Een neurologische kritiek
Hysteria, Anna O., and the Invention of Psychoanalysis
Richard WEBSTER, 1995
Sigmund Freud was born in 1856, in the small Austro-Hungarian town of Freiberg. Unusually he was born in a caul – a kind of membrane – and his mother immediately took this as a portent of his future fame. She called him ‘mein goldener Sigi’, and throughout his childhood and early adolescence in Vienna he was surrounded by his parents’ adulation and by their urgent expectation of his future greatness. As Freud embarked on a career in medicine, which eventually led him to study in the newly emerging field of neurology, these expectations seem to have become increasingly burdensome. For, although outwardly successful, he appears to have begun to despair of ever being granted the kind of world-redeeming revelation which he felt inwardly compelled to seek.
Freud’s earliest unsuccessful skirmish with fame took place in 1885 when, after experimenting with taking cocaine, he sought medical glory by publishing a paper on the drug as a miracle-therapy. In writing this paper, however, he failed to observe the crucial properties of the drug as a local anaesthetic while simultaneously omitting to warn against cocaine addiction. Freud, however, was not deterred by this unfortunate episode from seeking medical distinction. He almost immediately left Vienna for Paris where, from October 1885 to February 1886, he studied under the famous neurologist Charcot.
Charcot specialised in treating patients who were suffering from a variety of unexplained physical symptoms including paralysis, contractures (muscles which contract and cannot be relaxed) and seizures. Some of these patients sporadically and compulsively adopted a bizarre posture (christened arc-de-cercle) in which they arched their body backwards until they were supported only by their head and their heels. Charcot eventually came to the conclusion that many of his patients were suffering from a form of hysteria which had been induced by their emotional response to a traumatic accident in their past – such as a fall from a scaffold or a railway crash. They suffered, in his view, not from the physical effects of the accident, but from the idea they had formed of it.
Freud was immensely impressed by Charcot’s work on traumatic hysteria and took from it the notion that one of the principal forms of neurosis came about when a traumatic experience led to process of unconscious symptom-formation. He now began to develop this idea, and did so partly by reference to the work of a medical colleague, Josef Breuer. Freud was especially interested in the most unusual of all his colleague’s patients, the celebrated ‘Anna O.’ whom Breuer had begun to treat in 1880.
Anna O. was a twenty-one-year-old woman who had fallen ill while nursing her father who eventually died of a tubercular abscess. Her illness began with a severe cough. She subsequently developed a number of other physical symptoms, including paralysis of the extremities of the right side of her body, contractures, disturbances of vision, hearing and language. She also began to experience lapses of consciousness and hallucinations.
Breuer diagnosed Anna O.’s illness as a case of hysteria and gradually developed a form of therapy which he believed was effective in relieving her symptoms. He came to the conclusion that when he could induce her to relate to him during the evening the content of her daytime hallucinations, she became calm and tranquil. Breuer himself saw this as a way of ‘disposing’ of the ‘products’ of Anna O.’s ‘bad self’ and understood it as a process of emotional catharsis. The patient herself described it as ‘chimney sweeping’, and as her ‘talking cure’.
Breuer went on to extend this therapy. At one point in her illness, for a period of weeks, Anna O. declined to drink and would quench her thirst with fruit and melons. One evening, in a state of self-induced hypnosis, she described an occasion when she said she had been disgusted by the sight of a dog drinking out of a glass. Soon after this she asked for a drink and then woke from her hypnosis with a glass at her lips.
In his published account of the case, written some twelve years later, Breuer treated the story which Anna O. had related in a trance as a true account of an incident which had given rise to her aversion to drinking. He said he had concluded that the way to cure a particular symptom of ‘hysteria’ was to recreate the memory of the incident which had originally led to it and bring about emotional catharsis by inducing the patient to express any feeling associated with it.
The sudden disappearance of one of Anna O.’s many symptoms thus became the basis for what Breuer later described as a ‘therapeutic technical procedure’. According to both Freud and Breuer, this method had been applied systematically to each of Anna’s symptoms and as a result she was cured completely of her hysteria.
The case of Anna O. played a fundamental role in the development of Freud’s thought. She has frequently been described as the first psychoanalytic patient, a view which Freud himself, lecturing at Clark University in the United States, once endorsed:
If it is a merit to have brought psychoanalysis into being, that merit is not mine. I had no share in its earliest beginnings. I was a student and working for my final examinations at the time when another Viennese physician, Dr Josef Breuer first (in 1880-2) made use of this procedure on a girl who was suffering from hysteria .
