Breuer went down the stairs from the old man’s sickroom, his doctor’s bag in hand, his face grave. He had to see the girl, hear her cough, see if she had tuberculosis. Recha opened the parlor door, and there Bertha Pappenheim sat. Recha called out cheerfully, Dr. Breuer to see her!

Bertha coughed. Her cough was like a bark, like a little dog barking at him.

“No one,” writes Breuer in Studies in Hysteria, “perhaps not even the patient herself, knew what was going on inside her.”

She was cross-eyed. Breuer noticed a muscular spasm beneath her cheek. In Studies, Breuer writes, “An eye-doctor explained it (erroneously) as being due to the paresis of one of the abducent muscles.” The problem in her cheek is described in Breuer’s contemporaneous notes on the Pappenheim case, and her facial neuralgia is also mentioned by doctors who treated her later, when she was in sanitariums, when she was no longer under Breuer’s care—a problem of the trigeminal nerve.

The pain seems to have bothered her over a period of five to seven years. It seems that the pain disturbed Pappenheim before her breakdown and that it occurred intermittently through the whole course of her treatments and suffering, persisting long after she stopped working with Breuer. For Borch-Jacobsen, the neuralgia appeared briefly in the spring of 1880 and played, as Breuer wrote, “a quite subordinate role” in her illness.

It seems that the pain disturbed Pappenheim before her breakdown and that it occurred intermittently through the whole course of her treatments and suffering, persisting long after she stopped working with Breuer.

For Robert Skues, the neuralgia should not be conflated with the more general illness, the hysteria treated by Breuer: “While there was evidently some debate between the doctors as to whether it was of infra-orbital or zygomatic origin, there appears never to have been any question of it being hysterical.” For Skues, the pain in her face should be understood as a problem separate from her psychoneurological breakdown.

The ache in her face is something we can’t measure—even if we were in the room with her, we could not know its severity—but a trigeminal neuralgia, according to the Mayo Clinic website, causes “extreme shock-like pain that can last anywhere from a few seconds to as long as two minutes per episode.” According to the NIH, “the intensity of pain can be physically as well as mentally debilitating.” The pain can flare for patients when they eat, drink, smile, or even when a breeze blows across their skin.

Breuer pushed up the sleeves of her dress, to feel her pulse. She had not been sleeping. She had not been eating. In Anna Karenina, published just a couple of years before Breuer’s visit, a doctor examines young, pretty Kitty Scherbatsky for signs of tuberculosis, and Tolstoy is appalled: “With particular pleasure, it seemed, he insisted that maidenly modesty was merely a relic of barbarism and that nothing was more natural than for a not-yet-old man to palpate a naked young girl.”

Recha may have felt similar disgust, even as Breuer pressed his stethoscope between Bertha’s shoulder blades. He told her to open her mouth. There was no sign of infection. She would not, like her sisters or her father, die of TB.

In Studies, Breuer calls her cough a tussis nervosa. In his contemporaneous notes he calls it a tussis hysterica, and adds, “I classified the patient immediately as mentally ill on account of her strange behavior. Those around her saw nothing of this.” Breuer’s distinctions between mental and physical illness might have been lost on the Pappenheims. In Anna Karenina, the doctor discussing tuberculosis says “there are always moral and spiritual causes.” As Susan Sontag has argued, tuberculosis in the nineteenth century was seen as a disease of the will, a metaphor for psychological or moral corruption.

Breuer patted Bertha on the knee, and he stood. Recha showed the doctor downstairs, to the front hall. On the apartment’s central stairway, I’m guessing, he made a simple prescription. It was important that she stay out of her father’s room. There was the risk of contagion and also of the exacerbation of her anxiety. She must rest, he said.

If Bertha could not rest calmly at night, he may have suggested at this point, then she should take chloral, a simple white powder that could be mixed with water and drunk before bedtime. Having made his recommendations, he took up his hat and stick and left, back down to the Ringstrasse.

Early in his treatment of her, Breuer took away Bertha Pappenheim’s one real interest and activity, taking care of her father, and prescribed for her one of the two drugs that she would be addicted to for most of her twenties.

