This initiated a newer type of time consuming procedure for treatment. Anna would describe, in great detail, in reverse order leading to the initial event. In using this procedure, she was able to talk away permanently her other symptoms as well. What Breuer found was that if he could trace a symptom, through hypnosis or putting Anna in a relaxed state, to its initial experience, usually a traumatic event, the symptom would disappear. The beginnings of psychoanalysis were occurring during Breuer’s treatment of Anna, as Freud would modify this basic procedure (he would later abandon the use of hypnosis for the method of free association).
Eventually, Anna was determined to bring her treatment to an end by June 7, 1882, which was the one year anniversary of her being taken—against her will—to the country house. On the final day of the illness, Anna’s room was made to resemble her father’s room during his illness. At this point, Anna recalled a terrifying hallucination which Breuer believed “constituted the root of her whole illness” (1895, p. 40). Specifically, while Anna was helping to care for her seriously ill father, the following had occurred:
Once she was watching at night in the greatest anxiety for the patient, who was in a high fever, and in suspense, for a surgeon was expected from Vienna, to operate on the patient. Her mother had gone out for a little while, and Anna sat by the sick-bed, her right arm hanging over the back of her chair. She fell into a revery [waking dream] and saw a black snake emerge, as it were, from the wall and approach the sick man as though to bite him. … She tried to drive off the creature, but was as though paralyzed. Her right arm, which was hanging over the back of the chair, had “gone to sleep,” become anesthetic and paretic, and as she was looking at it, the fingers changed into little snakes with deaths-heads. (The nails.) Probably she attempted to drive away the snake with her paralyzed right hand, and so the anesthesia and paralysis of this member formed associations with the snake hallucination. When this had vanished, she tried in her anguish to speak, but could not. She could not express herself in any language, until finally she thought of the words of an English nursery song, and thereafter she could think and speak only in this language (Freud, 1910, p. 186).
As Breuer notes (1895, pp. 40-1), “During the original scene she had only been able to think and pray in English; but immediately after its reproduction she was able to speak German. She was moreover free from the innumerable disturbances which she had previously exhibited. After this she left Vienna and travelled for a while; but it was a considerable time before she regained her mental balance entirely. Since then she has enjoyed complete health.” As Freud would later comment to his American audience in 1909 at Clark University, “When, a number of years later, I began to use Breuer’s researches and treatment on my own patients, my experiences completely coincided with his” (1910, p. 186). Both men reported a successful outcome for Anna, who had suffered from a severe case of hysteria. Freud has a different version of how the treatment ended, which will be discussed below.
The cathartic method and the cure of the severely hysterical patient Anna O., which is the founding case of psychoanalysis, has been told and retold in various forms like I just presented above. It truly does seem like a successful outcome for the patient. Yet, keep in mind the importance of historical research, as sometimes the historical record does not match what is subsequently reported years later.
Historical Research: Comparing Data Fragments with Individual Claims
At least three separate claims made by Breuer and Freud deserve further scrutiny: (a) Breuer’s treatment cured Anna, (b) Anna was not given narcotics while in Breuer’s care, and (c) how exactly did Breuer’s treatment with Anna end? Prior to addressing each of the claims, let’s discuss the work of Henri Ellenberger and Albrecht Hirschmüller. Both discovered some data fragments that shed new light on the case. Moreover, the historical documents that they uncovered directly contradict some of the account provided by Breuer and Freud.
a. Did Breuer’s Treatment Cure Anna?
Henri Ellenberger (1972) was looking through a biography of Bertha Pappenheim (i.e., Anna O.) written by Dora Edinger, and noticed a picture of her, dated 1882, looking healthy and wearing riding clothes. This photograph contradicted Breuer’s version of a home-bound individual at the time. Ellenberger secured permission to examine the original picture, and had it examined under special light by the Montreal City Police. The name of a German town appeared: Konstanz. Specifically, Ellenberger wondered what Bertha was doing there because according to Breuer’s account she was supposed to be very ill in a sanitarium near Vienna. As Ellenberger (1972, p. 274) states, “Mrs. Edinger suggested that she could have been treated in one of the sanitariums which existed in that part of Europe. Actually, there was one famous sanitarium, in the little Swiss town of Kreuzlingen, quite close to Konstanz: the Sanatorium Bellevue. I asked the present director, Dr. Wolfgang Binswanger, if the medical archives contained a case history of Bertha Pappenheim. I learned from him that Bertha Pappenheim had actually sojourned there as a patient from July 12 to October 29, 1882. The patient’s file contained two documents: a copy of the case history written by Breuer himself in 1882, and a follow-up written by one of the doctors of the Sanatorium Bellevue.”