Freud, however, was understating his own role. Psychoanalysis would never have come into being if he had not transformed Breuer’s ‘talking cure’ by marrying it with Charcot’s views on traumatic hysteria and his own elaborate technique for reconstructing repressed memories through interpretation and free-association.
The patients whom Freud endeavoured to psychoanalyse at this early stage of his career, however, almost all resembled Anna O. in at least one respect; they came to Freud not because they were experiencing emotional distress but because they were suffering from physical symptoms. Freud’s first patient, for example, Frau Emmy von N., suffered speech difficulties, which Freud described as ‘spastic interruptions amounting to a stammer’. She was also plagued ‘by frequent convulsive tic-like movements of her face and the muscles of her neck’ and was compulsively given to making repetitive verbal exclamations and clicking sounds. Another patient, Lucy R., an English governess, suffered from strange olfactory hallucinations centring on the smell of burnt pudding. Yet another, Elisabeth von R., came to Freud because she had been suffering for more than two years from pains in her legs.
In all these cases Freud construed his patients’ illness as hysteria and set about uncovering the traumatic incident which had supposedly given rise to their symptoms. In order to help the process of analysis he developed what he called his ‘pressure technique’. This consisted in applying pressure to his patients’ forehead with his hands and instructing them to report faithfully ‘whatever appeared before their inner eye or passed through their memory at the moment of pressure’. Freud rapidly developed such faith in the effectiveness of this method for evoking pictures, ideas or unconscious ‘memories’ that he came to regard it as infallible, maintaining that if no images or memories were produced by the first application of pressure, repeated pressure would invariably be effective. When, in the course of treating Elisabeth von R. for her lameness, he suspected her of concealing thoughts from him, he decided to reinforce the physical pressure with mental pressure:
I no longer accepted her declaration that nothing had occurred to her, but assured her that something must have occurred to her. Perhaps, I said, she had not been sufficiently attentive, in which case I would be glad to repeat my pressure. Or perhaps she thought that her idea was not the right one. This, I told her, was not her affair; she was under an obligation to remain completely objective and say what had come into her head, whether it was appropriate or not. Finally I declared that I knew very well that somethinghad occurred to her and that she was concealing it from me; but she would never be free of her pains so long as she concealed anything. By thus insisting I brought it about that from that time forward my pressure on her head never failed in its effect. 
At this period Freud believed that, in the final stages of therapy, it was helpful ‘if we can guess the ways in which things are connected up and tell the patient before we have uncovered it’.  When, however, he presented Elisabeth von R. with his conclusion, namely that her illness had been precipitated by her falling in love with her brother-in-law, she objected that that this was not true. Freud, however, persisted in his explanation and eventually reported that his patient had been cured.
(at this point six or seven sections of the original book are omitted)
Freud and Charcot
The psychoanalytic movement is undoubtedly a powerful one which has endured one century and is likely to endure another. But from its very beginnings it has attracted criticism. This criticism has tended to become better informed with the passing of time. With almost a hundred of years of Freud scholarship to draw on, it is now possible, perhaps for the first time, to offer a considered and balanced judgement on the value both of Freud’s thought and of the movement he founded.
One of the obstacles which, perhaps more than any other, has stood in the way of a full understanding of Freud’s ideas, is that many of those who have written about psychoanalysis, in Europe, in Britain or in America, have been scholars involved in the humanities. Whether writing as champions or critics, they have tended to present psychoanalysis as a humanistic discipline. As a result we often forget that it was in its origins a medical movement.
Psychoanalysis was born not, as is frequently claimed, out of the foibles of emotionally unstable middle-class women who came to consult Freud in Vienna. It was born amidst the florid and sometimes extreme physical symptoms displayed by patients who had been consigned to one of France’s greatest hospitals – La Salpêtrière in Paris. The original begetter of the theory of unconscious symptom-formation – a theory which lies at the heart of psychoanalysis – was not Freud, nor even Breuer, but Jean Martin Charcot.
