Nietzsche had arrived fifteen minutes before his twelve-o‘clock appointment. Breuer found him sitting quietly in a corner of the waiting room, his wide-brimmed green felt hat on his head, his coat buttoned to his neck, his eyes closed. As they walked back into his office and settled into their chairs, Breuer attempted to put him at ease.
“Thank you for trusting me with your personal copies of your books. If any of your marginal notes contained confidential material, have no fear—I cannot decipher your script. You have a physician’s handwriting—almost as illegible as mine! Have you ever considered a career in medicine?”
When Nietzsche merely raised his head at Breuer’s weak joke, Breuer continued, undaunted, “But allow me to comment on your excellent books. I did not have time to finish them yesterday, but I was fascinated and stirred by many of your passages. You write extraordinarily well. Your publisher is not only lazy, but a fool: these are books a publisher should champion with his life blood.”
Nietzsche again made no reply, only bowing his head slightly to acknowledge the compliment. Careful, Breuer thought, perhaps he is of fended by compliments as well!
“But, to the business at hand, Professor Nietzsche. Forgive me for prattling on. Let us discuss your medical condition. Based on your previous physicians’ reports and my examination and laboratory studies, I am certain that your major condition is hemicrania, or migraine. I assume you have heard this before-two of your previous physicians mention it in their consultation notes.”
“Yes, other physicians have told me that I have headaches with migraine characteristics: great pain, often in only one side of the head, preceded by an aura of flashing lights and accompanied by vomiting. These I certainly have. Does your use of the term go beyond that, Doctor Breuer?”
“Perhaps. There have been a number of new developments in our understanding of migraine—my guess is that by the next generation we will have it under complete control. Some of the recent research addresses the three questions you posed. First, in respect to whether it will always be your fate to suffer such dreadful attacks, the data strongly indicate that migraine becomes less potent as a patient ages. You must understand that these are statistics only, referring simply to the odds—they provide no certainty about any individual case.
“Let us turn to the ‘hard one,’ as you put it, of your questions—that is, whether you have a constitutional condition like your father’s that will eventuate in death, madness, or dementia—I believe that’s the order in which you listed them?”
Nietzsche’s eyes widened, apparently in surprise at hearing his questions being so directly addressed. Good, good, Breuer thought, keep him off guard. He’s probably never had a physician who can be just as bold as he himself is.
“There is no evidence whatsoever,” he continued emphatically, “from any published study or from my own extensive clinical experience, that migraine is progressive or associated with any other brain disease. I don’t know what disease your father had—my guess is a cancer, possibly a brain hemorrhage. But there is no evidence that migraine progresses to these diseases or to any other.” He paused.
“So, before proceeding further, have I addressed your questions honestly?”
“Two of the three, Doctor Breuer. There was one other: Will I go blind?”
“I’m afraid that’s a question that cannot be answered. But I’ll tell you what I can. First, there is no evidence that your deteriorating vision is related to your migraine. I know it’s tempting to consider all symptoms as manifestation of one underlying condition, but that’s not the case here. Now, visual strain may aggravate, even precipitate a migraine attack—that’s another issue to which we will return later—but your visual problem is something entirely different. I do know that your cornea, the thin covering over the iris—here let me draw this picture. . . ”
On his prescription pad, Breuer sketched the anatomy of the eye, showing Nietzsche that his cornea was more opaque than it should be, most likely because of edema, accumulated fluid.
“We don’t know the cause of this condition, but we do know that progression is very gradual and that, though your vision may become more hazy, it is unlikely you will ever be blind. I cannot be entirely certain, because the opaque condition of your cornea makes it impossible for me to see and examine your retina with my ophthalmoscope. So you understand my problem in answering your question more completely?”
Nietzsche, who a few minutes before had taken off his coat and laid it in his lap along with his hat, now stood to hang both on the coat rack by the office door. As he sat down again, he exhaled loudly and appeared more relaxed.