Two important documents were discovered that need to be considered. One of the documents, which is a 21 ½ page report (translation of the document into English is available by Hirschmüller, 1978), does not contain Breuer’s name, but portions of the document are virtually identical to what Breuer would later write in Studies on Hysteria 13 years later. The document also contains some information left out of the later publication. For example, her family had lied to Anna about the seriousness of her father’s illness and she was not allowed to see him for the final two months of his life, which helps to explain why his death was such a shock to her. Along with Breuer’s 21 ½ page report, Ellenberger also discovered a 2 ½ page follow-up report written by Dr. Laupus at Bellevue titled, “Evolution of the Illness During the Sojourn in Bellevue from July 12, 1882, to October 29, 1882.”
Albrecht Hirschmüller would subsequently visit Bellevue, and discovered additional documents that had eluded Ellenberger. Specifically, he found letters about the case written to Robert Binswanger, the director of Bellevue at the time, from Breuer, Anna’s mother, Anna’s cousin (Fritz Homburger), and Anna herself after she had been discharged. A self-report from Anna about her own condition was also found as well as a preliminary report from Breuer about Anna’s condition that preceded Breuer’s 21 ½ page report. In Hirschmüller’s (1978) book, “The Life and Work of Josef Breuer,” all of the reports (including the two found by Ellenberger) and letters about Anna’s stay in Bellevue are translated into English and provided for the reader in the Appendices. The 21 ½ page report had a request that the original be returned; as the text was transcribed (Breuer likely wanted the report for his records, as this was prior to the days of photocopying machines). Hirschmüller (1978) also found documents in the Vienna City Psychiatric Hospital archives of a sanatorium in Inzersdorf (near Vienna) that recorded that Anna was admitted an additional 3 times for hysteria (July 30, 1883 to January 17, 1884; March 4, 1885 to July 2, 1885; June 30, 1887 to July 18, 1887).
What is most important is that just a few weeks after Anna’s “cure,” she was back in a psychiatric hospital, and would have to return to a psychiatric hospital at least three more times from 1883 to 1887. Evidence indicates that both Breuer and Freud were well aware that Anna was not “cured” by the cathartic method. For example, in August 1883, Breuer told Freud that Bertha was deranged (Appignanesi & Forrester, 1992). Likewise, Breuer had told Freud that a year after his treatment with Bertha had ended, that she was “quite unhinged and that he wished she would die and so be released from her suffering” (Jones, 1953, p. 225). Breuer had been kept informed about Bertha from medical reports, a personal visit in 1884, and likely from her brother whom Breuer corresponded with for many years (Hirschmüller, 1978).
Freud shared this information with Car
l Jung, who revealed that Anna had not been cured in a 1925 seminar in Zurich. As Jung stated, ““so much spoken about as an example of brilliant therapeutic success, was in reality nothing of the kind … There was no cure at all in the sense of which it was originally presented.” And yet, Jung added, “the case was so interesting that there was no need to claim for it something that did not happen”” (cited in Ellenberger 1972, p. 270). Finally, Martha Freud was friends with Bertha, and had visited her at least twice in 1887. She had written to her mother that Bertha was still suffering from hallucinations in the evenings, but was doing alright during the day which is a pattern consistent when she was under Breuer’s care (Appignanesi & Forrester, 1992; Jones, 1953). Yet, if you read Freud’s An Autobiographical Study (1925, p. 37), Freud notes that Breuer’s “patient had recovered and had remained well and, in fact, had become capable of doing serious work.” Apparently, Freud did not find it necessary to point out that this patient did not remain well, but for years after treatment ended continued to suffer from hysterical symptoms.
