Hilda Reilly's Blog: The Writing of Guises of Desire - Posts Tagged "hysteria"

The author of a biographical novel treads through a historical minefield. Get a fact wrong and the historians are up in arms; the validity of the entire work is compromised. Yet there is always more than one side to a story and in the past it has usually been the male side that has been able to make itself heard. This is particularly true of the medical case history. Here it is the doctor's voice which has always been to the fore, and again, until fairly recently, this has been a male voice. Medical historian Roy Porter draws attention to what he calls the 'patient-shaped' gap in medical history, pointing out that histories of epilepsy and hysteria exist, but none by epileptics and hysterics.
When I set out to write a novel about Bertha Pappenheim, the young woman diagnosed as hysterical who later came to be considered the 'founding patient' of psychoanalysis, it was with the hope that I might contribute to the filling of this gap. Of course, I can't know exactly how Bertha felt or thought; we are separated by a wide gulf of time and culture. But I could research the case to the best of my ability and put forward a reasonable hypothesis, which is no less, after all, than her own doctor was doing, not to mention the many therapists since then who have written about her.
My feeling from the beginning was that Bertha's condition was due to a multiplicity of factors, the principal one being neurological. One of the advantages I have had over earlier writers, including Bertha's own doctor, Josef Breuer, is that much more is now known about neurological disorders. In the 1880s, the time of her illness, there was still a general ignorance about this subject, even among the medical fraternity. In the case of Bertha, it now seems likely that a number of her symptoms could be attributed to a form of temporal lobe epilepsy, as suggested by Alison Orr-Andrawes.To get an idea of what it could be like to be experiencing such symptoms I researched personal accounts of present-day sufferers. This not only helped me in fleshing out the lived experience of Bertha, it also strengthened my suspicion that she did indeed have this form of illness.
It is likely that Bertha also had psychological problems as she was an intelligent young woman deprived of educational and career opportunities. With the greater understanding we now have of women's frustrations in this respect is not difficult to imagine how this could have impacted on her emotional state. She was also undoubtedly affected by the large amounts of chloral hydrate and morphine which she was taking, something which Breuer admitted but did not discuss in relation to her symptomatology. Finally, there was very probably a iatrogenic element. There is every indication that the 'talking treatment' generated a strong transference, with Bertha becoming extremely dependent on Breuer emotionally. Again, this is not something dealt with in the two published case histories.
The biographical novel can never claim to be as faithful to reality as an autobiography — though how many of those are true representations rather than accounts of how the author would like to be perceived? — but at least it can give a voice to the unvoiced, those who, for whatever reason, were unable to tell their stories themselves.

"Hysteria is not a pathological phenomenon, and can, in all respects,
be considered as a supreme means of expression."
Sigmund Freud, Studies in Hysteria, 1895

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

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

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

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

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

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

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

The diagnosis applied to Bertha Pappenheim – hysteria – is no longer in use. Many of the patients labelled as hysterical in the past would now be found to have an organic illness such as multiple sclerosis, epilepsy or brain tumour. Yet there still remain cases of patients whose symptoms defy all physical investigation. These patients are diagnosed as suffering from ‘conversion disorder’, ‘somatisation syndrome’ or ‘functional neurological disorder’ – in other words, hysteria under less pejorative names. Although, as with many of the 19th century hysterics, a possible physical cause for these conditions may be uncovered in the future there is a hard core of cases for which this is considered unlikely. The following are some of the criteria used to identify these ‘hard cases’:

Anatomical impossibility

An example of this is ‘glove anaesthesia’ where a patient complains of numbness in the hand, stopping at the wrist. This is invariably diagnosed as conversion syndrome because the sensory nerve that supplies the hand also supplies the arm and would not allow for this specific area of anaesthesia. Other localised areas of numbness occurring in the foot or leg (‘shoe anaesthesia’ and ‘stocking anaesthesia’) encounter the same problem.

Include symptoms which are known to occur in given circumstances

A classic example of this is whiplash injury, the neck injury often related to vehicle accidents. This is found to be more prevalent in countries where people are aware of the condition and how you are likely to get it. It is also found that membership of a support group or engaging in compensation claims for the injury tends to make it harder to get better, possibly because the symptoms are then constantly on the patient’s mind.

Susceptible to the placebo effect

Muscle cramping resulting in limb contracture (dystonia) can be treated with Botox injections. These take about 24 hours to have an effect. Sometimes, however, the Botox is found to work immediately, indicating a case of functional dystonia.

Can any of this help to throw light on the Bertha Pappenheim case?

The question of what is anatomically impossible is relevant to Bertha’s first visual disorder, a convergent squint. An eye specialist diagnosed this as due to a paresis of the abducens(sixth cranial nerve). Breuer discounted this, putting it down rather to hysteria. It has been suggested* that a psychogenic explanation would be impossible. As the abducens controls the external rectus muscle of the eye, a lesion to it makes it impossible to turn the eye outwards. At the same time, the now unopposed internal rectus muscle pulls the eye inward, causing the squint. This could not occur psychogenically as the voluntary motor pathways operated by the upper motor neurons govern entire movements and not individual muscles. So here it is the psychogenic explanation rather than the physical one which is an anatomical impossibility.

On the basis of the ‘whiplash’ scenario, we might expect hysterical symptoms to correspond with symptoms which the patient is already familiar with. It’s interesting to consider Bertha’s prosopagnosia (inability to recognise people’s faces) in relation to this criterion. Although now, thanks to Oliver Sacks, most people know what prosopagnosia is, there was so little awareness of it in the 1880s that not even Bertha’s doctor recognised it. It’s not likely then that she did and therefore even less likely that her subconscious would manage to conjure it up.

There’s no evidence that Breuer ever tried placebos with Bertha. But for contractures of the limb, use of a placebo is not the only means of revealing whether or not the problem is physical. In functional dystonia the muscles will usually relax during sleep or sedation. In a report discovered almost a century after the events, Josef Breuer describes Bertha’s contracture of the arm and leg. They would, he wrote, ‘relax neither when she was asleep nor under intoxication with 5.00 chloral’.

Three more nails in the coffin of Bertha’s hysteria diagnosis, I think.