Was Dora ‘ill’? Vrij Nederland (2 November 1985)

Was Dora ‘ill’?

Anthony Stadlen

Copyright © Anthony Stadlen 1985, 1989, 2020
Very slightly revised, 1989 and 2020

[Stadlen, A. (1985). ‘Was Dora wel ziek?’ (Dutch translation by Han Israëls of the then unpublished Was Dora ill?’) Vrij Nederland, 2 November 1985.
Stadlen, A. (1989). Was Dora ill?’ In Spurling 1989: Vol. 2, 196-203.
Spurling, L., (ed.) (1989). Sigmund Freud: Critical Assessments. London: Routledge.]

Freud’s ‘Dora’ case published in 1905 is the principal paradigm case for his theory of ‘hysteria’. It is therefore important to evaluate it.

In its first sentence Freud claims he will ‘substantiate my assertions made in 1895 and 1896 on the pathogenesis of hysterical symptoms and the psychical occurrences in hysteria through the detailed communication of an illness- and treatment-history’ (my translation).

Freud is claiming that:
(1) Dora was ‘ill’;

(2) her ‘illness’ was ‘hysteria’;

(3) his theory of its ‘pathogenesis’ is ‘substantiated’ by this case.
These are Freud’s central claims in the case. He makes many other claims but I shall not consider them here.

These central claims, implicit in Freud’s first sentence, have not been made explicit in the literature on the ‘Dora’ case. They have therefore not been properly examined.

The crux is Freuds claim that Dora is ‘ill’. For, if she is not ‘ill, she can have no ‘hysterical symptoms’; and there can be no ‘pathogenesis’. Thus, if she is not ill, the case can not substantiate’ any ‘assertions ... on the pathogenesis of hysterical symptoms’ by Freud or by anyone else.

Claim 2 can not be true unless Claim 1 is. Claim 3 can not be true unless Claims 1 and 2 are. How may we test the truth of Claim 1?

Freud’s claim that Dora was ‘ill’ was implicit in his first sentence. It must first be made explicit as we have just done. Then it must be tested as an hypothesis.

In even the most critical literature on the ‘Dora’ case it has simply been presupposed.

Freud does not try to justify the claim that Dora was ‘ill’. He does not, indeed, state it as a claim. For him it is an assumption: even a self-evident truth.

He does try to show that this or that physical complaint or emotional response of Dora’s is an ‘hysterical symptom’. He also asserts that her response on one particular occasion is itself sufficient ground for him to regard Dora without hesitation (‘unbedenklich’) as an ‘hysteric’. Thus he diagnoses this response of Dora’s as pathognomonic of ‘hysteria’.

He does not assert that she is ‘ill’ and try to prove it. He speaks, instead, repeatedly, of her ‘illness’. His discussions of her ‘hysteria’ reinforce his implied claim that she is ‘ill’. They reinforce it because Freud is making another unstated assumption: that hysteria is an illness’.

The diagnosis of ‘hysteria’, as Freud makes it, means this. Dora complains of, or appears to suffer from, physical ailments and emotional distress. Freud denies that her ailments are genuine. He denies that her distress is justified. Her ailments, he says, are not a physically determined result of organic illness. Her distress, he says, is not a socially intelligible response to interpersonal conflict. Thus his diagnosis of Dora’s ‘hysteria’ is an allegation that Dora is irrational.

But this is not all. Freud is not merely alleging that Dora is irrational. He is not even merely alleging that she is irrational in a particular way: ‘hysterically irrational’. ‘Hysterical irrationality’ might perhaps be a useful category. It would then be an empirical question whether this category applied to Dora.

No. What Freud is alleging is that Dora’s alleged ‘hysterical irrationality’, which – he alleges – mimics genuine ‘illness’ and justified distress, is itself the result of an actual ‘illness’ from which Dora suffers. This actual ‘illness’, he alleges, is ‘hysteria’.

Thus he says not merely that Dora’s physical ailments are not genuine. He says, rather, that she is suffering from a genuine ‘illness’, ‘hysteria’, which makes her imitate other genuine illnesses. And he says not merely that Dora’s emotional distress is not justified. He says, rather, that it is her ‘illness’ that is responsible for her unjustified distress and unjustifiably distressed behaviour.

Freud is saying that Dora is irrational; that she is ‘ill’; and that her irrationality is a result of  and evidence of  her ‘illness’.

