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An Overlooked Sexual Element in the Breuer-Anna O. Case.

The purpose of this paper is to review the variety of symptoms Josef Breuer's (1842-1925) patient, Bertha Pappenheim (1859-1936), known in the literature as 'Anna O.', manifested during the course of her groundbreaking therapy with Breuer in 1880-1882. This review will set the stage for a discussion of one particular symptom, her drinking aversion, the circumstances contributing to her symptom formation and a proposed reinterpretation of the latter within the context of the Breuer-Freud theory of the sexual etiology of neuroses as presented in the Studies on Hysteria (1895/2001; referred to hereafter as Studies).

Over the years, Breuer held fast to his account of the case of Anna O. As late as 1907, twenty-five years after he ceased being her personal physician, "he regarded the case as one which had been carried to complete cure without the finding of a sexual basis" (Cranefield, 1958, p. 321). Briefly, the Breuer-Freud theory, as summarized by Strachey (as cited in Breuer & Freud, 1895/2001) is as follows:
   The main theoretical position adopted by [Breuer and Freud] ...
   hold[s] that ... if an experience is accompanied by a large amount
   of 'affect', that affect is either 'discharged' in a variety of
   conscious reflex acts or becomes gradually worn away by association
   with other conscious mental material. In the case of hysterical
   patients ... neither of these things happens. The affect remains in a
   'strangulated' state, and the memory of the experience to which it
   is attached is cut off from consciousness ... [however] if the
   original experience, along with its affect, can brought into
   consciousness, the affect is by that very fact discharged or
   'abreacted', the force that has maintained the symptom ceases to
   operate, and the symptom itself disappears. (p. xviii-xix)


Overview of Breuer's Report of the Anna O. Case

Given the myriad of symptoms Anna O. displayed, I argue her drinking aversion, and the circumstances that gave rise to it, are freighted with sexual symbolism. Examining this symptom as sexual in nature may seem ironic, however, in light of Breuer's comment from 1895: "The element of sexuality was astonishingly undeveloped in her" (Studies, 1895/2001, p. 21-22). Breuer continued to maintain his position on Anna O.'s 'undeveloped sexuality' several years later. He wrote: "The case of Anna O., which was the germ-cell of the whole of psychoanalysis, proves that a ... severe case of hysteria can develop ... and be resolved without having a sexual basis. I confess that plunging into sexuality in theory and practice is not to my taste." (Breuer, as cited in Cranefield, 1958, p. 320, emphasis added). However, might Breuer have 'protested too much' regards the absence of sexuality in the Anna O. case? Is Breuer protecting Anna O. and her family by not introducing a sexual element in his published reports of the case? For example, Anna's pseudocyesis was revealed by Freud (1914/2001a), and then more explicitly by Jones (1953); it is not mentioned by Breuer in any of his reports (e.g., Studies, 1895/2001). Breuer confessed that he "suppressed (emphasis added) a large number of quite interesting details" in his report of the case in the Studies (1895/2001, p. 41). Breuer was well acquainted with Anna O.'s family and it is suggested "that he probably had been ... a consultant" physician to Anna's seriously ill father (Castelnuovo-Tedesco, 1994, p. 60). Freud was also acquainted with the Pappenheim family as was Breuer and Freud's inner psychoanalytic circle. Anna O. had been a social acquaintance of Freud's wife, Martha. Taken together, the element of familiarity with Anna O. and her family may have influenced Breuer's reported and very circumscribed and deliberately opaque picture of Anna O.'s condition and how her condition may have been associated with her home life. Thus, Breuer took measures of extreme confidentiality so as not to divulge sensitive information pertaining to her illness in the context of Anna's household and this would certainly include reporting elements of his patient's sexuality, which would have been a taboo subject. Breuer's biographer, Hirschmuller (1989), says: "It must...be asked whether Breuer did not too obviously try to keep the theme of sexuality out of the case report" (p. 108).

