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THE MADNESS OF DIONYSUS: A = NEUROSURGICAL=20 PERSPECTIVE ON FRIEDRICH NIETZSCHE

[LEGACIES]

Owen, Christopher M. M.D.; = Schaller, Carlo=20 M.D.; Binder, Devin K. M.D., Ph.D.

Department of Neurological = Surgery, University=20 of California, Irvine, Irvine, California (Owen) (Binder)

Department of Neurosurgery, = University of=20 Bonn, Bonn, Germany (Schaller)

Reprint = requests: Devin K. Binder, M.D., Ph.D., Department of=20 Neurological Surgery, 101 The City Drive South, Bldg. 56, Ste. = 400, ZOT=20 5397, Orange, CA 92868-3298. Email: dbinder@uci.edu

Received,=20 March 7, 2007.

Accepted,=20 May 4, 2007.

Article Outline=20

Figures/Tables=20

Abstract TOP=20

OBJECTIVE: To examine the = possibility that an=20 intracranial mass may have been the etiology of the headaches and=20 neurological findings of the philosopher Friedrich Nietzsche = (1844-1900)=20 and the cause of his ultimate mental collapse in 1889.

METHODS: The authors conducted a=20 comprehensive English and German language literature search on the = topic=20 of Nietzsche's health and illness, examining Nietzsche's own = writings,=20 medical notes from his physicians, contemporary medical = literature,=20 biographical texts, and past attempts at pathography. We also = examined=20 archived portraits and engravings of the philosopher from 1864 = onward. An=20 English language search in the modern literature on the topic of=20 psychiatric presentations of intracranial mass lesions was also=20 conducted.

RESULTS: From his late 20s = onward, Nietzsche=20 experienced severe, generally right-sided headaches. He = concurrently=20 suffered a progressive loss of vision in his right eye and = developed=20 cranial nerve findings that were documented on neurological = examinations=20 in addition to a disconjugate gaze evident in photographs. His=20 neurological findings are consistent with a right-sided = frontotemporal=20 mass. In 1889, Nietzsche also developed a new-onset mania which = was=20 followed by a dense abulia, also consistent with a large frontal=20 tumor.

CONCLUSION: A close examination = of=20 Nietzsche's symptomatic progression and neurological signs reveals = a=20 clinical course consistent with a large, slow growing, right-sided = cranial=20 base lesion, such as a medial sphenoid wing meningioma. Aspects of = his=20 presentation seem to directly contradict the diagnosis of = syphilis, which=20 has been the standard explanation of Nietzsche's madness. The = meningioma=20 hypothesis is difficult, though not impossible, to prove; imaging = studies=20 of Nietzsche's remains could reveal the bony sequelae of such a=20 lesion.

A casual = stroll through=20 the lunatic asylum shows that faith does not prove anything. = -=20 -Friedrich Nietzsche, The Antichrist, = sec. 51

In the writings of the famous = German=20 philosopher Friedrich Nietzsche (1844-1900), one sees the marks of = ill=20 health that plagued him throughout his adult life. Indeed, by his = own=20 account, the entire body of his later work was in no small part a = product=20 of his debilitating afflictions. Severe headaches, protracted = vomiting,=20 and visual disturbances had a marked effect on the course of his=20 philosophy and his life. His central principle of amor=20 fati, embracing the totality of one's fate, including = suffering, and=20 his attacks upon Christianity as a manifestation of resentiment, an ideological symptom of = physical and=20 psychological weakness, were both conceived primarily from his = attempts to=20 cope with, understand, and overcome his own painful illness (12).=20 Ultimately, Nietzsche utterly succumbed to progressive disease. = Insane at=20 the age of 44, the philosopher who proclaimed Above all, die at = the right=20 time! (11,=20 p 71), spent the last 10 years of his life as an invalid. However, = more=20 than a century after his death, the etiology of his illness = remains poorly=20 understood.