Let us now make a start at testing Freuds claims. We must look at some of his examples of Dora’s ‘illness’. We must ask, in the first place, whether these examples show her to be even irrational. If these examples do not show her to be even irrational, he has given no evidence that she is ill, whatever he means by ill. 

Doras physical ailments

One of her ailments was appendicitis. It was accompanied by a dragging of her right foot. At least two doctors had concurred in this diagnosis. They had been called in by Dora’s wealthy father. He would presumably have chosen competent physicians. This was when Dora was sixteen. It was about eighteen months before she started her analysis with Freud. He did not see her at the time. He does not claim to have examined her physically at any time. He does not claim to have sought, or received, reports from the examining doctors.

Freud, however, denies that Dora had appendicitis. He denies that the dragging of her foot was a genuine ailment. He asserts that both complaints were ‘hysterical’.

It is important to note that Freud does not examine the examining doctors’ evidence and find it wanting. He simply does not examine it. His assertion that these complaints were ‘hysterical’ is thus not based on evidence. Freud has neglected elementary medical procedure.

Freud, instead of referring to evidence, seeks to justify his assertion with an argument. His argument is complex. It is, however, circular.

Some words used by Dora in reporting a dream of hers remind Freud – not Dora herself – of some obscure technical terms, Vorhof and Nymphen, for parts of the female genitals. Freud admits that these are scarcely used even by physicians. He decides, however, that, since he was reminded of the words, Dora must therefore have intended them. He gives no evidence that she had ever met the words in their sexual sense. He insists, though, that she must have read them in an encyclopaedia (Konversationslexikon).

Dora says she has only once consulted an encyclopaedia. This was to look up appendicitis when her cousin had it. Freud then remembers that Dora too has had appendicitis. He reminds Dora of this. This reminds her that, after her attck of appendicitis, she could not walk properly and dragged her right foot. She tells Freud her foot drags sometimes even now. Freud writes, presumably quoting Dora, that the doctors whom she had consulted at her fathers desire had been very much astonished at this most unusual after-effect of an appendicitis....

This is the first time Freud has heard of Doras dragging right foot. It is either her second last or third last session with him. He has seen her six times a week for nearly eleven weeks but he has never noticed her foot dragging. He does not observe it even now. Nor does he examine her.

Dora mentions her dragging foot only in response to Freuds pursuit of his preoccupations. This gainsays his claim that it is hysterical. So-called hysterical symptoms’ are not discreet.

At this point, however, Freud declares: Here, then, we have a true hysterical symptom. He makes it clear he means the appendicitis and the dragging foot.

Dora, he insists, had read the sexual words in the encyclopaedia when she looked up appendicitis. She then, he says, simulated appendicitis herself, using her knowledge of its symptoms from the encyclopaedia, to punish herself for reading the sexual words. Her appendicitis, he explains, symbolised Doras wish to succumb to the seduction of her fathers friend Herr K. and to give birth to his child. The dragging foot, he continues, symbolised her wish to take this false step.

Freud has, in effect, used the alleged sexual meaning of Doras complaints to prove they are hysterical; and has, then, circularly, offered the symptoms as proof that such ‘symptoms have a sexual meaning.

What clinches the argument for him is Doras telling him about her dragging right foot. He appears to take her word for it that this is a most unusual after-effect of an appendicitis. He still does not ask the doctors.

He seeks, instead, an infantile model for the dragging foot. He considers he has found it when Dora confirms that she had injured the same foot when she was seven. She says she was laid up for some weeks with her swollen foot bandaged. Freud, compounding his already circular argument, takes this as further evidence that the current weakness of her foot is hysterical.

The psychoanalyst Felix Deutsch was consulted by Dora on two occasions twenty-two years later. He noticed that she was limping slightly with her right leg. She did not complain of this; but, when asked, said she had had the limp intermittently since childhood. Deutsch took this as striking evidence that such a symptom may persist through life, whenever there is a need to use it for the somatic expression of displeasure. He did not examine Doras foot. He did not say how he knew Dora was expressing displeasure through her limp. He simply assumed the limp was hysterical.

Certain of the assertions Freud makes in the course of his argument may be empirically tested. I consulted, for instance, the various Konversationslexika in which Dora could have looked up appendicitis in 1899. Vorhof does not appear at all (either in its own right or under any entry on sexuality). Nymphen is mentioned only fleetingly. Thus Freuds assertion that Dora has read both words in the encyclopaedia is empirically disproved.