As previously mentioned, along with Breuer’s 21 ½ page report, Ellenberger also discovered a 2 ½ page follow-up report written by Dr. Laupus at Bellevue. This document is also consistent with a patient who has not been cured, as Anna would lose her ability to use the German language just like in the care of Breuer. The case report by Dr. Laupus and the self-report written by Bertha herself (middle of 1882) about her illness flatly contradict the claim the Breuer had cured her of her loss of the ability to use German. As Laupus would write, Anna would lose her ability to use German in the evening and this “phenomenon occurred regularly each evening in such a way that as soon as the patient’s head was laid on the pillow she could no longer either understand or speak the German language. If she was speaking German at the time, the sentence was finished in English” (cited in Hirschmüller, 1978, p. 292). As Anna would write, “I, a native German girl, am now totally deprived of the faculty to speak, to understand or to read German. This symptom lasted during the time of a heavy nervous illness, I had to go through, in permanence longer than a year; since about 4 months it only returns regularly every evening” (cited in Hirschmüller, 1978, p. 296).
So, what are we to make of all this new evidence? From my perspective (which admittedly has its own biases that need to be controlled to maintain objectivity; see Chapter 3), it is clear that Bertha Pappenheim was not cured by Breuer’s treatment. She continued to suffer from hysteria as late as 1887. More disturbing, however, is that both Breuer and Freud knew that Anna was not cured, yet both perpetuated what most people would describe as a severe distortion in their professional papers by omitting the fact that when Bertha left Breuer’s care she would require being admitted to a mental institution at least 3 more times for hysteria over the years. As Hirschmüller (1978, p. 107) nicely summarizes, the idea that Anna O. “was completely cured does not square with the facts.”
b. The Use of Narcotics During Anna’s Treatment
Was Anna given narcotics while under Breuer’s care? While this may at first appear like a “picky” or trivial question to focus on, it does have large implications for the story of Anna O. because narcotics can cause symptoms that mimic those of hysteria. Breuer did say that Anna was given chloral hydrate, a nonbarbiturate sedative, at night to help her sleep, but wrote that he did not need to give her narcotics. As Ramos (2003) has pointed out, the dosage of chloral hydrate that Breuer himself reports giving to Anna is 10 times greater than the normal usage, and consistent with a person who has built up a high tolerance. Anna’s dosage was potentially lethal for a first-time user.
Also, the subsequently discovered 2 ½ page follow-up report written by Dr. Laupus indicates that Anna’s drug use for her first day of the clinic was 5 grams of chloral hydrate given at night (consistent with the high dosage given by Breuer), and morphine 80 mg/day. Morphine is a narcotic. This initial dosage needed to be increased because Anna was showing the signs of withdrawal. Ramos (2003) explains that the increased dosage was consistent with someone who had developed a high tolerance for morphine over a long period of time. When Anna was admitted to Bellevue, she showed the physical signs of a patient not only addicted to chloral hydrate, but one who was a morphine addict. Yet, Breuer had made it a point in Studies on Hysteria to note that she was not given any narcotics.
As even more compelling evidence, in mid-1882, Breuer wrote to the doctor in charge of the Bellevue Sanatorium (Dr. Binswanger), where Anna would eventually become a patient. These documents shed further light on the issue of whether or not Breuer gave Anna narcotics while in his care. Specifically in Breuer’s letter to Binswanger (mid-June 1882), he writes, “She is receiving daily 0.08-0.1 morphine by injection. My case history will justify me in this matter. I am not engaged in breaking her of this addiction since, despite her good will, when I am with her I am powerless to cope with her agitated state” (cited in Hirschmüller, 1978, p. 293). Likewise, the preliminary report by Breuer (late June) noted, “In recent months the patient has been receiving injections of morphine … morphine dosages became rather high (0.15-0.20 pro die), but are now reduced to 0.05-0.70 each day, and withdrawal from morphine will probably cause little difficulty as the patient desires it” (cited in Hirschmüller, 1978, p. 295).