Nietzsche's Development and = Deterioration=20 TOP=20

Friedrich Wilhelm Nietzsche (Fig.=20 1) was born in a small village of Prussian Saxony in 1844. The = son of=20 a Lutheran minister, he displayed precocious aptitudes for letters = and=20 music. He studied theology and classical language at Bonn and = later at=20 Leipzig, earning academic distinction and the respect of his = professors.=20 He accepted an offer of professorship in classical philology at = the=20 University of Basel when he was only 24 years old (9).=20 In the ensuing 10 years, he was plagued by progressively severe = headaches,=20 typically frontal, generally on the right side, and accompanied by = visual=20 disturbances, eye pain, nausea, and vomiting (6).=20 Although Nietzsche had always been myopic (6,17),=20 during his tenure at Basel, his right eye underwent a progressive = loss of=20 visual acuity. By the age of 30, he was essentially blind in his = right eye=20 (3,16).=20 The precise etiology of this asymmetric visual loss is unknown, = although=20 one ophthalmologist in 1877 attributed it to a retinal exudate (3),=20 which would be more suggestive of an intraocular inflammatory = process.

FIGURE 1. Friedrich = Wilhelm Nietzsche=20 (1844-1900).

These afflictions forced = Nietzsche to take at=20 least two extended sick leaves until he resigned his post and left = Basel=20 in 1879, 10 years after he was made the youngest professor in the = history=20 of the institution. He would return 10 years later, escorted by = his=20 closest friends, to be committed to a lunatic asylum. During those = intervening years, Nietzsche remained productive, despite the = headaches=20 that continued to interrupt his work. His headaches were episodic = and=20 typically rendered him incapacitated for periods of 4 to 9 days = (6).=20 In 1876, he was diagnosed with neuralgia after he expressed to a = physician=20 that he was worried he had a brain tumor (6).=20 Even after his mental breakdown in early 1889, records from his = doctors=20 note that he often complains of supra-orbital neuralgia on the = right side=20 (15,=20 p 193).

Examination of Nietzsche's work = (Table=20 1) suggests a progression of psychiatric symptoms superimposed = upon=20 his physical suffering. This has led some authors to assert that=20 Nietzsche's ultimate breakdown was purely the result of = psychiatric=20 disease, the intimations of which are found throughout his life = and work=20 (17).=20 His first book, The Birth of Tragedy from = the Spirit=20 of Music (1872), is a rich yet restrained dialectic. = Nietzsche's=20 middle works, typified in his Thus Spoke=20 Zarathustra (1884), have an exuberant and overwhelming style, = yet can=20 hardly be considered evidence of psychopathology. By the time he = wrote his=20 autobiography, Ecce Homo (1888), = however, his=20 voice had become manifestly grandiose. Coherent and deeply = insightful,=20 this book nonetheless bore the chapter titles Why I am So Wise, = Why I am=20 So Clever, Why I Write Such Good Books, and, lastly, Why I am a = Destiny.=20 In it, he called his Thus Spoke = Zarathustra The=20 greatest gift that could ever have been given to mankind (12,=20 p 675). Ecce Homo was finished in 1888, = a year=20 which saw Nietzsche complete four other major works in a furious = streak of=20 creative activity. Twilight of the = Idols was=20 written in a mere 10 days. Another, The=20 Antichrist, was the first in a planned series of four volumes = that=20 was to set forth nothing less than the revaluation of all = values.