Breuer agreed with Freud, in their collaboration on the Studies, to a sexual etiology of hysteria. As Britton (1999) remarked: "The ... erotic psycho-drama that took place within Breuer's treatment [of Anna O.] ... potentially gave Freud raw material for his theories of the Oedipus complex, identification, transference, countertransference, repetition compulsion ..." (Britton, 1999, p. 2). Her importance to psychoanalysis may be gauged by the following: "Freud ... who never treated her, mentioned her more often than any of his own patients and he came back to her case in his writings again and again" (Castelnuovo-Tedesco, 1994, p. 57).

Breuer's understanding of Anna O.'s asexuality, however, does not harmonize with Freud's later, retrospective, version of events. In a letter dated June 1932, Freud described the circumstances around Breuer's abrupt departure as Anna's physician and the psychosexual dynamics that arose between the two protagonists. Freud wrote:

What really happened with Breuer's patient I was able to guess later on, long after the break in our relations, when I suddenly remembered something Breuer had once told me in another context before we had begun to collaborate and which he never repeated. On the evening of the day when all her symptoms had been disposed of, he was summoned to the patient again, 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, 1970, p. 409-410)

Freud went on to recount how this was Breuer's lost opportunity: "At this moment he held in his hand the key that would have opened 'the doors to the Mothers', but he let it drop" (Freud, 1970, p. 409-410). Freud did undertake to interpret at least one of her symptoms ("Dr. B's child is coming!") in the 1932 letter, but did not offer in the Studies any reference to Anna O.'s possible transference, or for that matter, Breuer's possible 'counter-transference.' Why did Breuer, who "held in his hand the key ... let it drop?" Breuer, as Forrester (1986) suggests, "recognized the importance of sexuality in the etiology of neuroses" (p. 329). A clue to answering that question may perhaps be provided in the aforementioned 1907 letter to Forel. There he wrote:

Thus, at the time I learned a ... great deal: much that was of scientific value, but something of practical importance ... namely, that it was impossible as a 'general practitioner' to treat a case of that kind without bringing his activities and mode of life completely to an end. I vowed at the time that I would not go through such an ordeal again (Breuer, as cited in Cranefield, 1958, p. 320).

The "ordeal" to which he refers may have obstructed a closer look at a potentially sexual component operating between the two of them and yet, Breuer could not forget the import of the Anna O. case, further stating that the case was "instructive and scientifically important" (Breuer, as cited in Cranefield, 1958, p. 319). However, the last thing he wanted to take note of, much less to investigate, would be a potentially scandalous sexual element that could have very well implicated Breuer as instigating or suggesting sexual elements in their therapeutic dynamic. Yet, it was out of this therapeutic rapport that the notion of transference-counter-transference was eventually developed by Freud after hearing from Breuer, sometime later, his account of the case. Breuer made it very clear regarding his understanding of the importance of sexuality in hysteria; clearly indicated in the theoretical chapter he had written for the Studies. There he wrote:

It is a most unfortunate thing that clinical medicine ignores one of the most pathogenic factors or at least only hints at it delicately. This is certainly a subject in which the acquired knowledge of experienced physicians [I believe he would have included himself in the category of "experienced physicians"] should be communicated to their juniors, who as a rule blindly overlook sexuality--at all events so far as their patients are concerned (Breuer & Freud, 1895/2001, p. 246).

Breuer continues: "... perhaps it is worthwhile insisting again and again that the sexual factor is by far the most important (emphasis added) and the most productive of pathological results" (Breuer & Freud, 1895/2001, p. 246-247). In the 1907 letter, he further reinforced his point of view as follows:

Together with Freud I was able to observe the prominent place assumed by sexuality and I can give an assurance that this arose from no inclination towards the subject but from the findings--to a large extent most unexpected--of our medical experience (Breuer, as cited in Cranefield, 1958, p. 302).

A Man of Two Minds

Overall, Breuer would appear to be conflicted. On the one hand, he recognizes the operation of the sexual factor in hysteria, and on the other, his initial reluctance to collaborate with Freud on the Studies when it comes to acknowledging it as an important causal factor in neuroses, notably in the case of Anna O. Perhaps Breuer felt Freud had overreached in ascribing sweeping importance to one factor as the causal bedrock of hysteria. Breuer did say as much in the aforementioned letter. There Breuer wrote: "Freud is a man given to absolute and exclusive formulations: this is a psychical need which, in my opinion, leads to excessive generalization" (Breuer, as cited in Cranefield, 1958, p. 320).