“Thank you, Doctor Breuer. You are indeed a man of your word. Have you concealed nothing from me?”
A good opportunity, Breuer thought, to encourage Nietzsche to reveal more about himself. But I must be subtle.
“Concealed? A great deal! Many of my thoughts, feelings, reactions to you! Sometimes I wonder what a conversation would be like with a different social convention—with nothing concealed! But I give you my word I have concealed nothing of your medical condition. And you? Remember we have a reciprocal contract of honesty. Tell me, what do you conceal from me?”
“Certainly nothing of my medical condition,” Nietzsche replied. “But I do conceal as much as possible of those thoughts that are not meant to be shared! You wonder about a conversation with nothing concealed—its real name is hell, I believe. To disclose oneself to another is the prelude to betrayal, and betrayal makes one sick, does it not?”
“A provocative position, Professor Nietzsche. But while we are discussing disclosure, let me reveal one private thought. Our discussion on Wednesday was enormously stimulating to me, and I would welcome the opportunity for future talks with you. I have a passion for philosophy, yet studied far too little of it at university. My everyday medical practice rarely offers satisfaction for my passion—it smolders and longs for combustion.”
Nietzsche smiled but made no comment. Breuer felt confident; he had prepared himself well. The rapport was building, and the interview was on course. Now he would discuss treatment: first drugs, and then some form of “talking treatment.”
“But let us turn to the treatment of your migraine. There are many new medications which have been reported effective for some patients. I am speaking of such drugs as bromides, caffeine, valerian, belladonna, amyl nitrate, nitroglycerine, colchicine, and ergot, to name but a few on the list. I see from your records that you yourself have tried some of these. Certain of them have proven effective for reasons no one understands, some because of their general analgesic or sedative properties, and some because they attack the basic mechanism of migraine.”
“Which is?” Nietzsche asked.
“Vascular. Every observer agrees that the blood vessels, especially the temporal arteries, are involved in a migraine attack. They constrict vigorously and then seem to engorge. The pain may emanate from the walls of the stretched or constricted vessels themselves, or from the organs which cry for their normal blood supply, especially the membranes covering the brain—the dura mater and the pia mater.”
“And the reason for this anarchy of the blood vessels?”
“Still unknown,” Breuer responded. “But I believe we will have the solution shortly. Until then, we can only speculate. Many physicians, and among these I include myself, are impressed with the underlying pathology of rhythmicity in hemicrania. In fact, some go so far as to say that the disorder in rhythm is more fundamental than the headache.”
“I don’t understand, Doctor Breuer.”
“I mean that the rhythm disorder may express itself through any of a number of organs. Thus the headache itself need not be present in an attack of migraine. There may be such a thing as abdominal migraine, characterized by sharp attacks of abdominal pain, without head pain. Other patients have reported sudden episodes in which they feel suddenly despondent or elated. Some patients periodically have a sense that they have already experienced their current
experiences. The French call it déjà vu—perhaps that, too, is a variant of migraine.”
“And underlying the disorder of rhythm? The cause of causes? Shall we ultimately arrive at God—the final error in the false search for ultimate truth?”
“No, we may arrive at medical mysticism, but not God! Not in this office.”
“That’s good,” Nietzsche said with some relief. “It suddenly occurred to me that in speaking freely I have possibly been insensitive to your religious sentiments.”
“No danger of that, Professor Nietzsche. I suspect I am as devout a Jewish freethinker as you are a Lutheran one.”
Nietzsche smiled, more broadly than ever before, and settled even more comfortably into his chair. “If I still smoked, Doctor Breuer, now would be the time for me to offer you a cigar.”
Breuer felt decidedly encouraged. Freud’s suggestion that I emphasize stress as an underlying cause of migraine attacks is brilliant, he thought, and bound to succeed. Now I have properly set the stage. The time has come for action!
