When Nietzsche Wept

by Irvin D. Yalom

  “All this seems far removed from our task,” said Nietzsche. “Is there nothing more relevant?”

  “Well, of course, there are the many patients who have recently been coming to physicians for physical symptoms—such as paralysis, speech defect, or some form of blindness or deafness—whose cause lies entirely in psychological conflict. We call this condition ‘hysteria’—from the Greek word for the uterus, hysterus.”

  Nietzsche nodded quickly as though to indicate there was no need to translate the Greek for him. Remembering that he had been a professor of philology, Breuer hurried on. “We used to think these symptoms were caused by a wandering uterus, an idea that, of course, makes no sense anatomically.”

  “How did they explain the disease in men?”

  “For reasons still to be understood, it’s a female disease; there are still no documented cases of hysteria in males. Hysteria, I’ve always thought, is a disease that should be of particular interest to philosophers. Perhaps it is they, not physicians, who will explain why the symptoms of hysteria do not conform to anatomical pathways.”

  “What do you mean?”

  Breuer felt more relaxed. To explain medical issues to an attentive student was a comfortable and familiar role for him.

  “Well, to take one example, I have seen patients whose hands are anesthetized in a way that could not possibly be caused by a disorder of the nerves. They have a ‘glove’ anesthesia—no sensation below their wrist—just as if an anesthetic band had been tied around their wrist.”

  “And that doesn’t conform to the nervous system?” asked Nietzsche.

  “Right. The nervous supply to the hand doesn’t work that way: the hand is supplied by three different nerves—radial, ulnar, and median—each of which has a different origin in the brain. In fact, half of some fingers are supplied by one nerve, and the other half by another. But the patient doesn’t know this. It’s as though the patient imagines the entire hand is supplied by a single nerve, the ‘hand nerve,’ and then develops a disorder to conform with her imagination.”

  “Fascinating!” Nietzsche opened his notebook and jotted down a few words. “Suppose there were a woman expert in human anatomy, and she developed hysteria. Would she have an anatomically correct form of the disease?”

  “I’m certain she would. Hysteria is an ideational disorder, not an anatomical one. There is much evidence that it involves no real anatomical damage to the nerves. In fact, some patients can be mesmerized, and the symptoms vanish in minutes.”

  “So, removal by mesmerism is the current treatment?”

  “No! Unfortunately, mesmerism is not medically fashionable, at least not in Vienna. It has a bad reputation—primarily, I believe, because many of the early mesmerists were charlatans with no medical training. Furthermore, the mesmerism cure is always transient. But the fact that it works even briefly offers proof of the psychic cause of the illness.”

  “Have you, yourself,” asked Nietzsche, “treated such patients?”

  “A few. There is one patient I worked with extensively, whose case I should describe to you. Not because I recommend that you use this treatment with me, but because it will start us working on your list—your item number two, I think.”

  Nietzsche opened his notebook and read aloud, “ ‘Besieged by alien thoughts’? I don’t understand. Why alien? And what’s the connection with hysteria?”

  “Let me clarify. First, I call these thoughts ‘alien’ because they appear to invade me from without. I don’t want to think them, but when I order them away, they flee only briefly and soon, insidiously, infiltrate my mind again. And the types of thoughts? Well, they’re thoughts about a beautiful woman—the patient whom I treated for hysteria. Shall I start at the beginning and tell you the entire story?”

  Far from being curious, Nietzsche appeared uncomfortable at Breuer’s question. “As a general rule, I suggest you reveal only enough for me to comprehend the issue. I urge you not to embarrass or humiliate yourself; nothing good can come of that.”

  Nietzsche was a secretive man. That Breuer knew. But he hadn’t anticipated that Nietzsche would want him, too, to remain secretive. Breuer realized he had to take a stand on this issue: he had to reveal himself as fully as possible. Only then, he thought, can Nietzsche learn there is no horror in openness and honesty between people.

  “You may be right, but it seems to me that the more I am able to tell of my innermost feelings, the more relief I will gain.”