As Freud reflected: "When I ... began more and more resolutely to put forward the significance of sexuality in the aetiology of hysteria, he was the first to show the reaction of distaste and repudiation" (Freud, 1914/2001a, p. 12). Jones (1961) noted Breuer's "distaste" and remarked: "That disturbances in the sexual life were essential factors in the aetiology of neuroses ... was a doctrine Breuer could not easily stomach" (p. 224, emphasis in original). Yet, Breuer acquiesced, collaborated with Freud and eventually recognized the significance of what both he and Freud had produced. As Freud remarked: "At the time when he submitted to my influence and was preparing the Studies for publication, his judgment of their significance seemed to be confirmed. 'I believe', he told me, 'that this is the most important thing we two have to give to the world'" (Breuer & Freud, 1895/2001, p. xxviii).

This 'most important thing' very likely not only included the treatment of hysteria utilizing the methods of 'catharsis' and the "talking cure", but as well, the importance of the theory of hysteria which emphasizes the role played by disturbances in sexuality; as Breuer said, "I do not think I am exaggerating when I assert that the great majority of severe neuroses in women have their origin in the marriage bed" (Breuer & Freud, 1985/2001, p. 246, emphasis in original), or at the very least, in some form of sexual trauma.

Thus, Breuer does appear conflicted as this relates to the matter of disturbances in sexuality as a causal agent of hysteria. Perhaps we have a further clue to his ambivalence, provided by Strachey's observation of Breuer's initial reticence to collaborate with Freud in the Studies. Strachey said of Breuer: "we have the picture of a man half-afraid of his own remarkable discoveries" that came about through his eventful encounter with Anna O. (Strachey, in Breuer & Freud, 1895/2001, p. xxvi). Jones (1953) made a more pointed comment by referring, as he expressed it, to "a weakness in [Breuer's] personality that made it hard for him ever to take a definite stand on any question" (p. 255).

Similarly, Freud was outspoken about Breuer's hesitations on the matter of the sexual etiology in hysteria. In a letter Freud penned on November 8, 1895, about six months after the publication of the Studies, anticipating Jones' comment above, Freud wrote: "Recently at the College of Physicians Breuer gave a big speech in my honor and introduced himself as a converted [emphasis original] adherent to the sexual etiology. When I thanked him for this in private, he spoiled my pleasure by saying, 'All the same, I don't believe it'" (Freud, 1985, p. 151).

Breuer eventually endorsed the Freudian position and expressed his admiration of Freudian psychoanalysis years later. Breuer said: "I ... regard Freud's work as magnificent: built up on the most laborious study in his private practice and of the greatest importance" (Breuer, as cited in Cranefield, 1958, p. 320). This was a remarkable endorsement of Freud, and admission on Breuer's part, that he was able, in spite of the passage of twelve years since the publication of the Studies, and finding that the Freudian emphasis on the sexual origins of hysteria were not to his 'taste,' to offer Freud such a sincere and generous compliment.

The intrepid Freud, years before what materialized as their joint publication of the Studies, took note of what Breuer had to say about Anna O. "They had conversations about hysteria well before Freud's trip to Paris" to study with Charcot between 1885 and 1886 (McGrath, 1986, p. 162). In these discussions of the case study of Anna O., Freud states that this case had "accomplished more toward an understanding of neuroses than any previous observation" (Freud, as cited in McGrath, 1986, p. 162).

We may discern a noticeable character difference between Breuer and Freud, the former being more cautious and conservative in moving into uncharted territory, and the latter more bold and strident, going forward, beckoned by the enticing story of Breuer's patient and wishing to pursue its possibilities. In a letter dated February 1, 1900, Freud points to his temperamental disposition, which can serve as a contrast to that of Breuer's. Freud wrote:

... For I am actually not at all a man of science, not an observer, not an experimenter, not a thinker. I am by temperament nothing but a conquistador--an adventurer, if you want it translated--with the curiosity, daring, and tenacity characteristic of a man of this sort (Freud, 1985, p. 328).