TABLE 1. Major works of = Friedrich=20 Nietzsche (1844-1900)

The philosophical worth of these = works is=20 beyond question (9).=20 However, between December 1888 and January 1889, while still = revising the=20 proof of his autobiography, Nietzsche became overtly manic. His = friend=20 Jacob Burkhardt received a letter dated January 5, 1889, which = convinced=20 him at once that his friend was no longer sane (15).=20 In it, Nietzsche says that he would rather have remained a Basel = professor=20 than become God, but his ego was not so large. One of the five = postscripts=20 to that letter reads: I go everywhere in my student's jacket, and = here and=20 there slap people on the back and ask 'Are we content? I am the = god who=20 has created this farce!' (13,=20 p 348)

At the same time, Nietzsche's old = friend and=20 colleague Franz Overbeck received a postcard signed Dionysus, in = which=20 Nietzsche claimed that he was just having all anti-Semites shot(13,=20 p 347). He also posted a letter to King Umberto of Italy, whom he=20 addressed as his son, announcing that he would arrive in Rome on = Tuesday=20 and looked forward to his audience with the Pope (9).=20 Nietzsche never regained his sanity.

The Nature of Nietzsche's = Pathology TOP=20

The precise nature of Nietzsche's = pathology=20 has been inconsistently and inadequately described, despite = rampant=20 conjecture on the subject. Syphilis, schizophrenia, bipolar = disorder (17),=20 frontotemporal dementia (14),=20 and brain tumor (7,16)=20 have all been proposed, but evidence tends to be only partially = convincing=20 in each case. The suggestion has even been made that Nietzsche was = driven=20 mad by the idiocy of his contemporaries (9).=20 Nietzsche himself blamed his afflictions on listening to too much = Wagner,=20 asking, Has not this nerve shattering music ruined my health? (13,=20 p 180). Wagner, meanwhile, opined that excessive masturbation was = at the=20 root of Nietzsche's troubles (6,=20 p 203).

Nietzsche's own physicians agreed = on the=20 etiology of some of his major symptoms. Their contemporary = descriptions=20 have persisted throughout most subsequent accounts of his life and = illness. His chronic headaches, nausea, and visual disturbances = were taken=20 to be migraines. Elsewhere his dyspepsia is ascribed to his abuse = of=20 chloral hydrate, prescribed as a sleep aid (15).=20 His progressive visual loss was considered simple myopia, although = at=20 least one account suggests that he had retinitis in his right eye = (3).=20 As for his madness and subsequent collapse, syphilis was certainly = the=20 most likely etiology of dementia in a middle-aged man in 1889 (5),=20 and has been the standard explanation of Nietzsche's ultimate = decline.

Given the severity and multitude = of=20 Nietzsche's symptoms viewed in aggregate, it is decidedly = non-Oslerian to=20 posit migraines, myopia, retinitis, and a psychiatric disorder=20 collectively as causative in Nietzsche's case. Diagnostic = confusion is=20 perhaps hardly surprising as Nietzsche consulted with many = physicians and=20 yet prided himself on =E2=80=A6the insistence on not allowing = myself any longer to=20 be cared for, waited on, and doctored=E2=80=A6I took myself in hand, I made myself healthy again (12,=20 p 680). It is, therefore, reasonable to propose that he was not = entirely=20 forthcoming with his physicians regarding the totality of his = medical=20 history.

The Syphilis Hypothesis TOP=20

To explain Nietzsche's = constellation of=20 symptoms, many authors have implicated syphilis, the Great = Imitator (5).=20 However, Sax (16)=20 and Schain (17)=20 make powerful arguments that Nietzsche did not have syphilis at = all,=20 citing his protracted life of 10 years after the onset of paretic = symptoms=20 and the fact that he never developed the characteristic syphilitic = tremor.=20 Indeed, late in 1890, nearly 2 years after his mental breakdown,=20 Nietzsche's friend and disciple Peter Gast still took delight as = Nietzsche=20 improvised on the piano at the asylum: Oh if you had been = listening! Not=20 one wrong note! Interwoven tones of Tristan like = sensitiveness=E2=80=A6Beethoven=20 like profundity=E2=80=A6 it beggars description. Oh, for a = phonograph! (15,=20 p 216). Such virtuosity would be unexpected in a patient = experiencing=20 advanced neurosyphilis.

