Friedrich Nietzsche and Josef Breuer never met. And, of course, psychotherapy was not invented as a result of their encounter.

Nonetheless, the life situation of the major characters is grounded in fact, and the essential components of this novel—Breuer’s mental anguish, Nietzsche’s despair, Anna O., Lou Salomé, Freud’s relationship with Breuer, the ticking embryo of psychotherapy—were all historically in place in 1882.

Friedrich Nietzsche had been introduced by Paul Rée to the young Lou Salomé in the spring of 1882 and, over the next months, had had a brief, intense, and chaste love affair with her. She would go on to have a distinguished career as both a brilliant woman of letters and a practicing psychoanalyst; she would also be known for her close friendship with Freud and for her romantic liaisons, especially with the German poet Rainer Maria Rilke.

Nietzsche’s relationship with Lou Salomé, complicated by the presence of Paul Rée and sabotaged by Nietzsche’s sister, Elisabeth, ended disastrously for him; for years he was anguished by his lost love and by his belief that he had been betrayed. During the latter months of 1882—those in which this book is set—Nietzsche was deeply depressed, even suicidal. His despairing letters to Lou Salomé, parts of which are quoted throughout the book, are authentic, though there is uncertainty about which were merely drafts and which were actually sent. Wagner’s letter to Nietzsche cited in chapter 1 is also authentic.

Josef Breuer’s medical treatment of Bertha Pappenheim, known as Anna O., occupied much of his attention in 1882. In November of that year, he began to discuss the case with his young protégé and friend, Sigmund Freud, who was, as the novel describes, a frequent visitor to the Breuer home. A dozen years later, Anna 0. was to be the first case described in Freud and Breuer’s Studies on Hysteria the book that launched the psychoanalytic revolution.

Bertha Pappenheim was, like Lou Salomé, a remarkable woman. Years after her treatment with Breuer, she went on to a career as a pioneering social worker so distinguished as to be posthumously honored by West Germany in 1954 in a commemorative postage stamp. Her identity as Anna 0. was not public knowledge until Ernest Jones revealed it in his 1953 biography, The Life and Work of Sigmund Freud.

Was the historical Josef Breuer obsessed with erotic desire for Bertha Pappenheim? Little is known of Breuer’s internal life, but the relevant scholarship does not rule out that possibility. Conflicting historical accounts agree only that Breuer’s treatment of Bertha Pappenheirn evoked complex and powerful feelings in both parties. Breuer was so preoccupied with his young patient and spent so much time visiting her that his wife, Mathilde, did grow resentful and jealous. Freud spoke explicitly to Ernest Jones, his biographer, of Breuer’s emotional overinvolvement with his young patient and in a letter to his fiancée, Martha Bernays, written at the time, reassured her that nothing of that sort would ever happen with him. The psychoanalyst George Pollock has suggested that Breuer’s strong response to Bertha may have had its roots in his having lost his mother, also named Bertha, at an early age.

The account of Anna O.’s dramatic delusional pregnancy and Breuer’s panic and precipitous termination of therapy has long been part of psychoanalytic lore. Freud first described the incident in a 1932 letter to the Austrian novelist Stefan Zweig, and Ernest Jones repeated it in his Freud biography. Only recently has the account been questioned, and Albrecht Hirschmüller’s 1990 biography of Breuer suggests that the entire incident was a myth of Freud’s making. Breuer himself never clarified the point and, in his published 1895 case history, compounded the confusion surrounding the Anna 0. case by grossly and unaccountably exaggerating the efficacy of his treatment.

It is remarkable, considering Breuer’s vast influence on the development of psychotherapy, that he turned his attention to psychology for only a short segment of his career. Medicine best remembers Josef Breuer not only as an important research investigator in the physiology of respiration and equilibrium, but also as a brilliant diagnostician who was physician to an entire generation of great figures in fin de siècle Vienna.

Nietzsche suffered from poor health for most of his life. Although, in 1889, he collapsed and slipped irrevocably into the severe dementia of paresis (a form of tertiary syphilis, from which he died in 1900), there is general consensus that for most of his earlier life he suffered from another illness. It is likely that Nietzsche (whose clinical picture I have portrayed following Stefan Zweig’s vivid 1939 biographical sketch) suffered from severe migraine. For this condition, Nietzsche had consulted many physicians throughout Europe and might easily have been persuaded to seek medical consultation with the eminent Josef Breuer.

It would have been out of character for a distressed Lou Salomé to have applied to Breuer to help Nietzsche. She was not, according to her biographers, a woman significantly burdened by guilt and is known to have ended many love affairs with apparently little remorse. In most matters, she guarded her privacy and did not, as far as I can ascertain, speak publicly of her personal relationship with Nietzsche. Her letters to him have not survived. Most likely they were destroyed by Elisabeth, Nietzsche’s sister, whose feud with Lou Salomé lasted a lifetime. Lou Salomé did indeed have a brother, Jenia, who was studying medicine in Vienna in 1882. It is highly unlikely, however, that Breuer would have presented the case of Anna 0. at a student conference in that year. Nietzsche’s letter (following chapter 12) to Peter Gast, a friend and editor, and Elisabeth Nietzsche’s letter (following chapter 7) to Nietzsche are fictional, as is the Lauzon Clinic and the characters of Fischmann and Breuer’s brother-in-law Max. (Breuer was, however, an avid chess player.) All of the dreams reported are fictional, except two of Nietzsche’s: those of his father rising from the grave and the old man’s death rattle.

In 1882, psychotherapy had not yet been born; and Nietzsche, of course, never formally turned his attention in that direction. Yet in my reading of Nietzsche, he was deeply and significantly concerned with self-understanding and personal change. For chronological consistency, I have confined myself to citing Nietzsche’s pre-1882 works, primarily Human, All Too Human, Untimely Meditations, Dawn, and The Gay Science. I have, however, assumed as well that the great thoughts of Thus Spake Zarathustra, much of which he wrote a few months after the close of this book, were already percolating in Nietzsche’s mind.

Copyright © 1992 by Basic Books, Inc.