The evidence is inconsistent with what Breuer reported in Studies on Hysteria, as Anna was given narcotics according to letters that he himself had written, and she also possessed the symptoms of a morphine addict. As the case report written by Dr. Laupus notes, the first task of her treatment under his care was to break her morphine addiction (Hirschmüller, 1978). Unfortunately, while there was some initial success, Anna developed severe facial pains and when other treatments for the pain were unsuccessful (e.g., leeches, electrical treatments, arsenic), morphine injections were once again started and continued through her discharge. It is interesting that both Anna’s mother and cousin comment on the lack of progress in Anna breaking her addiction in their letters to the director of the sanatorium. For example, Anna’s mother writes (October 7, 1882), that while initially there was “a ray of hope that it will be possible to suspend morphine injections, I learn most unhappily from the other that the patient cannot remain for as much as a single day without the drug, and B[ertha] is just as dependent on it now as she ever was” (cited in Hirschmüller, 1978, p. 303).
The data fragments of history clearly indicate that under Breuer’s care, Bertha was given morphine, and had developed a strong dependence. Ramos (2003) makes a compelling argument that Anna’s later and more severe hysterical symptoms are largely the result of a patient who is addicted to chloral hydrate and morphine. Although it is unclear exactly how Anna ultimately became better (to my knowledge, no one has uncovered any historical documentation that settles this important question), it likely did not occur until after she broke her drug addictions. One interpretation of how Bertha finally recovered has little if anything to do with the effectiveness of psychoanalysis, but of a drug addict being able to successfully overcome her addiction.
c. How did Anna’s Treatment with Breuer End?
Exactly how did Breuer’s treatment with Anna end? Breuer’s account of how his treatment with Anna ended was later contradicted by Freud and Freud’s biographer Ernest Jones in several ways. Jones (1953) reported that Freud told him that Breuer had developed a strong countertransference and his wife became jealous when her husband would talk repeatedly about this particular attractive patient. According to Freud, in a letter to Martha, this was not the only time that Anna had elicited feelings in her doctor, “a colleague [at the sanatorium] is completely enchanted by the girl [Bertha], by her provocative appearance…” (cited in Appignanesi & Forrester, 1992, p. 81). Martha responded with: “It is curious that no man other than her physician of the moment got close to poor Bertha, that is when she was healthy she already [had the power] to turn the head of the most sensible of men – what a misfortune for the girl. You will laugh at me, dearest, I so vividly put myself in the
place of the silent Frau Mathilde [Breuer] that I could scarcely sleep last night” (p. 82). This account has Breuer developing feelings for his attractive young patient, and at this point he decided to end his treatment of Anna.
The account of how Breuer ended his treatment does not stop there. Freud, in a letter written almost exactly 50 years after the event to Stefan Zweig (June 2, 1932) gives additional information (which is also commented upon by his biographer Ernest Jones) as to what happened on the final day of Anna’s treatment. Freud recounts suddenly remembering Breuer telling him in a different context that on the evening of the day in which Anna’s symptoms had finally disappeared, Breuer was called back to his patient and “found her confused and writhing in abdominal cramps. Asked what was wrong with her, she replied: “Now Dr. B.’s child is coming!” … Seized by conventional horror he took flight and abandoned the patient to a colleague. For months afterwards she struggled to regain her health in a sanatorium.” (Freud, 1960, p. 413). Jones (1953) notes that the next day, Breuer and his wife left for a second honeymoon in Venice, which resulted in the birth of a daughter (Dora Breuer), and Freud (1960, p. 413) noted in his letter that this was “not without significance for the deeper connections!”
What are we to make of this new version? First, let’s start with the story that this event resulted in Dora Breuer’s conception as the result of a second honeymoon. This version is contradicted by the historical record, and provides a great example of historical fiction (i.e., something that can be demonstrated as factually false; see Chapter 2). Ellenberger found in the public records in Vienna that Dora was born on March 11, 1882 (Anna’s treatment ended on June 7, 1882). The time of conception (approximately June 1881) was during the time Anna was transferred to the country house. Thus, this aspect of the story is factually untrue, and can be classified as historical fiction (see Chapter 2).
Freud, Murder, and Fame: Lessons in Psychology’s Fascinating History Page 6