Even if both words had been in an encyclopaedia this would not, of course, prove Dora knew them. Nor, if she had known them in their sexual sense, would this prove they were, in their sexual sense, relevant to her dream: they were Freuds associations. Nor, if they were relevant, would this prove her appendicitis and dragging foot were hysterical.

Freuds account of the sequence of events indicates – though neither he nor Deutsch notices this – that shortly after Dora injured her foot in childhood (and was laid up for weeks with it swollen and bandaged) she went on a mountain trip. After it she was again made to rest. Her doctor said she was now suffering the effects of Überanstrengungover-exertion or strain.

Might the mountain trip not have been premature? Might it not have led, if Dora had not exercised and strengthened her foot in preparation, to a permanent weakness of her right foot?

Why, too, did Freud so readily discount a direct physical link between Dora’s appendicitis and dragging right foot?

I discussed the case with my colleague Dr Aaron Esterson, coauthor of Sanity, Madness and the Family: Families of Schizophrenics (Laing and Esterson, [1964], 1970) and author of The Leaves of Spring: A Study in the Dialectics of Madness (Esterson, 1970), to whose research method in these books I am indebted in my work on Dora’ and other case studies. He agreed that Freud gave no evidence for revising the original medical diagnoses. Dr Esterson, who practised as a General Practitioner before becoming a psychiatrist, said that Doras dragging foot suggested her appendicitis was pelvic.

Mr P. R. E. Baird, Consultant Orthopaedic Surgeon at St Stephens Hospital, London, and Professor K. E. F. Hobbs, Professor of Surgery at the Academic Department of Surgery, the Royal Free Hospital, London, agreed with Esterson. They also confirmed that, from Freuds account, Doras childhood foot injury could well have led to recurrent difficulties with her right foot in later life.

Professor Hobbs said that pelvic appendicitis could well have also caused later dragging of Doras right foot even if the foot were not permanently weakened by the childhood injury. He pointed out that pain in the right leg is even used as a diagnostic test (the psoas spasm) for pelvic appendicitis.

These prosaic possibilities were ignored by Freud and Deutsch. Their diagnosis that these ailments were hysterical ignored the most obvious and most probable explanations.

Doras emotional distress

Her emotional distress included her feelings about what she saw as a tacit agreement between her father and his friend Herr K. This agreement, as she saw it, was that her father would permit Herr K. to molest Dora sexually in return for sexual favours from Herr K.s wife. Freud states that, in his view, Doras perceptions of her fathers thus bartering her for sexual purposes were accurate. He says this was one particular respect in which it was easy to see that her reproaches were justified.

Freud writes, however, that when a patient brings forward a sound and incontestable train of argument during psychoanalytic treatment, the physician is liable to feel a moments embarrassment....’ Freud’s solution is to turn back each particular reproach on to the speaker himself’.

Hence, while agreeing with Doras perceptions, Freud regards her as sick because her perceptions upset her. While finding it easy to see that her reproaches were justified, he saw her as sick for making them.

Her father and Herr K. both alleged she was deluded. Herr K. declared she had imagined his sexually molesting her. Her father supported Herr K. in this. Her father also claimed Dora was imagining his own affair with Frau K. Freud believed Dora on both counts. On both counts, however, he found further evidence of Dora‘hysteria’. A healthy girl, he considered, would not be so upset that her father and his friend were lying to her and about her and were saying she was deluded.

Dora’s disgust: the pathognomonic symptom

Among those phenomena that Freud calls symptoms of Dorahysteria there is one that has a privileged status. This was her response on one crucial occasion. The occasion was Herr K.’s first reported attempt to seduce Dora. It was in his shop. He had invited her and his wife. Dora was, in Freud’s words, a child of fourteen’. They were to watch a church procession.

‘He persuaded his wife, however, to stay at home, and sent away his shop assistants, so that he was alone when the girl arrived. When the time for the procession approached, he asked the girl to wait for him at the door which opened onto the staircase leading to the upper storey, while he pulled down the outer shutters. He then came back and, instead of going out by the open door, suddenly clasped the girl to him and pressed a kiss upon her lips.

