When Nietzsche Wept

by Irvin D. Yalom

  He listened to Mathilde’s light snores. There lay his real worry! She had folded her life into his. She was loving, she mothered his children. Her dowry from the Altmann family had made him a wealthy man. Though she was bitter about Bertha, who could blame her? She had a right to her bitterness.

  Breuer looked again at her. When he married her, she was the most beautiful woman he had ever seen—and still was. She was more beautiful than the empress, or than Bertha or even Lou Salomé. What man in Vienna did not envy him? Why, then, could he not touch her, kiss her? Why did her open mouth frighten him? Why this frightening notion that he had to escape her grasp? That she was the source of his anguish?

  He watched her in the darkness. Her sweet lips, the graceful dome of her cheekbones, her satiny skin. He imagined her face aging, wrinkling, her skin hardening into leathery plaques, falling away, exposing the ivory skull beneath. He watched the swell of her breasts, resting upon the rib bars of her thoracic cage. And recalled once, walking on a windswept beach, coming upon the carcass of a giant fish—its side partially decomposed, its bleached, bare ribs grinning up at him.

  Breuer tried to wash death from his mind. He hummed his favorite incantation, Lucretius’ phrase: “Where death is, I am not. Where I am, death is not. Why worry?” But it didn’t help.

  He shook his head, trying to shake off these morbid thoughts. Where had they come from? From speaking with Nietzsche about death? No, rather than inserting these thoughts into his mind, Nietzsche simply released them. They had always been there; he had thought them all before. Yet where in his mind were they housed when he wasn’t thinking about them? Freud was right: there had to be a reservoir of complex thoughts in the brain, beyond consciousness but on alert, ready at any time to be mustered and marched onto the stage of conscious thinking.

  And not just thoughts in this nonconscious reservoir, but feelings as well! A few days ago, while riding in a fiacre, Breuer had glanced at the fiacre next to him. Its two horses trotted along pulling the cab in which sat two passengers, a dour-faced elderly couple. But there was no driver. A ghost fiacre! Fear flashed through him, and he had had an instantaneous diaphoresis: his clothes drenched within seconds. And then the driver of the fiacre came into view: he had simply been bending over to adjust his boot.

  At first, Breuer had laughed at his foolish reaction. But the more he thought about it, the more he realized that, rationalist and freethinker though he might be, his mind nonetheless harbored clusters of supernatural terror. And not too deep either: they were “on call,” only seconds from the surface. Ah, for a tonsil forceps that could rip out these clusters, roots and all!

  Still no sleep on the horizon. Breuer stood up to adjust his twisted nightshirt and to fluff the pillows. He thought again about Nietzsche. What a strange man! What stirring talks they’d had! He liked such talking, it made him feel at ease, in his element. What was Nietzsche’s “granite sentence”? “Become who you are!” But who am I? Breuer asked himself. What was I meant to become? His father had been a Talmudic scholar; perhaps philosophic disputation was in his blood. He was glad for the few philosophy courses he had taken at university—more than most physicians because, at his father’s insistence, he had spent his first year there in the faculty of philosophy before entering his medical studies. And glad he had maintained his relationship with Brentano and Jodl, his philosophy professors. He really should see them more often. There was something cleansing about discourse in the realm of pure ideas. It was there, perhaps only there, that he was unsullied by Bertha and carnality. What would it be like to dwell all the time, like Nietzsche, in that realm?

  And the way Nietzsche dared to say things! Imagine! To say that hope is the greatest evil! That God is dead! That truth is an error without which we cannot live! That the enemies of truth are not lies, but convictions! That the final reward of the dead is to die no more! That physicians have no right to deprive a man of his own death! Evil thoughts! He had debated Nietzsche on each. Yet it was a mock debate: deep in his heart, he knew Nietzsche was right.

  And Nietzsche’s freedom! What would it be like to live as he lived? No house, no obligations, no salaries to pay, no children to raise, no schedule, no role, no place in society. There was something alluring about such freedom. Why did Friedrich Nietzsche have so much of it and Josef Breuer so little? Nietzsche has simply seized his freedom. Why can’t I? groaned Breuer. He lay in bed growing dizzy with such thoughts until the alarm rang at six.