Casting further doubt on the = syphilis=20 diagnosis, the actual event of Nietzsche's presumed infection is = known=20 only through third-hand accounts at best. There is an = oft-recounted tale=20 of Nietzsche's visit to a brothel in Cologne in 1865, which was=20 romanticized by Thomas Mann in Dr. = Faustus;=20 however, this is not taken seriously even by authors who maintain = that=20 Nietzsche did indeed have syphilis (5,=20 p 185). Nietzsche himself wrote that he was put off by those = apparitions=20 in tinsel and gauze, (6,=20 p 64) and on the evening in question, he confined himself to = playing on=20 the piano in the brothel's parlor. Interestingly, the psychiatrist = Carl=20 Jung (1875-1961) had a considerable role in popularizing the = notion that=20 Nietzsche had syphilis (5,=20 p 186). His chief evidence for this, however, was based on rumors = that=20 Nietzsche had been infected with an unspecified venereal disease = in 1867=20 and on a recurring dream of Nietzsche's involving a toad (8,=20 p 193). Jung interpreted Nietzsche's toad dream as evidence for = the=20 subconscious apprehension that he had been infected with syphilis. = Jung=20 also hypothesized that Nietzsche was actually infected at a = homosexual=20 brothel, although his evidence for this is scarcely more = compelling (5,=20 p 189). Even assuming that Nietzsche was infected during his = college=20 years, this would mean he suffered a 23-year latency period during = which=20 he was often ill, followed by a 10-year survival after the onset = of=20 fulminant neurological symptoms. Although not unheard of, this = would place=20 Nietzsche at the extreme of longevity for cases of tertiary = syphilis (16).

Potential Evidence for an = Intracranial=20 Mass Lesion TOP=20

As early as 1926, the suggestion = was made=20 that Nietzsche's symptoms could have been caused by a brain tumor = (7,=20 p 151). Sax (16)=20 also offers alternate explanations for Nietzsche's constellation = of=20 symptoms, including optic nerve meningioma. He bases this surmise = on the=20 picture reproduced in Figure=20 2, circa 1874, which supposedly demonstrates evidence of = proptosis:=20 Note the prominence of the right eye, which almost appears to = bulge out of=20 the head=E2=80=A6 (16,=20 51). To our scrutiny, this claim is tenuous at best. The left eye, = however, is clearly adducted toward the camera, and the right = appears to=20 be gazing straight ahead, suggesting a right abducens palsy. This = is=20 clearly not the case in the 1865 photograph, in which the right = eye is=20 obviously abducted past midline (Fig.=20 2). The 1875 photograph shows a dilated right pupil and = disconjugate=20 gaze, albeit more subtly. We found no photographs taken after 1874 = in=20 which Nietzsche can be seen to abduct his right eye past midline = (Fig.=20 2). Although we found no evidence that Nietzsche or his = physicians=20 ever mention double vision, if the vision of his right eye had=20 deteriorated to the extent suggested (3),=20 one would not expect him to have noticed a horizontal = diplopia.

FIGURE 2. Photographs and = an engraving=20 of Nietzsche revealing the development and progression of a = right=20 Cranial Nerve VI palsy between 1874 and 1882. A dilated = right pupil=20 is also discernible in the 1875=20 photograph.

Nietzsche's Physical Findings = TOP=20

In January 1889, Nietzsche was = brought to the=20 asylum at Basel by his friends Jacob Burkhardt and Franz Overbeck = after=20 they received disturbing letters posted from Turin. Upon arrival = there, he=20 was frankly manic, complaining of the bad weather and promising = that for=20 you good people, I shall prepare the loveliest weather tomorrow = (15,=20 p 170). He was coherent enough though to relate a recent history = of severe=20 headaches and nausea to his examining physician. His neurological=20 examination was described as follows:

Pupillary disparity, right = larger than=20 left, reaction sluggish. Convergent strabismus-acute myopia. = Tongue=20 heavily furred, no deviation, no tremor! Facial nerve almost = normal; right=20 nasolabial fold slightly contracted. Exaggerated patellar reflex; = plantar=20 reflexes normal=E2=80=A6(15,=20 p 170).