Upon further reflection, Freud wrote:

I have strong reasons for suspecting that after all her symptoms had been relieved Breuer must have discovered from further indications the sexual motivation of ... transference [emphases added], but that the universal nature of the unexpected phenomenon escaped him, with the result that, as though confronted by an 'untoward event' he broke off all further investigation" (Freud, 1914/2001, p. 12).

However, the breaking off of all further investigation may have been in part prompted by what Freud's eminent biographer, Ernest Jones has suggested:

It would seem that Breuer had developed what we should ... call a strong counter-transference to his interesting patient. At all events he was so engrossed that his wife became bored at listening to no other topic, and before long became jealous. She did not display this openly, but became unhappy and morose. It was not long before Breuer, with his thoughts elsewhere, divined the meaning of her state of mind. It provoked a violent reaction in him, perhaps compounded of love and guilt, and he decided to bring the treatment to an end (Jones, 1961, p. 203).

Perhaps we can appreciate that Breuer was aware of the strong feelings Anna O. felt for him, and the corresponding feelings he had for her, and these feelings, along with the element of sexuality now evident in both Anna O. and himself, along with Breuer's wife's displeasure over her husband's absorption in the case, led him to abandon further treatment of Anna O. It may be noted years later Anna O. never spoke of her illness at the time Breuer was her physician to her biographer, Dora Edinger (1963) and she refused to allow the young women in her care to be psychoanalyzed (Sulloway, 1979, p. 57). "Psychoanalysis," she remarked in the 1920s, "is in the hand of the physician what the confessional is in the hand of the Catholic clergyman: it depends on the person applying it and the.application whether it is a good instrument or a double-edged sword" (as cited in Edinger, 1963, 12-13). As for Breuer, it was safer to abandon his patient for both his integrity as a physician and for the sake of his marriage. Regrettably, Breuer did not seize the moment; 'he held the key in his hand but let it drop', and as I have argued elsewhere: Breuer's is a "tale of missed opportunity" (Marchese, 2017, p. 387) since he failed to explore the ramifications of the ubiquity of the transference process as this process emerges in psychotherapy.

On the basis of the foregoing and in light of the absence of any theoretical interpretation of the drinking aversion, I am prompted to ask the following question: What was the symbolic, sexual, significance of this symptom, interpreting it within the context of Breuer and Freud's theory of the sexual etiology of hysteria as this theory was expounded in the Studies?

Give the Man His Due

In his opening remarks, on September 6, 1909 to an American audience at Clark University in Worcester, Massachusetts, Freud declared the first official recognition of his method, psychoanalysis. He said, "it seemed like the realization of some incredible day-dream" (Freud, 1977, p. 4). However, Freud made it very clear to his audience at that time that it was not he, but rather Breuer, friend, colleague, and collaborator, who was initially responsible for laying the foundations of psychoanalysis. Freud said the following:

If it is a merit to have brought psycho-analysis into being, that merit is not mine. I had no share in its earliest beginnings. I was a student and working on my final examinations at the time when another Viennese physician, Dr. Josef Breuer, first (in 1880-82) made use of this procedure on a girl who was suffering from hysteria (Freud, 1977, p. 9).

The opinion that Freud advanced in 1909 is further reinforced decades later by the principal translator and editor of The Standard Edition of the Complete Psychological Works of Sigmund Freud (Breuer & Freud, 1895/2001), James Strachey. Strachey says of the Studies that "Breuer's treatment of Fraulein Anna O., on which the whole work [Studies] was founded, took place between 1880 and 1882" (Strachey, in Breuer & Freud, 1895/2001, p. x) Thus, as a result of the Breuer-Anna O. collaboration, we can say with confidence that the "talking cure" formed the foundation of Freud's technique of "free association" (Breuer & Freud, 1895/2001, p. 56, Strachey, note 1).