Dora was disgusted. She tore herself free from the man, and hurried past him to the staircase and from there to the street door.’ This response of Doras Freud considers in itself sufficient ground for him to diagnose Dora unhesitatingly (unbedenklich’) as an hysteric. Thus, for Freud, Doras disgust at Herr K.s sexually molesting her  with, as Freud agrees, her fathers implicit permission  is pathognomonic of hysteria.

The little scene in Herr K.s shop was, Freud says, surely just the situation to call up a distinct feeling of sexual excitement in a girl of fourteen who had never before been approached.’ Hence, for Freud, the diagnosis is clear. In this scene ... the behaviour of this child of fourteen was already entirely and completely hysterical. I should without question consider a person hysterical in whom an occasion for sexual excitement elicited feelings that were exclusively or preponderatingly unpleasurable; and I should do so whether or no the person were capable of producing somatic symptoms.

Freud here presents a new – indeed, a highly original – criterion for hysteria. He does not seek to justify it. He simply asserts it. This new criterion appears to be a consequence of the (revised) theory of hysteria that was to be substantiated by the Dora case. Once again Freud is caught in circularity.

This logical and scientific weakness is matched by the ethical debility of Freuds approach.

Freuds own words convey how curious was his attitude to the attempted seduction of a child. Freud himself, as we have seen, calls Dora a child of fourteen’. (My historical research shows that she was almost certainly thirteen, below the age of consent in Austria at that time.) This is quite apart from her fathers collusion.

Her fathers collusion made this a double seduction. It was of an incestuous nature. It entailed Doras fathers attempts to seduce Dora into accepting Herr K.s seduction.

Here is one more glimpse of Freuds attitude to Herr K.s continuing attempts to seduce Dora.

Dora, speaking of Herr K.s attempt to seduce her in the woods by an Alpine lake, told Freud: ‘...Herr K. had made me a present of an expensive jewel-case a little time before. Freud remarked: Then a return-present would have been very appropriate. Perhaps you do not know that jewel-case (Schmuckkästchen) is a favourite expression for ... the female genitals.

Dora was here speaking of a time when she was fifteen or younger. At the time of speaking she was just eighteen. Doras family and the K. family now lived in Vienna. Doras father was continuing his liaison with Frau K. Freud says: ... she frequently met her father with Frau K. in the street. She also met Herr K. very often, and he always used to turn round and look after her; and once when he had met her out by herself he had followed her for a long way....

Freud, in recounting the above exchange about the jewel-case, describes without shame  and without apparent insight – how, while responsible as her physician and therapist for the supposedly ill Dora, he effectively acted as procurer for Herr K.

Doras presenting symptoms and her fathers presenting of Dora

Our findings so far must throw doubt, too, on Freuds initial account of Doras ‘hysterical symptoms. His account is, in any case, by ordinary medical standards, defective. Freud does not always say what in it derives from whom. He does not say whether he has received any medical reports from any doctors. He does not always distinguish between his own observation of Dora, her reports of her observation of herself, and reports from her father.

Freud does say that parts of his account derive from Doras father. He does not say which parts do. This throws still more doubt on his already doubtful account. For what kind of witness was Doras father?

Freud makes plain that Doras father has an interest in having Dora diagnosed as psychologically or nervously ill. Freud, in fact, presents her father as quite prepared to lie to Freud about his sexual relationship with Frau K., and to support what Freud admits are Herr K.slanders’ about Dora, rather than speak frankly for the sake of his daughters supposedly precarious mental health.

Freud describes how Doras father urged him, at the outset, to try and bring her to reason’. By this, Freud makes clear, her father meant that Freud should persuade Dora to drop her allegations about her fathers affair with Frau K. and about Herr K.s molesting of Dora.

Freud writes: ... it must be confessed that Doras father was never entirely straightforward. He had given his support to the treatment so long as he could hope that I should talk Dora out of her belief that there was something more than friendship between him and Frau K. His interest faded when he saw that it was not my intention to bring about that result.

This is usually taken as showing Freuds integrity. It is supposed to show how Freud refused to collude with Doras father. My argument above, however, shows that Freud colluded with Doras father in a far more subtle and effective way than her father asked.

Her father had sought to seduce Dora into accepting Herr K.s seduction. Then, when that failed, he tried to persuade her she had imagined this double seduction and was therefore ill. Then, when that failed, he handed her over to’ Freud. Freud, in order to induce Dora to see herself as ill, did not need to talk” Dora out of her belief. It would be enough if he could talk her into seeing herself as ill because her belief upset her.