He leaned forward in his chair and spoke confidently and deliberately. “I am most interested in your question about the cause of a disordered biological rhythm. I believe, as do most authorities on migraine, that a fundamental cause of migraine lies in one’s general level of stress. Stress can be caused by a number of psychological factors—for example, upsetting events in one’s work, family, personal relationships, or sexual life. Though some consider this viewpoint unorthodox, I believe it is the wave of the future for medicine.”
Silence. Breuer was unsure of Nietzsche’s reaction. On the one hand, he was nodding his head as though agreeing—but also flexing his foot, always a sign of tension.
“How does my answer strike you, Professor Nietzsche?”
“Does your position imply that the patient chooses his illness?”
Be wary, Josef, of that question! Breuer thought.
“No, that was not at all my meaning, Professor Nietzsche, although I have known patients who in some strange way profited from medical illness.”
“You mean, for example, young men who injure themselves to escape military service?”
A treacherous question. Breuer grew even more wary. Nietzsche had said that he had served in the Prussian artillery for a short time and been discharged because of a clumsy peacetime injury.
“No, something more subtle”—ach, a clumsy mistake, Breuer instantly realized. Nietzsche would take offense at the phrase. But seeing no way to rectify it, he continued. “I refer to a young man of military age who escapes the military because of the advent of some actual disease. For example”—Breuer stretched for something completely removed from Nietzsche’s experience—“tuberculosis or a debilitating skin infection.”
“You have seen such things?”
“Every physician has seen such strange ‘coincidences.’ But to return to your question, I do not mean that you choose your illness—unless, of course, you profit in some way from your migraine. Do you?”
Nietzsche was silent, apparently deeply immersed in reflection. Breuer relaxed and commended himself. A good response! That’s the way to andle him. Be direct and challenging; he likes that. And phrase questions in a way that engages his intellect!
“Do I in any way profit from this misery?” Nietzsche finally responded. “I have reflected on that very question for many years. Perhaps I do profit. In two ways. You suggest that the attacks are caused by stress, but sometimes the opposite is true—that the attacks dissipate stress. My work is stressful. It requires me to face the dark side of existence, and the migraine attack, awful as it is, may be a cleansing convulsion that permits me to continue.”
A powerful answer! One Breuer had not anticipated, and he scrambled to regain his balance.
“You say you profit from illness in two ways. The second?”
“I believe I profit from my poor vision. For years now, I have been unable to read the thoughts of other thinkers. Thus, separate from others, I think my own thoughts. Intellectually I have had to live off my own fat! Perhaps that’s a good thing. Perhaps that’s why I have become an honest philosopher. I write only from my own experience. I write in blood, and the best truth is a bloody truth!”
“You have thus been cut off from all colleagueship in your profession?”
Another mistake! Again, Breuer caught it immediately. His question was off the point and reflected only his own preoccupation with recognition from colleagues.
“That’s of little concern to me, Doctor Breuer, especially when I consider the shameful state of German philosophy today. I long ago walked out of the halls of the academy, and did not neglect to slam the door behind me. But as I think about it, perhaps this is yet another advantage of my migraine.”
“How so, Professor Nietzsche?”
“My illness has emancipated me. It was because of my illness I had to resign my position at Basel. If I were still there, I’d be preoccupied with defending myself from my colleagues. Even my first book, The Birth of Tragedy, a relatively conventional work, evoked so much professional censure and controversy that the Basel faculty discouraged students from signing up for my courses. In my last two years there, I—perhaps the best lecturer in Basel history—spoke to audiences of only two or three. I am told Hegel lamented on his deathbed that he had only one student who understood him, and even that one student misunderstood him! I am unable to claim even one misunderstanding student.”
Breuer’s natural inclination was to offer support. But fearing to offend Nietzsche again, he settled for a nod of comprehension, taking care not to convey sympathy.