Other writers have expressed a similar sentiment that would harmonize with Freud, Strachey, Ellenberger and Breger's assessment of Breuer and Anna O.'s contribution, the overall importance of the Studies, both of which contributed to the foundations of psychoanalysis. Clack (2013) says, "The clinical practice detailed in the Studies on Hysteria stems from Breuer's 'cathartic method'" (p. 35). She continues: "In this method, therapeutic suggestions were made to the hysterical patient whilst they were under hypnosis ... [and] under hypnosis, symptoms were traced to their source. This was a significant development, for once the source of the symptom was identified, its power to affect the hysteric's actions was undermined and the symptom disappeared" (Clack, 2013, p. 35).

As Breuer remarked in summary at the end of his report on Anna O., "I have ... described the astonishing fact that from the beginning to end of the illness all the stimuli [that gave rise to her symptoms] ... together with their consequences, were permanently removed by being given verbal utterance ... and I have only to add an assurance that this was not an invention of mine which I imposed on the patient" (Breuer & Freud, 1895/2001, p. 46).

Thus, it was Breuer's attentive listening to Anna O., and encouraging her to express the emotion that had long been denied expression, that she provided the clues that led to the first formulations of psychoanalysis.

"She was ...", noted Breger (2009), "the first psychoanalytic patient, and Breuer's cathartic method the real beginning of psychoanalysis as a theory and therapy" (p. 30). Ellenberger (1972) concurred with Breger's assessment as to the importance of the Anna O. case. As Ellenberger remarked: "To this day, the most elementary account of psychoanalysis begins with the story of ... 'Anna O.' ... and [her] story [is] given as the prototype of a cathartic cure and one of the basic occurrences that led Freud to the creation of psychoanalysis" (p. 267).

Freud was unequivocal, as were many others, in recounting the early history of psychoanalysis, crediting Breuer, as well as acknowledging Anna O.'s contribution, as the one who "brought psycho-analysis into being" (Freud, 1977, p. 9).

Symptoms and Recovery

In describing the variety of symptoms displayed by Anna O., the following have typically been mentioned: a convergent squint, disturbances in speech and communication expressed in her inability to speak (Breger, 2009, p. 34-35); paralyses in the form of contractures in the right upper and lower extremities, paresis of the neck muscles, tactile anesthesia, linguistic disorganization (Ellenberger, 1972, p. 268); periods of somnambulism, a severe cough, hallucinations of snakes which was "how she saw her hair"; a loss of her command of grammar and syntax, having become "almost completely deprived of words," putting words together "laboriously out of four or five languages" consisting of her native German coupled with English, Italian, and French; periods of extreme anxiety, including "violent outbursts of excitement ... succeeded by profound stupor"; "absences", (a term Breuer borrowed from the French to describe alternations of consciousness, or a splitting of personality), in which in one state she was lethargic and melancholy but otherwise normal. This state alternated with another which she called her "naughty state," or her "absence" in which she was highly agitated and susceptible to hallucinations and uncontrollable behavior (Breuer & Freud, 1895/2001, p. 23-26) and finally, a drinking aversion (Ellenberger, 1972, p. 277), or drinking inhibition, to which I will refer in more detail below, offering a psychosexual interpretation of it. This last symptom, the drinking aversion, is reported by Breuer as follows:

It was in the summer period of extreme heat, and the patient was suffering badly from thirst ... she found it impossible to drink. She would take up the glass of water she longed for, but as soon as it touched her lips she would push it away ... As she did this, she was ... in an absence [emphasis original] . She lived only on fruit, such as melons, etc., so as to lessen her tormenting thirst. This lasted for some six weeks, when one day she grumbled about her English lady-companion ... and went on to describe, with every sign of disgust [emphasis added] how her little dog--horrid creature--had drunk out of a glass there. (Breuer, as cited in Breuer & Freud, 1895/2001, p. 34-35)

Thereafter, for the aforementioned six weeks, Anna refused to drink out of a glass. It was not until she recounted this past episode to Breuer in an auto-hypnotic state, giving "verbal utterance" (Breuer & Freud, 1895/2001, p. 6) to the memory of it and the associated disgust she felt at the time which gave rise to this symptomatic aversion, did the symptom disappear.