Freud, if the above analysis is correct, did not simply misdiagnose Doras complaints. He failed properly to analyse the primary problem. This was not any complaint of Doras but her fathers complaint about Dora. The primary presenting problem was not manifested by Dora in signs or symptoms of illness. It was manifested by Doras father in his allegation that she was ill.

We have now examined a few of the ways in which Freud describes Dora as ill. Is there any evidence in them that she was even irrational? This claim, it will be recalled, was implicit in Freuds implicit claim that she was ill.

In the above I have looked only at what should have been obvious from Freuds (and Deutschs) text. Freuds claims can, of course, also be tested in the light of historical data on Dora and the other dramatis personae. But we shall not be able to see the historical data unless we have cleared our minds of the preconception that Dora was ill’.

Postscript, 2020

I am deeply grateful to the late Dr Aaron Esterson, who discussed my research in depth and detail with me over the years, and to the late Professor Frank Cioffi, who was also closely interested in my research and, as Chair of the Philosophy Department, ensured that the University of Essex formally sponsored it. I thank the Nuffield Foundation for awarding me six Small Grants for my research programme Freuds Paradigm Cases and the Foundations of Psychoanalysis.

I thank Han Israëls for commissioning and translating my article, above, for publication in the colour supplement of the Amsterdam newspaper Vrij Nederland on Saturday 2 November 1985. I also thank him for inviting me to participate in an associated event, Freud op de divan (Freud on the couch)in Paradiso, Amsterdam, the previous evening, Friday 1 November 1985, Doras 103rd birthday.

Jeffrey Masson and I were the main speakers in the Paradiso event; speakers at a podium discussion after our lectures were A. van Dantzig, Karel van het Reve, Kristofer Schipper, Louis Tas, H. Thoden van Velsen; the chairman was Max Pam.

I gave Masson an English copy of my article. He said he fully agreed with it. But, he asked, why did I question that Dora was ill?

This did not surprise me. As I had written earlier that year (Stadlen, A. Doras Illness: A Case for Historical DetectionThe Times Higher Education Supplement, 14 June 1985: 14):
Family therapists, historians, feminists have studied different aspects of Dora’s illness’. Virtually all agree she was ill’. 
But I am grateful to Masson and his wife for attending and praising, twenty-three years later, on 20 November 2008, my seminar Were they ill? FreudDora’, Laing and EstersonMary Irwin, and the presumption of illness, which met fierce opposition (so that I never got as far as Mary Irwin’) in the Auckland Family Counselling and Psychotherapy Centre, New Zealand.

Since my article Was Dora ill? was written to be translated for a Dutch Saturday newspaper colour supplement, there were no notes, references, or bibliography. But I hope readers will be able to check most of my assertions on FreudDora case without difficulty.

The time-sequence of Doras foot injury and mountain trip may be seen from comparison of Freud, Standard Edition, 7: 21, 103.

Some of my other statements on chronology, for instance on dates and on Doras age at various points of the narrative, are not derivable from Freuds text alone; in these instances they are always based on my historical research findings. But my argument is independent of this minimal historical grounding. (I have other, extensive, historical data; but I do not draw on them here.)

Felix Deutschs account of Dora is in his A Footnote to FreudFragment of an Analysis of a Case of Hysteria, Psychoanalytic Quarterly, 1957, 26: 159-67.

Laurence Spurling, editor of the four-volume Sigmund Freud: Critical Assessments (1989) in which the English version of my article appeared, asked me to add a note explaining what I meant by ill’. I did so, as follows:
I have been asked what I mean by ill: do I mean, with Thomas Szasz, that only bodily illness is illness? But it does not matter what I, or Thomas Szasz, mean by ill. The issue is what Freud means by it. Freud, in calling Dora ‘ill, alleges she is irrational. If she is not irrational she is not ‘ill’ in his sense. If she is irrational he must still show she is ‘ill’ in his sense. Only if she is ‘ill in his sense does it make sense to ask, with Szasz, if she is truly ill. But does Freud show that she is irrational even once? Where in the Dora case can Szaszs question arise?
In other words, as with the patients in Laing and Estersons Sanity, Madness and the Family (1964, 1970), the issue is the bizarre grounds, and often the absence of grounds, given by both family and professionals for their presumption of illness’ in a family member – whatever they may understand illness’ to mean.    

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