  Nietzsche stiffened, but nodded for Breuer to continue.

  “The story begins two years ago, when one of my patients asked me to take over the medical care of her daughter, whom I shall refer to as Anna O. so as not to disclose her real identity.”

  “But you’ve told me your pseudonym method, so her real initials must be B.P.”

  Breuer smiled, thinking, “This man is like Sig. He forgets nothing”— and went on to describe the details of Bertha’s illness. “It’s also important that you know that Anna O. was twenty-one years old, extraordinarily intelligent, well educated, and astonishingly beautiful. A breath—no, a cyclone—of fresh air to a rapidly aging forty-year-old man! Do you know the kind of woman I describe?”

  Nietzsche ignored the question. “And you became her physician?”

  “Yes, I agreed to become her physician—and have never betrayed that trust. All the transgressions I am about to reveal consist of thoughts and fantasies rather than deeds. First, let me concentrate upon the psychological treatment.

  “During our daily meetings she automatically entered a light trance state in which she discussed—or, as she put it, ‘discharged’—all the disturbing events and thoughts of the last twenty-four hours. This process, which she referred to as ‘chimneysweeping,’ proved useful in helping her to feel better for the next twenty-four hours but had no effect on her hysterical symptoms. Then, one day, I stumbled upon an effective treatment.”

  And Breuer proceeded to describe how he had erased not only each of Bertha’s symptoms by tracking down its original cause but, finally, every part of her illness when he helped her discover and re-experience its fundamental cause—the horror of her father’s death.

  Nietzsche, who had been eagerly taking notes, exclaimed, “Your treatment of this patient strikes me as extraordinary! Perhaps you’ve made a momentous discovery in psychological therapeutics. Perhaps, too, it may be of value for your own problems. I like the possibility of your being helped by your own discovery. For one can never really be helped by another; one must find the strength to help oneself. Perhaps you, like Anna O., must discover the original cause of each of your psychological problems. Yet you said that you don’t recommend this treatment approach for yourself. Why not?”

  “For a number of reasons,” Breuer responded with the certainty of medical authority. “My condition is very different from Anna’s. For one thing, I have no hypnoidal propensities: I have never experienced any unusual states of consciousness. That’s important, because I believe that hysteria is caused by a traumatic experience occurring while the individual is in an aberrant state of consciousness. Because the traumatic memory and the increased cortical excitation exist in an alternate consciousness, they cannot therefore be ‘handled,’ or integrated, or worn away during everyday experience.”

  Without interrupting his account, Breuer rose, stoked the fire, and laid on another log. “Also, and perhaps even more important, my symptoms are not hysterical: they do not affect the nervous system or some part of the body. Remember, hysteria is a female disease. My condition is, I think, qualitatively closer to normal human Angst or misery. Quantitatively it is, of course, greatly magnified!

  “Another thing, my symptoms are not acute: they have developed slowly over years. Look at your list. I cannot identify a precise beginning to any one of those problems. But there is another reason why the therapy I employed on my patient may not be useful to me—a rather disturbing reason. When Bertha’s symptoms——”

  “Bertha? I was r
ight when I guessed her first initial was B.”

  Breuer closed his eyes in distress. “I fear I’ve blundered. It’s terribly important to me that I not violate my patient’s right to privacy. Especially this patient. Her family is very well known in the community, and it is also widely known I was her physician. Hence, I have been careful to speak little to other physicians of my work with her. But it is cumbersome to use a false name here, with you.”

  “You mean it’s difficult to speak freely and unburden yourself while at the same time having to remain on guard with your words lest you use the wrong name?”

  “Exactly.” And Breuer sighed. “Now I have no choice but to continue to speak of her by her true name, Bertha—but you must swear to reveal it to no one.”

  At Nietzsche’s ready “Of course,” Breuer took a leather cigar case from his jacket pocket, extracted a cigar, and, his companion refusing it, lit it for himself. “Where was I?” he asked.