Breuer's report is as follows: "After giving energetic [verbal and emotional] expression to the anger she held back, she asked for something to drink, drank a large quantity of water without difficulty and woke from her hypnosis with the glass at her lips; and thereupon the disturbance vanished, never to return" (Breuer & Freud, 1895/2001, p. 34).

As Fink (2017) comments on this episode: "This was the first symptom Breuer was able to help her with--using a technique ["talking cure" as she called this technique] that she spontaneously invented" (p. 16). Anna O.'s symptom was the first to which the 'cathartic' method had been employed by Breuer. "Pappenheim [Anna O.] and Breuer discovered that this talk and the emotional discharge produced when the memory of the original disturbing incident emerged had a curative effect" (Mitchell & Black, 1995, p. 3). Others have described this particular episode in similar terms (e.g., Breger, 2009; Clack, 2013; Ellenberger, 1972; Fink, 2017), and although Anna O.'s symptom was therapeutically addressed successfully by Breuer in collaboration, it should be noted that neither Breuer, nor subsequent investigators, discussed the symbolic significance of Anna's drinking aversion. Rather, they tended to merely describe the circumstances, as reported above, that Anna O. had disclosed to Breuer to account for her symptomatic aversion. How ironic since the retelling of this episode over the years has not suggested an underlying sexual element that may have been associated to the onset of Anna's dramatic symptom.

What might have the dog's lapping up water out of a glass in the bedroom of Anna's English companion, suggested to Anna? Although Breuer suggested Anna may have been ignorant of the intimacies of sexuality, it does not rule out the possibility that Anna albeit unconsciously, interpreted the dog's drinking from the glass as symbolic, as indicative, of sexual action. It taxes credulity that the twenty-one year old Anna, described by Breuer as "markedly intelligent, with an astonishing quick grasp of things and penetrating intuition ... possessed of a powerful intellect ... [having] great poetic and imaginative gifts, which were under the control of a sharp and critical commonsense" (Breuer & Freud, 1895/2001, p. 21), that Anna would have been unable to construe the dog's behavior at the glass, in the bedroom of her English lady-companion, as not having sexual associations she would find difficult to ignore, and repugnant. And further, that no other investigator then and since, ventured to speculate, based upon Breuer's glowing description of Anna's intellectual and emotional qualities, that she would have been ignorant of various kinds of sexual manifestations.

It should be noted at this point that Breuer subscribed to the position that both he and Freud proffered in regards to the causes of hysteria; principally, disturbances in sexuality as an important causal agent. As Breuer observed, "The sexual instinct is undoubtedly the most powerful source of persisting increases of excitation (and consequently of the neuroses" (Breuer & Freud, 1895/2001, p. 200). Further, if excitation arising from the sexual instinct is not discharged through normal channels; for example, satisfying sexual relations or at the very least verbal utterance with an associated expression of affect (emotion), it, the accumulated excitation, finding no satisfactory release, may be converted into the psychophysical expressions of hysterical symptoms. In the case of Anna O., she suppressed all expression of her upset at the time: "The patient had said nothing, as she wanted to be polite" (Breuer & Freud, 1895/2001, p. 34) during the episode she had witnessed in the bedroom of her English companion. It was only after she gave "energetic expression," discharging the suppressed affect in words (verbal utterance) and releasing the pent-up affect, did she find relief and was then able to drink "a large quantity of water without difficulty . whereupon the disturbance [drinking aversion] vanished, never to return" (Breuer & Freud, 1895/2001, p. 35).