Along with the strabismus, right = Cranial=20 Nerve III palsy and hyper-reflexia, the exclamation point after no = tremor=20 is notable, as the presence of tremor would be an expected finding = in=20 tertiary syphilis (5,16).

Nietzsche remained at Basel for 1 = week before=20 his mother requested that he be moved closer to her home in = Germany.=20 Nietzsche was transferred to the Psychiatric Clinic at the = University of=20 Jena, then under the direction of noted neuropsychiatrist Otto = Binswanger=20 (1852-1929) (Fig.=20 3). A description of Nietzsche's arrival there indicates that, = Looking=20 up at the ceiling he enters the room with majestic strides and = gives=20 thanks for the 'magnificent reception' (15,=20 p 183). His physical examination upon arrival at Jena is = documented as=20 follows:

FIGURE 3. Otto Binswanger = (1852-1929),=20 Director of the Jena Asylum. He described encephalitis = subcorticalis=20 chronica progressiva, later known as Binswanger's=20 disease.

Pupils right wide, left rather = narrower,=20 left contracted with slight irregularity, all reactions normal on = left, on=20 right only reaction to convergence, consensual reactions only on=20 left=E2=80=A6symmetrical smile, tongue non tremulous with = deviations to=20 right=E2=80=A6Romberg negative=E2=80=A6screws left shoulder up = spasmodically when=20 walking=E2=80=A6slight ankle clonus on left=E2=80=A6head = percussion not sensitive, facial=20 nerves sensitive (15,=20 p 183).

Although this examination appears = to document=20 an Argyll-Robertson pupil, it should be noted that the Jena = records were=20 made by persons who had paralysis (i.e., syphilis) in mind all the = time,=20 and that a subsequent review of cases from Basel diagnosed as = syphilis=20 around the same time were in fact schizophrenia (15,=20 p 236).

Whereas Dr. Binswanger's = colleagues, most=20 likely students given that Nietzsche's limited finances meant he = was a=20 second-class patient at Jena, seemed satisfied with paralytic = syphilis as=20 a diagnosis, at least one of them subsequently questioned = this:

In Jena the diagnosis had been = made:=20 'Progressive paralysis on a syphilitic basis.'=E2=80=A6But he did = live on for=20 almost a dozen years in a tolerable physical condition. Was he = really=20 syphilitic? I began to doubt it more and more as time went = on=E2=80=A6(18,=20 p 225).

Nietzsche's longstanding history = of=20 lateralized headaches, associated cranial nerve palsies, and = contralateral=20 hyper-reflexia are more suggestive of an intracranial mass lesion, = specifically a mass in the vicinity of the optic canal, superior = orbital=20 fissure, cavernous sinus, and medial portion of the sphenoid wing. = In=20 1889, however, the art of neurological localization was still in = its=20 infancy, and the potential significance of many of Nietzsche's = presenting=20 signs was only beginning to be appreciated. The routine use of = reflex=20 examination was only instituted in 1886 by S. Weir Mitchell in=20 Philadelphia. Before the 1890s, neurological texts did not contain = descriptions of detailed cranial nerve examinations. It was only = after the=20 first successful surgical resections of intracranial lesions in = Queen's=20 Square and Glasgow in the 1880s that discrete localization began = to have=20 any widespread importance for practicing neurologists (4).

Perhaps even more intriguingly, = an enlarging=20 intracranial mass fits Nietzsche's psychiatric progression as = well.=20 Although psychiatric manifestations of frontal tumors are more = typically=20 in the form of negative symptoms, there are well documented series = of=20 frontal and frontotemporal mass lesions presenting as mania (1,2,10,19).=20 Manic presentation has particularly been described in tumors that=20 interrupt the frontolimbic pathways (19),=20 and right-sided pathology has been shown to correlate with = positive=20 psychiatric symptoms. Indeed, an intracranial mass lesion, = particularly in=20 frontotemporal locations, is an important consideration on the = list of=20 differential diagnoses in the evaluation of secondary mania (1,19).