  “You were talking about why your new treatment method might not be relevant to your own problems—something about a ‘disturbing’ reason.”

  “Yes, the disturbing reason,” and Breuer exhaled a long fume of blue smoke before continuing. “I was fool enough to boast of having made an important discovery when I presented her case to a few colleagues and medical students. Yet only a few weeks later, when I transferred her care to another physician, I learned that almost all her symptoms had recurred. You see how awkward my position is?”

  “Awkward,” Nietzsche replied, “because you’ve announced a cure that may not be real?”

  “I often daydream of finding the people who attended that conference and telling each one that my conclusions were wrong. A concern not unusual for me—my perception of my colleagues’ opinions really distresses me. Even though I have evidence of their respect, I continue to feel like a fraud—that’s another issue that plagues me. Add it to your list.”

  Nietzsche dutifully opened his notebook and wrote for a moment.

  “But to continue with Bertha, I’m not entirely clear about the cause of her relapse. It may be that, like the mesmerism cure, my treatment is only temporarily successful. But it may also be that the treatment was effective but was undone by its catastrophic ending.”

  Nietzsche again picked up his pencil. “What do you mean, ‘catastrophic ending’?”

  “For you to understand, I must first tell you what transpired between Bertha and me. There’s no sense in being delicate about it. Let me come right out and say it. I, old fool that I am, fell in love with her! I became obsessed with her. She was never out of my mind.” Breuer was surprised by how easy—in fact, exhilarating—it was to reveal so much.

  “My day was divided into two segments—being with Bertha and waiting to be with her again! I met with her for an hour every day of the week, and then even began visiting her twice a day. Whenever I saw her, I felt great passion. Whenever she touched me, I felt sexually aroused.”

  “Why did she touch you?”

  “She had difficulty walking and clutched my arm as we strolled. Often sudden, severe contractures required me to do a deep massage of her thigh muscles. Sometimes she cried so pitifully I was forced to hold her in my arms to comfort her. Sometimes when I sat next to her, she spontaneously entered into a trance, put her head on my shoulder, and ‘chimneyswept’ for an hour. Or she’d put her head in my lap and sleep like a baby. There were many, many times when it was all I could do to contain my sexual feelings.”

  “Perhaps,” said Nietzsche, “only by being a man does a man release the woman in woman.”

  Breuer’s head jerked up. “Perhaps I misunderstand you! You know, of course, that any sexual activity with a patient is wrong—anathema to the physician’s Hippocratic oath.”

  “And woman? What is woman’s responsibility?”

  “But this is not woman—this is patient! I must be missing your point.”

  “Let us return to it later,” Nietzsche replied calmly. “I still haven’t heard the catastrophic end.”

  “Well, it seemed to me Bertha was improving, her symptoms were clearing up, one by one. But her physician was not doing too well. My wife, Mathilde, who has always been understanding and even-tempered, began to resent, first, the amount of time I was spending with Bertha, and then, even more, my talking about her. Fortunately I was not so foolish as to tell Mathilde about the nature of my feelings, but I believe she suspected them. One day she spoke to me in anger and forbade me ever to mention Bertha again. I began to resent my wife and even developed the irrational idea that she stood in my way—that, were it not for her, I could start a life with Bertha.”

  Breuer stopped, noticing that Nietzsche had closed his eyes. “Are you all right? Have you had enough for one day?”

  “I’m listening. Sometimes I see better with closed eyes.”

  “Well, there was another complicating factor. I had a nurse, Eva Berger, Frau Becker’s predecessor, who, during our ten years together, had become a close friend and confidante. Eva became very concerned. She worried that my mad infatuation with Bertha might lead to ruin, that I might be unable to resist my impulses and do something foolish. In fact, out of her friendship for me, she offered herself as a sacrifice.”

  Nietzsche’s eyes shot open. Breuer saw a lot of eyewhite.

  “What do you mean, ‘sacrifice’?”