As Breuer further comments: "excitation of the sexual affect is quite frequently converted [emphasis added] into hysterical somatic phenomena" if not sufficiently brought to satisfaction through normal release (Breuer & Freud, 1895/2001, p. 246), and normal release, at the very least, would be, verbal expression. As Breuer & Freud, (1895/2001) make clear: "... language serves as a substitute for action; by its help, an affect can be 'abreacted'" (p. 8), and thus the discharge of emotion that has been denied expression can be now fully discharged, verbally, with curative effect. As Breuer and Freud, 1895/2001) stated:
   To our great surprise ... each individual hysterical symptom
   immediately and permanently disappeared when we had succeeded in
   bringing to light the memory of the event by which it was provoked
   and in arousing its accompanying affect, and when the patient had
   described that event in the greatest possible detail and had put
   the affect into words [emphasis original]. Recollection without
   affect almost invariably produces no result. The psychical process
   which originally took place must be repeated as vividly as
   possible; it must be brought back to its status nascendi and then
   given verbal utterance (p. 6).


The above psychotherapeutic procedure, then, has a curative effect by "bring[ing] to an end the operative force of the idea which was not abreacted in the first instance, by allowing the strangulated affect to find a way out through speech" (Breuer & Freud, 1895/2001, p. 17, emphasis original).

Returning now to the episode of the dog drinking from the glass, I offer the following interpretation. In order for Anna O. to show such profound "disgust" at the time and subsequently refusing to drink from a glass for at least six weeks, placing her health in danger as a result, this episode was very likely associated with her understanding of oral sex. The dog, in lapping up the water from a glass, the glass with its oval, orifice like opening, which perhaps suggests the opening of the vagina and the action of lapping up the water as representing an exchange of bodily fluids, repulsed Anna, so much so, that she developed a profound and dramatic life threatening symptom that went beyond merely remaining mute out of "politeness." She summarily stopped drinking from a glass for six weeks! This symptomatic refusal to drink from a glass corresponds quite nicely with Breuer's observation: "excitation of ... sexual affect is quite frequently converted into hysterical somatic phenomena" (Breuer & Freud, 1895/2001, p. 246). This is precisely what happened to Anna O., she was horrified at the sight of the dog--"horrid creature" (Breuer & Freud, 1895/2001, p. 34)--drinking from the glass and converted her disgust, sexual affect, arousal, into abhorrence which revealed itself in the somatic symptom of refusing to drink from a glass. It will be recalled: "She lived only on fruit, such as melons, etc., so as to lessen her tormenting thirst" (Breuer & Freud, 1895/2001, p. 34) for an extended period of time. Breuer's therapeutic intervention permitted Anna O. to recall the memory of the incident and its associated affect and this released Anna O. from the drinking aversion symptom, restoring to her the capacity to drink normally again.

In a famous summary statement, Breuer and Freud (1895/2001) wrote: "Hysterics suffer mainly from reminiscences" (p. 7, emphasis original). Thus, hysteria is caused by trapped memories and the feelings associated with them. Those memories and feelings had they been lived through in an ordinary way become split off from the rest of the mind, only to fester and rise to the surface in the form of disconcerting and seemingly inexplicable symptoms, as was the case in Anna O.'s condition. The sexual element was very much in evidence in the case of Anna O. The refusal to drink following the incident in her lady companion's bedroom, as indicated above, was freighted with sexual symbolism. The dog's behavior at the glass of water so repulsed Anna, a witness to a symbolic sexual act that, given matters of propriety, should not be displayed by a household pet publicly and with seeming tolerance of her mistress.

Giving verbal expression, as Anna O. was able to do in her therapy with Breuer, along with energetic cathartic expression of emotion long held in check, harmonizes with emphasis on the necessity to recall the provoking event, putting the memory of it into words, as well as discharging the accumulated affect that heretofore had not been expressed. Thus, with abreaction or discharge of the original experience through recall of the precipitating event that brought about the hysterical symptom in the first place, the "force that has maintained the symptom ceases to operate, and the symptom disappears" (Breuer & Freud, 1895/2001, p. xix).