Charcot was not a psychologist, he was a neurologist. His greatest gift was a genius for anatomical dissection and post-mortem diagnosis. His greatest handicap was that he practised neurology at a time when techniques of tissue-staining were primitive, X rays had not been discovered and the instruments of investigation which have made modern neuroscience possible did not exist. The electroencephalogram (EEG), which would revolutionise neurology and psychiatry, was not in general use until the 1940s. Other techniques for brain-imaging, such as Magnetic Resonance Imaging (MRI), were not introduced until the closing decades of the twentieth century. Even today, at the beginning of the twenty-first century, the process of charting the brain’s intricate functioning has barely begun. As Rita Carter writes in her book Mapping the Mind, ‘the vision of the brain we have now is probably no more complete or accurate than a sixteenth-century map of the world.’
In 1886, at the time of Freud’s crucial encounter with Charcot, the map was scarcely drawn at all. Neurologists inhabited a world of almost complete diagnostic darkness, illuminated only by the occasional gleam of medical insight. Perhaps more importantly still, leading neurologists remained blissfully unaware of the depth of their ignorance. Charcot himself believed that the work of neurology was almost complete.
What this meant in practice was that many subtle neurological disorders, such as temporal lobe epilepsy, and frontal-lobe epilepsy, were unrecognised in Charcot’s day. At the same time, the internal pathology of head injuries remained an almost complete mystery. Closed head injuries, which produce concussion without leaving any external injury, were simply not recognised. This was the diagnostic darkness within which the fundamental principles of psychoanalysis were formulated. The medical and intellectual consequences are perhaps best illustrated by Charcot’s classic case of traumatic hysteria – a case involving a patient known as ‘Le Log–––‘.
Le Log––– was a florist’s delivery man in Paris. One evening, in October 1885, he was wheeling his barrow home through busy streets when it was hit from the side by a carriage which was being driven at great speed. Le Log–––, who had been holding the handles of his barrow tightly, was spun through the air and landed on the ground. He was picked up completely unconscious. He was then taken to the nearby Beaujon hospital where he remained unconscious for five or six days. Six months later he was transferred to La Salpêtrière. By this time the lower extremities of his body were almost completely paralysed, there was a twitching or tremor in the corner of his mouth, he had a permanent headache and there were ‘blank spaces in the tablet of his memory’. In particular he could not remember the accident itself. But, because there had never been any signs of external injury, Charcot decided that Le Log––– was a victim of traumatic hysteria and that his symptoms had arisen as a result of the psychological trauma he had suffered. Charcot came to this conclusion knowing full well that some weeks after his accident Le Log––– had suffered heavy nose-bleeds and a series of violent seizures – seizures which Charcot deemed hysterical.
In the century which has passed since Charcot made this diagnosis, the face of neurology – and of general medicine – has been transformed. If Le Log––– were to be brought today to a hospital in practically any part of the Western world there can be no doubt that doctors would recognise a case of closed head injury complicated by late epilepsy and raised intracranial pressure.
From this we may derive a conclusion which is both simple and terrible in its implications: Le Log–––, the classic example of a patient who supposedly suffered from traumatic hysteria, did not forget because he was frightened. He forgot because he was concussed. His various symptoms were not produced by an unconscious idea. They were the result of brain damage.
We are here confronted by what may well be the most momentous medical misunderstanding which has taken place in the last two centuries. For Charcot’s failure to recognise cases of closed head injury, and the symptoms they gave rise to, would shape the development of psychoanalysis. It was the main factor which would eventually lead Freud to elaborate his entire theory of unconscious symptom-formation – or ‘repression’.
More Medical Mistakes
Charcot’s misdiagnosis of Le Log––– (and of other victims of similar accidents) was not an isolated medical misunderstanding. It was but one part of a vast labyrinth of medical error which had been created over hundreds of years, and which Charcot himself had brought to an unprecedented level of complexity. In conditions where hundreds of subtle neurological disorders and other medical conditions remained wholly or largely unrecognised, the failure to make accurate medical diagnoses had led, almost inevitably, to the massive inflation of a pseudo-diagnosis – ‘hysteria’.
When Charcot was confronted by patients who adopted the arc-de-cercleposition by compulsively arching themselves backwards, he was not to know that this posture (which is sometimes combined with rhythmic pelvic thrusting) was a characteristic manifestation of frontal lobe epilepsy. In fact this form of epilepsy would not be fully described until another hundred years had passed. Even temporal lobe epilepsy, with its bizarre hysterical-seeming symptoms, was not recognised until the 1930s or 1940s. Confronted by the symptoms of these medically uncharted conditions, Charcot had little option but to place them in the catch-all diagnostic category of an illness – ‘hysteria’ – for whose existence no reliable clinical evidence has ever been produced.
