeuner. Enleve. Tired. Voglio dormir. Ne dors pas noche. Je veux dormir adesso.’
Italian, French, English. Bertha knew all those languages. But why should she want to start speaking them now? And why jumble them all together like this? Mrs Pappenheim clenched her hands and stepped further into the room. ‘Bertha, what’s all this nonsense? Speak German, please.’
‘I am speaking German,’ Bertha said in English. She closed her eyes."
    From Guises of Desire by Hilda Reilly

"For alongside of the development of the contractures there appeared a deep-going functional disorganization of her speech. It first became noticeable that she was at a loss to find words, and this difficulty gradually increased. Later she lost her command of grammar and syntax; she no longer conjugated verbs, and eventually she used only infinitives, for the most part incorrectly formed from weak past participles. And she omitted both the definite and indefinite article. In the process of time she became almost completely deprived of words. She put them together laboriously out of four or five languages and became almost unintelligible."
      From Studies in Hysteria by Sigmund Freud and Josef Breuer

The disruption of Bertha's speech faculty was undoubtedly complex and it's perhaps not surprising that Breuer was at a loss to explain it in anything other than psychogenic terms. In addition to the difficulties described above, she went on to lose her command of German completely and for a while could speak only in English.

One of the obstacles to arriving at a neurological interpretation of Bertha's symptoms may have been the theory of retrograde amnesia formulated around the same time by French neurologist Theodule Ribot. According to this, any damage to memory areas of the brain would result in newer memories being affected before older ones. Extending this to the language function, it was therefore expected that languages learned later in life would be affected before earlier ones and that the mother tongue would be the last to suffer.

However, subsequent cases of multilingual patients affected by strokes and the like have not borne this out. American neuropsychologist Laurence Miller reports that the order in which languages are recovered in such cases is variable, and that individual patients can even exhibit different types of aphasic syndrome in their different languages. Research carried out by neurosurgeon George Ojemann while operating on bilingual patients indicated that, although some brain areas were common to both languages, there were also peripheral areas involving only one of the languages. This kind of anatomical distribution of language function makes it easier to see how language disruption could manifest itself in seemingly aberrant and arbitrary ways.

Perhaps the most fascinating writing on the subject is to be found in the reports of those who have had personal experience of language impairment as it gives insight into what the condition feels like.

In Stroke: A Diary of Recovery, Douglas Ritchie describes it thus:
"I could day-dream……. I could think, actively, without using words, and coming down to earth, I rehearsed speeches silently. But there was the blank wall. The minute I rehearsed speeches with my tongue, even though I kept silent, the words would not come……
It was like starting a motor car. The engine ticked over and speeded up, but the moment one sought to put the car into gear, something went wrong with the clutch, the gear crashed with an ugly sound the engine stopped."

In Auto-Observation of Aphasia by French doctor Jacques Lordat, written in the 19th century, Lordat describes being at times in a state of what he called paramnesia "a faulty use of known and remembered sounds. Thus when I wanted to ask for a book, I pronounced the word for handkerchief. However, immediately after having uttered this word, I retracted it, feeling that another was indicated."

Equally intriguing is The Man Who Lost His Language by Sheila Hale in which she writes of the aftermath of her husband's stroke. John Hale never recovered his power of speech, or at least as the term is generally understood, yet he managed a form of communication based on constant repetition of the syllables da woahs, modulated and infused with emotion as if in normal conversation, apparently believing that the sounds he was uttering were making perfect sense to his listeners.

Works such as these were of more help to me than the case history in getting to the raw feel of what Bertha's experience must have been like. The personal perspective is invaluable as a complement to the medical one.

• Hale, Sheila, The Man Who Lost His Language (Allen Lane, 2002)
• Riese, Walter, Auto-Observation of Aphasia, Bulletin of the History of Medicine 28 (1954)
• Ritchie, Douglas, Stroke: A Diary of Recovery (Faber and Faber, 1974)

Following my previous post, no one came out in favour of The Various Guises of Desire. So I guess that has to be consigned to the trash can. On the other hand, several people suggested Guises of Desire as a better alternative. More on that later.

In the meantime, I had been toying with other ideas.

The Viennese Patient. Catchy enough but what about its significance? Bertha Pappenheim was undoubtedly Viennese - or was she? Her mother was born in Germany and her father in Hungary - but so too were most of the patients of early psychoanalysis. Bertha does not stand out particularly by virtue of her Viennese-ness. Once I'd realised this, the title lost its attraction for me.