  “Good morning, Doctor Breuer,” Frau Becker greeted him when he arrived at his office at ten thirty after his morning round of home visits. “That Professor Nietzsche was waiting in the vestibule when I arrived to open the office. He brought these books for you and asked me to tell you that they are his personal copies with handwritten marginal notations containing ideas for future work. They are very private, he said, and you should show them to no one. He looked terrible, by the way, and acted very strangely.”

  “How so, Frau Becker?”

  “He kept blinking his eyes as though he couldn’t see or didn’t want to see what he was seeing. And his face was pallid, as though he were going to faint. I asked him if he needed any help, some tea, or whether he wanted to lie down in your office. I thought I was being kind, but he seemed displeased, almost angry. Then he wheeled around without a word and went stumbling down the stairs.”

  Breuer took Nietzsche’s packet from Frau Becker—two books tidily wrapped in a sheet of yesterday’s Neue Freie Presse and tied with a short piece of cord. He unwrapped them and placed them on his desk next to the copies given to him by Lou Salomé. Nietzsche may have exaggerated by saying that he would have the only copies of these books in Vienna, but undoubtedly he was now the only Viennese with two copies of them.

  “Oh, Doctor Breuer, aren’t these the same books that grand Russian lady left?” Frau Becker had just brought in the morning mail and, removing the newspaper and cord from his desk, noticed the titles of the books.

  How lies breed lies, Breuer thought, and what a vigilant life a liar is forced to live. Frau Becker, though formal and efficient, also liked to “visit” with patients. Was she capable of mentioning to Nietzsche “the Russian lady” and her gift of books? He had to warn her.

  “Frau Becker, there’s something I must tell you. That Russian woman, Fräulein Salomé—the one you’ve taken such a liking to—is, or was, a close friend of Professor Nietzsche’s. She was worried about the professor and was responsible for his referral to me through friends. Only he doesn’t know that, as now he and Fraulein Salomé are on the worst of terms. If I am to have any chance of helping him, he must never learn of my meeting with her.”

  Frau Becker nodded with her usual discretion, then glanced out the window to see two patients arriving. “Herr Hauptmann and Frau Klein. Whom do you wish to see first?”

  Giving Nietzsche a specific appointment time had been unusual. Ordinarily Breuer, like other Viennese physicians, merely specified a day and saw patients in the order of their arrival.

  “Send in Herr Hauptmann. He needs to return to work.”

  After his last morning patient, Breuer decided to study Nietzsche’s books before his visit the next day, and asked Frau Becker to tell his wife that he’d not come upstairs until dinner was actually on the table. Then he picked up the two cheaply bound volumes, each less than three hundred pages. He would have preferred to read the copies Lou Salomé had given him so that he could underline and write in the margins as he read. But he felt compelled to read Nietzsche’s own copies, as if to minimize his duplicity. Nietzsche’s personal markings were distracting: much underlining and, in the margins, many exclamation points and cries of “YES! YES!” and occasionally “NO!” or “IDIOT!” Also many scribbled notes, which Breuer could not make out.

  They were strange books, unlike any others he had ever seen. Each book contained hundreds of numbered sections, many of which bore little relation to one another. The sections were brief, at the most two or three paragraphs,
often only a few sentences, and sometimes simply an aphorism: “Thoughts are the shadows of our feelings—always darker, emptier and simpler.” “No one ever dies of fatal truths nowadays—there are too many antidotes.” “What good is a book that does not carry us beyond all books?”

  Evidently Professor Nietzsche felt qualified to discourse on every subject—music, art, nature, politics, hermeneutics, history, psychology. Lou Salomé had described him as a great philosopher. Perhaps. Breuer wasn’t ready to render judgment on the content of his books. But it was clear that Nietzsche was a poetic writer, a true Dichter.