What made the resulting labyrinth of medical error all but inescapable was that practically every other physician had become lost within it. Over and over again, highly trained medical practitioners, confronted by some of the more subtle symptoms of epilepsy, head injury, cerebral tumours, multiple sclerosis, Parkinson’s disease, Tourette’s syndrome, autism, syphilis, encephalitis, torsion dystonia, viral hepatitis, reflux oesophagitis, hiatus hernia and hundreds of other common or uncommon conditions, would resolve their diagnostic uncertainty by enlarging the category of hysteria yet further. As a result medical misconceptions which sprang from one misdiagnosis would almost inevitably receive support, and apparent confirmation, from misdiagnoses made by other physicians.
Just such a process of spectral ‘corroboration’ through multiple misdiagnosis lies at the heart of the development of psychoanalysis. For when Freud prevailed upon Breuer to publish an account of the case of Anna O., Charcot’s own medical misjudgments were compounded in a manner which would have lasting consequences. In the closing years of the nineteenth century it was almost inevitable that Breuer should have construed Anna O.’s bizarre-seeming, apparently unrelated symptoms, as ‘hysteria’. At the beginning of the twenty-first century, however, it is clear that each of Anna O.’s most significant symptoms corresponds to a specific kind of brain lesion or a recognisable pattern of brain pathology. More importantly still, many of these symptoms are typical components of complex partial seizures – which is to say a particular form of temporal lobe epilepsy.
Characteristic manifestations of such seizures include blurred vision, double-vision, feelings of de-personalisation, prosopagnosia (the inability to recognise faces), visual illusions which include the misidentification of objects, distortions in which upright objects appear tilted, or the walls of the room appear to bend. All of these symptoms Anna O. had. Not only this but the apparently unrelated dysfunctions which Breuer describes suggest a particular pattern of brain pathology. Anna O.’s problem with speech, for example, resembles the language deficit known as ‘non-fluent aphasia’. This is caused by a lesion in the language-area of the brain (Broca’s area) on the left side of the frontal lobe. Because such lesions generally involve the adjacent motor cortex, most patients also suffer from a partial paralysis of the right side of the body, which is usually greater in the arm. In other words the conjunction of Anna O.’s disturbances of language with the paralysis which affected her right extremities, far from suggesting ‘hysteria’, indicates diffuse damage to a particular region of the brain. The underlying medical condition which gave rise to such brain pathology is likely to remain for ever unknown. But the neurological basis of Anna O.’s illness, though still disputed by some, has by now been placed beyond reasonable doubt.
If this were the only misdiagnosis ever to have played a role in the development of psychoanalysis it would be momentous, since it led to the very creation of the technique. When Freud himself attempted to apply this technique to his own patients, however, he left behind him a trail of similar misdiagnoses.
Freud’s first patient, Frau Emmy von N, was, as we have seen, afflicted by convulsive movements of her face and neck and the compulsion to shout out and make clicking sounds. Just such movements of the muscles of the face and neck, coupled with involuntary utterances, are classic signs of Tourette’s syndrome. Today Frau Emmy would almost certainly be diagnosed as suffering from a variant of this neurological disorder.
Lucy R, the English governess who experienced hallucinations centring on the smell of burnt pudding, was another of Freud’s patients whose symptoms would now be seen as having a neurological origin. Recurrent olfactory hallucinations are frequently found in temporal lobe epilepsy; the neurologist Doris Trauner, for example, writes that ‘Some patients complain of intense olfactory hallucinations that in most cases are unpleasant (e.g. a smell of rotten eggs or burnt toast)  In the case of Elisabeth von R, Freud himself admitted that the pain she experienced in her legs was ‘rheumatic in origin’ but claimed (implausibly) that it had been taken over by hysteria as ‘a mnemic symbol of her painful psychical excitations’.  In yet another case, that of Dora, Freud knew that doctors had diagnosed appendicitis and that this was accompanied by a dragging of the right foot. He confidently repudiated this diagnosis, claiming that Dora’s abdominal pains were the throes of a hysterical childbirth, and that her dragging foot indicated her knowledge that she had made ‘a false step’. Two surgeons, however, have since pointed out that a dragging foot could be caused by pelvic appendicitis, and that pain in the right leg is even used as a diagnostic test for this condition. 