Anna O. required further treatments for various physical and psychological ailments that arose subsequent to the Breuer phase of treatment. Perhaps Breuer, in not confronting the sexual components of his patient's hysteria, left the treatment of Anna O. incomplete. For example, she was a resident patient at the Sanatorium Bellevue and on three subsequent occasions at the Fries and Breslauer Sanatorium following the Breuer period (Crews, 2017, p. 350; Ellenberger, 1972, p. 267). Her life post-treatment, although it eventually proved to be remarkably productive, was still plagued by crippling symptoms and thus Breuer did not get to the bottom of her condition for he did not wish to explore the sexual component attached to the case. However, the importance of collaboration between doctor and patient in facilitating patient recovery most certainly applies to Anna O. Her active participation in the treatment process was instrumental in whatever recovery she was able to achieve in her therapeutic encounter with Breuer. Breuer also benefitted from this encounter, recognizing that tracing symptoms back to the circumstances that give rise to them is essential in bringing about a degree of relief from them. Anna O., it could be argued, instructed Breuer on the matter of a technique that was beneficial to her. She was astutely aware that the talking cure, involving recall of long suppressed memory and discharging the emotion that had been denied expression at the time that circumstances gave rise to her symptoms, were absolutely essential to her recovery. In spite of whatever theoretical model governed Breuer and Freud's approach to the treatment of hysteria at that time, the clinical encounter between Breuer and Anna O. provided the raw material that influenced the shaping of an explanation as to why hysterical symptoms develop in the first place and how in treatment it is possible to discover a technique that was a key to understanding the causation of symptoms and how the latter may be then viewed and treated afresh. A reexamination into the history of the Breuer-Anna O. encounter offers a fresh look at one particular symptom, her drinking aversion in the context of the role of sexuality in contributing to symptom formation, draws attention to the necessity of brushing off the dust that may accumulate when seminal case studies and earlier contributions in the history and development of classical psychoanalysis are not occasionally revisited, redefined, reexamined. And finally, although the emphasis throughout this paper has been on Anna O.'s hysteria, it is important to recognize that she regained her health and came into being as a different person: "efficient, purposeful, emotionally steady, constructively creative, and fearlessly devoted to social justice" (Crews, 2017, p. 356). She went on to write poems, dramas, and stories for children and did welfare work in Germany. In 1895, she became director of the Frankfurt's Jewish Orphanage for Girls, and founded a girl's club featuring library and a lecture series, and then the National Association of Jewish Women, serving as its first president. She died in March, 1936 and after World War II, she was remembered as an "almost legendary figure in the field of social work; to the extent that the government of Western Germany [in the late 1940s] honored her memory by issuing a postage stamp with her picture" (Ellenberger, 1972, p. 271). Thus, Bertha Pappenheim, former patient of Dr. Josef Breuer, carried forward the value of being listened to, a hysteric who was taken seriously by her doctor. After regaining her health, and by interceding on behalf of those whose voices were not heard, actively becoming a spokesperson for those who had been historically relegated, much like the hysterics of a former age, to the margins of society, she carried the legacy of Breuer, Freud and psychoanalysis forward into the field of mental health. The "spartan life style, unremitting hard work, and dedicated altruism" (Castelnuovo-Tedesco, 1994, p. 57) combined with courage and idealism, won the day for Anna O. as she underwent a remarkable transformation through her therapeutic encounter with Breuer and influenced the theory and development of psychoanalysis. She moved from being an invalid with the most remarkably complex set of symptoms to becoming a socially productive person who championed the cause of women's rights. Whatever her estimation of her time with Breuer may have been, as noted in her remark cited earlier in the paper, she did uphold Freud's observation about what might be expected insofar as a cure for hysteria is concerned. Freud said: "much will be gained if we succeed in transforming.hysterical misery into common unhappiness" (Breuer & Freud, 1895/2001, p. 305). Bertha Pappenheim may not have enjoyed a happy carefree life, but her life was remarkably productive and for that she will be remembered as a helper of humanity.

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Frank J. Marchese

York University, Toronto, Ontario, Canada

Author info: Correspondence should be sent to: Dr. Frank Marchese, Psychology Dept., York University, Toronto, Ontario, Canada. frankm@yorku.ca
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Article Type:Case study
Date:Jun 1, 2018
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