  Some of Nietzsche’s declarations appeared ridiculous—a silly pronouncement, for example, that fathers and sons always have more in common than mothers and daughters. But many of the aphorisms stung him into self-reflection: “What is the seal of liberation?—No longer being ashamed in front of oneself!” He was struck by one particularly arresting passage:

  Just as the bones, flesh, intestines and blood vessels are enclosed in a skin that makes the sight of man endurable, so the agitations and passions of the soul are enveloped in vanity; it is the skin of the soul.

  What to make of these writings? They defied characterization except that, as a body, they seemed deliberately provocative; they challenged all conventions, questioned, even denigrated conventional virtues, and extolled anarchy.

  Breuer glanced at his watch. One fifteen. No more time for leisurely browsing. Knowing he would be summoned for dinner any minute, he sought passages that might offer him practical help in tomorrow’s meeting with Nietzsche.

  Freud’s hospital schedule did not usually allow him to come to dinner on Thursdays. But today Breuer had invited him especially so they could go over the consultation with Nietzsche. After a full Viennese dinner of savory cabbage and raisin soup, wiener schnitzel, spätzle, Brussels sprouts, baked breaded tomatoes, Marta’s home-made pumpernickel, baked apple with cinnamon and Schlag, and seltzer water, Breuer and Freud retired to the study.

  As he described the medical history and symptoms of the patient he was calling Herr Eckart Müller, Breuer noticed Freud’s eyelids slowly closing. He had confronted Freud’s postprandial lethargy before and knew how to deal with it.

  “So, Sig,” he said briskly, “let’s get you prepared for your medical matriculation examinations. I’ll pretend I’m Professor Northnagel. I couldn’t sleep last night, I’ve got some dyspepsia, and Mathilde is after me again for being late to dinner, so I’m cross enough today to imitate the brute.”

  Breuer adopted a thick North-German accent and the rigid, authoritarian posture of a Prussian: “All right, Doctor Freud, I have given you the medical history on Herr Eckart Müller. Now you’re ready for your physical examination. Tell me, what will you be looking for?”

  Freud’s eyes opened fully, and he ran his finger around his collar to loosen it. He did not share Breuer’s fondness for these mock exams. Though he agreed they were good pedagogically, they always agitated him.

  “Undoubtedly,” he began, “the patient has a lesion in his central nervous system. His cephalgia, his deteriorating vision, his father’s neurological history, his disturbances in equilibrium—all point to that. I’m suspicious of a brain tumor. Possibly disseminated sclerosis. I’d do a thorough neurological examination, checking the cranial nerves with great care, especially the first, second, fifth, and eleventh. I’d also check the visual fields carefully—the tumor may be pressing on the optic nerve.”

  “What about the other visual phenomena, Doctor Freud? The scintillations, the blurred vision in the morning which improves later in the day? Do you happen to know of a cancer that can do this?”

  “I’d get a good look at the retina. He may have some macular degeneration.”

  “Macular degeneration that improves in the afternoons? Remarkable! That’s a case we should write up for publication! And his periodic fatigue, his rheumatoid symptoms, and his vomiting of blood? That’s caused by a cancer, too?”

  “Herr Professor Northnagel, the patient may have two diseases. Fleas and lice, too, as Oppolzer used to say. He may be anemic.”

  “How would you examine for anemia?”

  “Do a hemoglobin and a stool guiac.”

  “Nein! Nein! Mein Gott! What do they teach you in the Viennese medical schools? Examine with your five senses? Forget the laboratory tests, your Jewish medicine! The laboratory only confirms what your physical examination already tells you. Suppose you’re on the battlefield, Doctor—you’re going to call for a stool test?”

  “I’d check the patient’s color, especially the creases of his palms and his mucosal membranes—gums, tongue, conjuctiva.”

  “Right. But you forgot the most important one, the fingernails.”

  Breuer cleared his throat, continuing to play Northnagel. “Now, my aspiring young doctor,” he said, “I give you the results of the physical. First, the neurological examination is completely and absolutely normal—not a single negative finding. So much for a brain tumor or disseminated sclerosis, which, Doctor Freud, were unlikely possibilities in the first place, unless you know of cases that persist for years and erupt periodically with severe twenty-four- to forty-eight-hour symptomatology and then dissolve entirely with no neurological deficit. No, no, no! This is not structural disease but an episodic physiological disorder.” Breuer drew himself up and, exaggerating his Prussian accent, pronounced, “There’s only one possible diagnosis, Doctor Freud.”