I next considered Becoming Anna O. Incorporating Anna O into the title would make it meaningful to a wider range of readers and throw it up more frequently on Google searches. Then I discovered a book titled Becoming Anna. It's not a good idea to give a book a title which is the same as, or similar to, that of another book. Plus, this title was open to the same arguments made against the following one, suggested by a blog reader:

From Bertha P to Anna O.

I thought carefully about this one before deciding that it only covered part of the story. Yes, it summarises Bertha's passage from normal (for the time, place and social setting) young woman to patient treated for a multi-stranded medical condition as depicted by Breuer. But the novel goes beyond that, postulating more than is suggested in the case study and ending when Bertha is nearing the end of her later, and highly successful, professional life. I didn't want her identity to be subsumed into that of the case study.

At the same time I was thinking about the kind of artwork I'd like to see on the cover. That, along with the title, is crucial to getting a book noticed.

The first idea that came to mind was Klimt, a Viennese artist of about the same period is Bertha. I started looking at his paintings. Much as I liked them I felt that they were too well known and too 'strong' in a way which would risk eclipsing the image of the novel itself. Then I came across his sketches. I knew at once that here I would find something which encapsulated the essence of my story. Most of all it was the eroticism conveyed by many of his drawings of naked or semi-nude young women. It struck me that this, above all, is what my novel is about. I was reminded of what I wrote in my last post about Terri Marie's advice on choosing a title, that it was awaiting discovery and when recognized would instill you with confidence and catalyse the energy of the book - 'like a light shining through the window'. So it was with the Klimt sketches.

I hadn't realised until this point how important the undercurrents of eroticism in my novel are. I had seen it more as simply a many-faceted story. Now I can see that the main driving force is the steadily increasing erotic charge (albeit not always in guises which we would immediately recognise) which leads to the dramatic culmination - and points in turn to the choice of title which, on that basis, should probably be Guises of Desire.

The whole process of searching for title and artwork has been like subjecting the content of my novel to study under a microscope. It has homed in on what it is principally about, clarified it and enabled me to sum it up. 

Now that I'm nearing the end of the book I need to decide on a title. So far I've been through several working titles: Bertha P (unlikely to attract attention, in fact, guaranteed not to); The Story of Bertha P (not much better); A.K.A. Anna O (well, I suppose the name Anna O is more recognizable than Bertha P, but not widely so, and there is also the problem of punctuation: should it be aka, AKA, a.k.a., A.k.a or A.K.A?).

My latest idea is The Various Guises of Desire. Now this I really like. It's pleasingly euphonious, with subtle hints of eroticism, perhaps the thinking woman's Fifty Shades of Grey. But could I be accused of misrepresentation? After all, it isn't a bodice ripper.

I don't think so. In fact, it seems to me highly apt. I don't agree with a lot of Freud's thinking but I do believe he was onto something with his ideas about what he unfortunately termed 'polymorphous perversity', which looms large in my version of the Bertha Pappenheim story. It also chimes with my thesis that Bertha's absence states were associated with a form of temporal lobe epilepsy and that during them she experienced states of mystical rapture.

Some people I've consulted don't like it.

Does this matter? No title, no book is going to please everyone. And at the moment I can't think of anything else.

Literary agent Rachelle Gardner has some practical suggestions on the subject. I've applied most of them and find that they throw up nothing that would contraindicate my choice.

Writer Terri Marie gives more visceral advice. The title will come from within, she says. It is simply awaiting discovery and when recognized will instill you with confidence and catalyse the energy of the book - 'like a light shining through the window'. This is much how I feel about The Various Guises of Desire.

Votes, please, from readers of this blog. Or if you can think of something yourself, please suggest! A free copy of the book to anyone who can provide the eventual title. 

A recent BBC news article draws attention to a number of myths about the sinking of the Titanic that have been perpetuated by the various film versions. Stories such as the blocking of the escape routes of the steerage passengers, or of the band playing 'Nearer, My God, to thee' as the ship went down, based on flimsy or non-existent evidence, have proved too popular to allow the record to be set straight.  Film makers, unwilling to let truth stand in the way of a good story, have felt free to impose their own agenda on the events.

Bertha Pappenheim has been similarly traduced. It seems now to be an integral part of her history that, shortly after Breuer stopped treating her, he was called back urgently to find her in a state of pseudocyesis (hysterical pregnancy), imagining that she was giving birth to Breuer's child. 

Few people would still maintain that Bertha was cured when Breuer's treatment ended in 1882. It is known that shortly after his final visit Bertha was admitted to a clinic in Switzerland where she remained for several months, being treated for morphine addiction and recurrences of earlier symptoms. Further spells of hospitalisation followed. Yet the story of the hysterical pregnancy is still widely subscribed to, particularly by therapy professionals and academics who find in it a rich seam of interpretations to be mined according to their own particular school of thought.