“Bertha Pappenheim never spoke about this period of her life,” wrote Dora Edinger, who worked with Pappenheim closely in Frankfurt at the JFB.

All the stories we have of her breakdown—the girl watching her father’s sickbed, the hallucinations of snakes, the frustrated attempt at prayer, the entire “latent” period of her hysteria, as Borch-Jacobsen points out, all of this comes to us through a series of unreliable narrators. Pappenheim spoke her stories to Breuer when she was sick, drugged, and maybe hypnotized. She went through her memories hundreds of times, says Breuer. He selected from the various accounts to reconstruct her his- tory, wrote notes down in 1882, and then rewrote the story a dozen years later for Studies.

She was her parents’ third daughter. The second, Flora, died of TB before Bertha was born. The oldest, Henriette, died of the same disease at sixteen in 1865, when Bertha was six. Her brother Wilhelm was a year younger than she. She had attended a Catholic school, where she had learned English, French, and German. She took piano lessons and was taken to the theater. She was passionately fond of Shakespeare and Goethe, but her education ended with her high school, and in 1880 Wilhelm went to university while she stayed home.

Historian Marion A. Kaplan writes:

She may have been jealous of the special treatment accorded [Wilhelm], particularly the education she was denied….Her intellectual gifts were stifled as she, like her German (and Victorian) middle-class counterparts, trained to become a leisured lady.

Later, in Frankfurt, Bertha Pappenheim complained about the lack of value that Jewish men felt for their daughters:

This can already be seen in the different reception given a new citizen of the world. If the father, or someone else asked what “it” was after a successful birth, the answer might be either the satisfied report of a boy, or— with pronounced sympathy for the disappointment—”Nothing, a girl,” or, “Only a girl.”

In Frankfurt, Pappenheim kept a picture on her wall of two roosters fighting, and she said it reminded her of the way she used to fight with her brother.

She and Freud were almost exact contemporaries—he was three years older than her and lived three years longer—but while the world opened itself to him, to her it was completely closed. She was trained for Viennese high culture (the romance languages, the piano playing) and then kept apart from it.

“The attractive, imaginative, young woman was expected to settle down and await marriage,” writes Kaplan. “After completing school, höhere Töchter [good daughters] stayed at home and embroidered their dowries until they met suitable husbands.” As Zweig puts it, “A girl of good family had to live in an entirely sterilized atmosphere from her birth to the day she went to her bridal bed.”

Freud, relatively progressive, forbade his sisters (about Bertha’s age) from reading Balzac or Dumas, for fear the novels would corrupt their virgin souls. Policing of a daughter’s mind and body was the rule. As Zweig writes:

Young girls were not left alone for a moment, for their own protection. Girls had governesses whose duty it was to make sure that they did not—God forbid!—take a step out of the front door unescorted; they were taken to school, taken to dancing classes and music lessons, and then collected again. Every book they read was checked, and above all young girls were kept constantly occupied in case they engaged in any dangerous ideas.

In 1880, Bertha Pappenheim was past twenty and bored. She had essentially two obligations in life: to get married, and to believe in her parents’ religion. She did neither. In his contemporaneous notes, but not in Studies, Breuer wrote, “In her life religion serves only as an object of silent struggle and silent opposition.” And in a letter: “The patient comes from an Orthodox Jewish home though she herself is wholly without faith.”

As Kaplan argues in her essay, “For Love or Money,” most marriages in both the German and the Jewish bourgeoisies were arranged. Daughters typically had little choice in the matter. Through marriages, families consolidated business alliances. A joke of the time:

Goldberg: Do you hear, the Chinese sell their daughters in the marketplace?

Silverberg: The marketplace! Why don’t they do it in private, like us?

From Pressburg to Frankfurt, ambitious Jewish bachelors and their mothers must have yearned for an introduction. Bertha would come with a massive dowry and trousseau. The man who married her would have his fortune made.