  “Her words were that she would do anything to prevent me from ruining myself. Eva knew that Mathilde and I were having virtually no sexual contact, and thought that was why I clove to Bertha. I believe she was offering to release my sexual tension.”

  “And you believe she was doing this for you?”

  “I’m convinced of it. Eva is a very attractive woman and had her choice of many men. I assure you she did not make the offer because of my good looks: this balding head, this briar-patch beard, and these ‘handles’ ”—and he touched his large, protruding ears—“as my playmates always called them. Also, once she confided to me that she had had, years before, an intimate and disastrous relationship with an employer that had ultimately cost her her job, and had sworn, ‘Never again!’ ”

  “And did Eva’s sacrifice help?”

  Ignoring the skepticism, possibly scorn, in the pronunciation of “sacrifice,” Breuer answered matter-of-factly. “I never accepted her offer. I was fool enough to think that lying with Eva would be a betrayal of Bertha. Sometimes I regret that very much.”

  “I don’t understand.” Nietzsche’s eyes, though still wide with interest, showed signs of weariness, as though he had now seen and heard far too much. “What is it that you regret?”

  “Not accepting Eva’s offer, of course. I think about that lost opportunity very often. It is another of those unwelcome thoughts that plague me.” Breuer pointed to Nietzsche’s notebook. “Put it on the list.”

  Nietzsche picked up his pencil again and, as he added another item to Breuer’s expanding list of problems, asked, “This regret—I still don’t understand it. If you had accepted Eva, how would you now be different?”

  “Different? What does being different have to do with it? It was a unique opportunity—one that will never come my way again.”

  “It was also a unique opportunity to say no! To say a blessed ‘no’ to a predator. And that opportunity you grasped.”

  Breuer was stunned by Nietzsche’s comment. Obviously Nietzsche knew nothing about the intensity of sexual yearning. But there was no point yet in debating this issue. Or, perhaps he hadn’t made it clear that Eva might have been his for the asking. Couldn’t Nietzsche understand that one must seize opportunities when they present themselves? Yet, there was something intriguing about his “blessed no” statement. He’s a curious mixture, Breuer thought, of massive blind spots and lightning originality. Again, Breuer had an intimation that this strange man might have something of value to offer him.

  “Where were we? Oh yes, the final calamity! All along I had thought that my sexual affair with Bertha was entirely autistic—that is, as
transpiring only in my mind—and that I had entirely concealed it from her. Imagine my shock, then, when one day I was informed by her mother that Bertha had proclaimed she was pregnant with Dr. Breuer’s baby!”

  Breuer described Mathilde’s outrage when she heard about the false pregnancy and her angry demands that he immediately transfer Bertha to another physician and discharge Eva as well.

  “So what did you do?”

  “What could I do? My whole career, my family, my whole life was at stake. It was the worst day of my life. I had to tell Eva to leave. Of course, I offered to allow her to continue to work for me until I could help her find another position. Although she said she understood, she didn’t return to work the next day, and I’ve never seen her again. I’ve written her several times, but she never answered.

  “And with Bertha, things were even worse. When I visited her the next day, her delirium had cleared, and with it her delusion that I had impregnated her. In fact, she had complete amnesia for the entire episode and responded catastrophically to my announcement that I could no longer be her physician. She cried—pleaded with me to change my mind—begged me to tell her what she had done wrong. And, of course, she had done nothing wrong. Her outburst about ‘Doctor Breuer’s baby’ was part of her hysteria. Those were not her words, that was her delirium speaking.”

  “And whose delirium was it?” asked Nietzsche.

  “Well, of course it was her delirium, but not her responsibility, any more than one has responsibility for the random, bizarre happenings of a dream. People say strange, incoherent things in such a state.”

  “Her words do not strike me as incoherent or random. You suggested, Doctor Breuer, that I should simply interject any comments that occur to me. Let me make an observation: I find it remarkable that you are responsible for all of your thoughts and all of your deeds, whereas she”—Nietzsche’s voice was stern, and he shook his finger at Breuer—“she, by virtue of her illness, is exonerated from everything.”