“And still another advantage of my illness occurs to me, Doctor Breuer: my medical condition resulted in my release from the military. There was a time when I was foolish enough to seek a dueling scar”—here Nietzsche pointed to the small scar on the bridge of his nose—“or to demonstrate how much lager I could contain. I was even so foolish to consider a military career. Remember in those early days I was without a father’s guidance. But my illness spared me all this. Even now, as I speak, I begin to think of even more fundamental ways my illness had helped me. . . ”
Despite his interest in Nietzsche’s words, Breuer grew impatient. His objective was to persuade his patient to engage in a talking treatment, and he had made the offhanded comment about profiting from illness only as a prelude to his proposal. He hadn’t counted on the fertility of Nietzsche’s mind. Any question tossed to him, the smallest grain of a question, sprouted lush foliage of thought.
Nietzsche’s words flowed now. He seemed prepared to discourse for hours on the subject. “My illness has also confronted me with the actuality of death. For some time, I have believed that I had an incurable disease which would kill me at an early age. The spectre of imminent death has been a great boon: I have worked without rest because I feared I would die before I could finish what I need to write. And isn’t a work of art greater if the end is catastrophic? The taste of my death in my mouth gave me perspective and courage. It’s the courage to be myself that is the important thing. Am I a professor? A philologist? A philosopher? Who cares?”
Nietzsche’s tempo increased. He seemed pleased with his flow of thoughts. “Thank you, Doctor Breuer. Talking to you has helped me consolidate these ideas. Yes, I should bless my illness, bless it. For a psychologist, personal suffering is a blessing—the training ground for facing the suffering of existence.”
Nietzsche seemed fixed on some inward wision, and Breuer no longer felt that they were engaged in a conversation. He expected, at any minute, his patient to take out pen and paper and begin composing.
But, then, Nietzsche looked up and spoke to him more directly. “Do you remember, on Wednesday, my sentence of granite: ‘Become he who you are’? Today I tell you my second granite sentence: ‘Whatever does not kill me, makes me stronger.’ Thus I say again, ‘My illness is a blessing.’ ”
Gone, now, was Breuer’s sense of command and conviction. He had intellectual vertigo as
Nietzsche, once again, had turned everything topsy-turvy. White is black, good is bad. His miserable migraine, a blessing. Breuer felt the consultation slipping away from him. He struggled to regain control.
“A fascinating perspective, Professor Nietzsche, one I’ve never heard expressed before. But certainly we agree, do we not, that you have already reaped the major benefit of your illness? Now, today, in midlife, armed with the wisdom and the perspective that the illness begat, I am sure you can work more effectively without its interference. It has served its function, has it not?”
While he was talking and collecting his thoughts, Breuer rearranged the objects on his desk: the wooden model of the inner ear, the Venetian swirled blue-and-gold glass paperweight, the bronze mortar and pestle, the prescription pad, the massive pharmaceutical formulary.
“Besides, as I understand you, Professor Nietzsche, you do not describe choosing an illness so much as you describe conquering and benefiting from one. Am I correct?”
“I do speak of conquering, or overcoming, an illness,” Nietzsche replied, “but as to choosing—I’m not sure; perhaps one does choose an illness. It depends on who the ‘one’ is. The psyche does not function as a single entity. Parts of our mind may operate independently of others. Perhaps ‘I’ and my body formed a conspiracy behind the back of my own mind. The mind is, you know, fond of back alleys and trapdoors.”
Breuer was startled at the similarity of Nietzsche’s statement to Freud’s position the day before. “You suggest that there are independent walled-off mental kingdoms within our mind?” he asked.
“It is impossible to escape that conclusion. In fact, much of our life may be lived by our instincts. Perhaps the conscious mental representations are afterthoughts—ideas thought after the deed to provide us with the illusion of power and control. Doctor Breuer, once again I thank you—our conversation has presented me with an important project to consider this winter. Please forgive me for a moment.”
When Nietzsche Wept Page 12