  Freud flushed deeply. “I don’t know.” He looked so forlorn that Breuer halted the game, dismissed Northnagel, and softened his tone.

  “Yes, you do, Sig. We discussed it last time. Hemicrania, or migraine. And don’t feel ashamed about not thinking of it: migraine is a house-call disease. Clinical aspirants rarely ever see it because migraine sufferers seldom go into the hospital. Without question, Herr Müller has a severe case of hemicrania. He has all the classic symptoms. Let’s review them: intermittent attacks of unilateral throbbing headaches—often familial, by the way—accompanied by anorexia, nausea and vomiting, and visual aberrations—prodromal light flashing, even hemianopsia.”

  Freud had taken a small notebook from his inside coat pocket and was jotting down notes. “I’m beginning to remember some of my reading about hemicrania, Josef. Du Bois-Reymond’s theory is that it’s a vascular disease, the pain caused by a spasm of the brain arterioles.”

  “Du Bois-Reymond is right about it being vascular, but not all patients have arteriole spasm. I’ve seen many with the opposite—a dilation of the vessels. Mollendorff thinks the pain is caused not by spasm but by a stretching of the relaxed blood vessels.”

  “What about his loss of vision?”

  “There’s your fleas and lice! It’s the result of something else, not the migraine. I couldn’t focus my ophthalmoscope on his retina. Something obstructs the view. It’s not in the lens, not a cataract, but in the cornea. I don’t know the cause of this corneal opacity, but I’ve seen it before. Perhaps it’s edema of the cornea—that would account for the fact that his vision is worse in the morning. Corneal edema is greatest after the eyes have been closed all night and gradually resolves when fluid is evaporated from the opened eyes during the day.”

  “His weakness?”

  “He is slightly anemic. Possibly gastric bleeding, but probably dietary anemia. His dyspepsia is so great that he can’t tolerate meat for weeks at a time.”

  Freud continued to take notes. “What about prognosis? Did the same disease kill his father?”

  “He asked me the same question, Sig. In fact, I’ve never had a patient before who absolutely insists on all the blunt facts. He made me promise to be truthful with him and then posed three questions: Will his disease be progressive, will he go blind, will he die of it? Have you ever heard of a patient talking like that? I promised I’d answer him in our session tomorrow.”

  “What will you tell him?”

  “I can give him a lot of reassurance based on an excellent study by Liveling, a B
ritish physician, the best medical research I’ve seen coming out of England. You should read his monograph.” Breuer held up a thick volume and handed it to Freud, who slowly leafed through the pages.

  “It’s not translated yet,” Breuer continued, “but your English is good enough. Liveling reports on a large sample of migraine sufferers and concludes that migraine becomes less potent as the patient ages and also that it is not associated with any other brain disease. So, even though the disease is inherited, it’s highly unlikely that his father died of the same disease.

  “Of course,” Breuer continued, “Liveling’s research method is sloppy. The monograph doesn’t make it clear whether his results are based on longitudinal or cross-sectional data. Do you understand what I mean by that, Sig?”

  Freud responded immediately, apparently more at home with research method than with clinical medicine. “The longitudinal method means following individual patients for years and discovering that their attacks lessen as they grow older, does it not?”

  “Precisely,” said Breuer. “And the cross-sectional method—”

  Freud interrupted like an eager schoolboy in the front row of the class. “The cross-sectional method is a single observation at one point in time—in this case, that the older patients in the sample show fewer migraine attacks than younger ones.”

  Enjoying his friend’s pleasure, Breuer gave him another opportunity to shine. “Can you guess which method is more accurate?”

  “The cross-sectional method can’t be very accurate: the sample may contain very few old patients with severe migraine, not because the migraine gets better, but because such patients are too sick or too discouraged with medical doctors to agree to be studied.”