If there should be any residual doubt about whether Freud’s ideas about hysteria led him to make serious diagnostic errors, it is dispelled by Freud himself. In 1901 he described an occasion when a fourteen-year-old girl had fallen ill ‘of an unmistakable hysteria’. Freud claimed that the hysteria ‘cleared up’ under his care. However the girl still complained of the abdominal pains ‘which had played the chief part in the clinical picture of hysteria.’ Two months later she died of sarcoma of the abdominal glands. Although Freud sought to mitigate his error by claiming that hysteria had used the tumour as ‘a provoking cause’, there could not conceivably have been any evidence to support this view. 
Did Freud Cure his Patients?
If Freud’s early patients were, for the most part, not suffering from psychological disturbances at all, and if Freud’s therapeutic technique was founded on the medical errors of Charcot, it might well be asked how it was that he (and Breuer) succeeded in curing so many patients in the remarkable fashion attested to by the early case histories.
The first patient whose cure by psychoanalysis was proclaimed to the world was, of course, Anna O.. In his account of the case Breuer quite clearly described how, after a climactic session in which Anna O. had recalled a frightening hallucination, ‘the whole illness was brought to a close.’ The story of her dramatic cure became the founding miracle of psychoanalysis. In fact, however, no such cure ever took place. A year after Breuer had broken off his treatment of Anna O., he had confided to Freud that the patient he had supposedly cured ‘was quite unhinged and that he wished she would die and so be released from her suffering’. Anna O. did subsequently improve, but a few years later, after a long stay in a sanatorium, she was still suffering from hallucinatory states in the evening.
The manner in which Freud dealt with this knowledge is perhaps best understood by reference to another case in which he became involved. In 1885, while researching the effects of cocaine, he persuaded a colleague, Ernst von Fleischl-Marxow, to take the drug in order to wean him from an addiction to morphine. Although Freud publicly reported that his colleague had been cured and that ‘no cocaine habituation set in’, Fleischl-Marxow had in fact become severely addicted to cocaine and had been reduced to a state of physical and mental wretchedness.
Just as, in 1885, Freud had reported the treatment of his colleague as having been successful, so, ten years later, he endorsed Breuer’s published case history, even though he knew that Breuer’s claim to have cured Anna O. was false. In recounting his own psychoanalytic cases Freud frequently gave an assessment of his therapeutic role which was misleading in a similar way.
When he described the outcome of his treatment of Emmy von N. he equivocated, attempting to claim some therapeutic credit even though it is clear that her illness was not cured. In the case of Elisabeth von R. he was obliged to admit that her lameness had returned after the completion of the treatment. He then gave his case history a fairy-tale ending when he claimed that he had managed to obtain an invitation to a private ball she was attending and was able to observe his former patient, six months after the treatment ended, ‘whirl past in a lively dance’. Freud’s own implicit estimation of his role in this alleged cure was not shared by his patient. Years later, talking to her daughter, she described Freud as ‘just a young, bearded nerve specialist they sent me to’. He had tried ‘to persuade me that I was in love with my brother-in-law, but that wasn’t really so’. 
Once again it is Freud himself who dispels any doubts there may be about his habit of presenting as cures or partial cures, courses of treatment which had in fact been unsuccessful. For it is clear from his own subsequent statements (and above all from his private admissions to Fliess) that, when he claimed publicly that he had tested his seduction theory successfully on eighteen patients and implied that some of these had been cured, he was not telling the truth. The real situation, as he would eventually confide in Fliess, was that he had not succeeded in curing a single patient, and there was no clinical evidence that his theory had any merit whatsoever.
SE = Standard Edition PF = Penguin Freud
WFWW = Why Freud Was Wrong
 Mapping the Mind, Weidenfeld, 1998, p.4
 Why Freud Was Wrong, pp. 112-35; p. Xvi
 WFWW, p. 159
 SE2, p.135; PF3, p. 237
 PF8, p. 143; WFWW, p. 198 (note).
 SE6, p. 146 (note); PF5 pp. 197-8 (note)
 WFWW, p. 164
 SE11, pp. 9-20
 SE2, pp. 154; PF3, p. 223
 SE2, p. 295, PF3, p. 282