Anna O: Fourteen Contemporary Reinterpretation s provides some interesting examples. There we find:

·      Walter Stewart M.D. wondering if the pseudocyesis signified 'a breakthrough in which the patient was finally able to accept the feminine role involving impregnation and childbirth', or if it represented 'a virgin birth', or the 'condition on which she could separate from Breuer, or 'the enactment of what she most feared - that a man would seduce, impregnate, and abandon her';

·      Joseph Martorano, psychopharmacologist, speculating that medication would have lessened the transference and thus probably prevented the pseudocyesis;

·      Anne Steinmann, psychoanalyst, claiming that 'with a female analyst it is quite unlikely that Anna O. would experience the hysterical childbirth she did when working with Breuer, as her sexual fantasies would be explored directly';

·      Hyman Spotnitz, psychiatrist and psychoanalyst, putting forward the theory that the pseudocyesis was a recreation by Bertha of the recent pregnancy of Breuer's wife.

The pseudocyesis first made its appearance in a letter from Freud to Stefan Zweig in 1932. In it, Freud outlined the story as something he had reconstructed on the basis of what he had guessed as a result of something he had remembered Breuer telling him in a different context. So already the links in the chain of reasoning are looking tenuous. Freud went on to say that he had been so convinced of the truth of his conjecture that he had published it somewhere. The 'where' of the publication was never specified, but Freud backed up his claim to its veracity by saying that Breuer's daughter had shown the account to her father shortly before his death and that he had confirmed it. However, there is no record of any such account ever having been published by Freud.

The story finally entered public circulation with the appearance of Ernest Jones' biography of Freud in the 1950s. Since then it has gone from strength to strength in providing grist for the psychoanalytic mill, despite being shot down by medical historians such as Albrecht Hirschmuller and Henri Ellenberger.

Did Freud believe in his own 'reconstruction'? Possibly. Even if he didn't, he may have felt that it embodied a more general truth, the propagation of which justified the lie.

I think that something dramatic may well have happened at the end of Bertha's treatment by Breuer. I'm still trying to work out what this could feasibly have been. 

I've finished the first draft of A.k.a. Anna O, a stage at which it's useful to get feedback from unbiased readers. I've been surprised to find that there's been some perplexity.

The main sources of this are:

·      scenes in which Bertha, in a regressed state, experiences episodes of what Freud was later to call 'polymorphous perversity';

·      the way in which Bertha's illness waxes and wanes for no obvious reason;

·      the ending, for which I had envisaged an alternative scenario to the rumour spread about later by Freud, to the effect that after Breuer terminated her treatment, Bertha experienced a hysterical childbirth.

One of the reasons for my surprise at readers' incomprehension was that my MA tutor had sometimes commented on my tendency to overstatement, leaving little for the reader to infer, and a lack of subtext. Had I now overcompensated, producing a narrative that was too opaque? 

Another comment was that it was difficult to categorise. 'I don't know what kind of person I would recommend it to,' one of my readers said. 'It's difficult to say what genre it is.'

An article in the current issue of Mslexia discusses a genre I'd never heard of - lit lite. It goes on to define this as 'a broad genre of entertaining well-written novels with mind-broadening content, likely to appeal to book groups'. It gives as examples The Love Song by Andrea Levy and The Help by Kathryn Stockett, both of them with narratives revelatory of the time and place in which they're set. This could be an answer to my reader's question about genre. A.k.a. Anna O provides insight into the social and cultural climate of late 19th century Vienna and the early days of psychoanalytic thought.

It could also be classified as a novel of ideas. I've just come across a definition of this genre by David Barash who writes that a novel of ideas 'must broach one or more intellectual questions or debates that persist beyond the confines of the novel itself'. In the case of Bertha Pappenheim, the questions I focus on are:

·      Hysteria: its nature (or even existence), and misdiagnosis in the case of neurological disorders ill-understood

·      Transference: the phenomenology of the patient-therapist relationship

·      The published case history of Bertha Pappenheim: its scientific and historical validity.

As such, A.k.a. Anna O should appeal to psychotherapy professionals and people who are familiar with the theories developed together by Breuer and Freud. But I want its interest to persist not only beyond the confines of the novel, but beyond the confines of a narrow niche readership. So now I have to go back to the drawing board and try to make it more comprehensible to the general reader.

It did occur to me that the confused reactions were somehow apt. After all, this was how both Breuer and Bertha herself must have felt in the face of her symptoms. I know, of course, that I can't expect readers to be satisfied with this. As Tom Clancy has pointed out: 'The difference between fiction and reality is that fiction has to make sense.'