Jokes and stories she told later in life suggest that she escaped several planned engagements, but we don’t know how many. In her essay on marriage, Kaplan reports that the families of some prospective bridegrooms hired detectives to look into their fiancées’ lives. So Pappenheim’s illness, even in the fall of 1880—her cross-eyes, her face pain, her lack of sleep and appetite—all these things might have been kept secret from the outside world.

All through the fall she had stayed up, night after night, tending to her father. Self-sacrificing, self-dramatizing, she demonstrated her devotion to her father, even as in silent opposition she refused to play out her obligatory role. She started suffering that pain in her face. She stopped eating.

And meanwhile, every day, she had to put on the elaborate costume of her gender and class. Again, I go to Zweig:

Merely dressing to look like a lady—never mind the etiquette of high society—just putting on such gowns and taking them off was a complicated procedure, and impossible without someone’s help. First there were the countless little hooks and eyes to be done up behind a lady’s back from waist to neck, a maid had to exert all her strength to tie her mis- tress’s corset; her long hair—and let me remind you that thirty years ago all European young women…had hair that fell to their waists when they unpinned it—had to be curled, set, brushed and combed and piled by a hairdresser called in daily and using a large quantity of hairpins, combs, and slides, curling tongs and hair curlers, all this before she could put on her petticoats, camisoles, little bodices and jackets, like a set of onion skins, turning and adjusting until the last remnant of her female form had disappeared.

She stayed up every night, and then in the morning was imprisoned in her clothes by her maids. For the rest of the day, she was kept in enforced idleness. Breuer was not blind to her condition. As he writes in Studies:

This girl of an overflowing mental vitality led an extremely monotonous life in her puritanically minded family, a life that she embellished for herself in a way that was probably decisive in the development of her illness. She systematically cultivated the art of daydreaming, calling it her “private theater.” While everyone else believed her to be present, she was living out fairy tales in her mind, yet was always alert when spoken to so that no one was aware of it. Her domestic duties, which she carried out irreproachably, were almost incessantly accompanied by this mental activity.

The classical Freudian explanation of Bertha Pappenheim’s symptoms is that she was acting out the pain in her mind—that’s the theory of hysterical conversion, or conversion disorder. “Hysterical symptoms,” wrote Freud in 1905, “are the expression of [the patients’] most secret and repressed wishes.”

The Freudian conception doesn’t include political and social stressors, but Pappenheim’s “hysteria,” as Marion A. Kaplan wrote in 1984, was “integrally related to the position of women of the day.” So many of the great feminists of the late nineteenth and early twentieth centuries suffered breakdowns as they moved from adolescence to adulthood, so many were described as “hysterical.”

So many of the great feminists of the late nineteenth and early twentieth centuries suffered breakdowns as they moved from adolescence to adulthood, so many were described as “hysterical.”

“Her life,” writes Kaplan, “can be compared to those of other social reformers, many of whom suffered through crises similar to hers in kind, but not in extent.” All over Europe and North America, women were falling victim. Kaplan makes a list— starting with Jane Addams and Josephine Butler—of activists who were afflicted with “nervous depressions and a sense of maladjustment.” She quotes the great German suffrage leader Hedwig Dohm:

When, in place of the knowledge and truth for which I was reaching out, they put into my hand the…cooking spoon,—they drove a human soul, which was created perhaps to live splendidly and fruitfully, into a desert of wild fantasies and sterile dreams.

In 1880, Bertha Pappenheim lived in a society that denied her agency, she was under tremendous psychological stress, and she had a terrible pain in her face. FND doctors describe the etiology of the condition as multifactorial, the many stresses of a person’s life acting together to dis- able the brain’s capacity to control the body.

The pain of the trigeminal neuralgia, the stress of staying up all night with a father who is dying of the same disease that killed her sisters, the gloom of a stifling homelife of boredom through which she persisted in “private theater” and “silent opposition”—I am not here to diagnose Bertha Pappenheim, but if you look at the charts of predisposing, precipitating, and perpetuating factors that can contribute to a functional neurological breakdown, her case ticks off every box. Put enough pressure on any one of us, and we are liable to break.

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The Secret Mind of Betha Pappenheim: The Woman Who Invented Freud’s Talking Cure by Gabriel Brownstein is available via PublicAffairs.