After spending 1 year as an = inpatient in=20 Jena, Nietzsche was released to the care of his mother. He stayed = at her=20 home in the small resort city of Naumburg until her death in 1897, = at=20 which time his sister, Elisabeth, took over his care and moved him = to her=20 home in Weimar. After his release from Jena, his manic symptoms = gradually=20 gave way to a dense abulia (17).=20 He became passive, docile, and emotionally labile. By 1893, he was = mute=20 and akinetic, although he is rumored to have spoken once = subsequently. He=20 said only I believe I have written some good books (6,=20 p 349) before lapsing back into a silence that would persist until = his=20 death in 1900. His cause of death has been variously reported as = stroke=20 (5)=20 or pneumonia (15).=20 At the behest of his sister, no autopsy was performed.

Perspective TOP=20

Although many authors have = assumed that=20 Nietzsche's neurological and psychiatric deterioration was largely = or=20 entirely the result of neurosyphilis, it is clear that the = diagnosis=20 itself is in doubt and alternative possibilities should be = considered. A=20 large, slow-growing, frontal cranial base tumor such as a = meningioma (Fig.=20 4) could explain Nietzsche's documented signs and symptoms, = including=20 right-sided frontal headaches, an afferent pupillary defect and = loss of=20 visual acuity in the right eye (although some evidence suggests an = intraocular etiology for this); a right Cranial Nerve III palsy, a = right=20 Cranial Nerve VI palsy (either via mass effect or direct = involvement),=20 contralateral long tract signs (left ankle clonus and patellar=20 hyperreflexia); and particularly the supraorbital neuralgia noted = at Jena=20 via involvement of the right V1 at the cavernous sinus or superior = orbital=20 fissure. It is not unexpected that the localizing significance of = these=20 findings was not appreciated at the time of Nietzsche's acute = presentation=20 in 1889. A cranial base tumor could grow large enough to cause = psychiatric=20 symptoms, including mania, and could also account for the = emotional=20 lability, depression, and abulia that Nietzsche developed two = years after=20 his manic presentation and maintained until his death in 1900 (2).

FIGURE 4. Magnetic = resonance imaging=20 scans of a right-sided meningioma demonstrating mass effect, = midline=20 shift and bifrontal edema (A,=20 post-gadolinium axial T1-weighted scan; B, axial fluid-attenuated = inversion=20 recovery image). Such a lesion arising in the cranial base = could=20 have been responsible for Nietzsche's cranial neuropathies, = and=20 continued expansion could have caused his psychiatric=20 symptoms.

This hypothesis is also unique = among other=20 attempts to explain Nietzsche's pathology in that it is = conceivably=20 testable. A meningioma large enough to account for Nietzsche's=20 presentation and progression should have left an enduring mark = upon his=20 relic. Radiographic studies could reveal hyperostosis, erosions, = or=20 calcifications along the base of Nietzsche's cranium. His body = lies in=20 rest at his family's plot in R=C3=B6cken, in the modern German = state of=20 Saxony-Anhalt between Leipzig and Wei=C3=9Fenfels (Fig.=20 5).

FIGURE 5. Nietzsche's = gravesite at=20 R=C3=B6cken, Germany.

Acknowledgments TOP=20

Christopher M. Owen, M.D., is = supported by a=20 postgraduate research fellowship from the University of = California,=20 Irvine. We thank Michael Owen, M.D., for his assistance and = support in=20 revising this article. We dedicate this article to the memory of = Professor=20 Martin C. Dillon, Ph.D. (1938-2005), Distinguished Teaching = Professor of=20 Philosophy at the State University of New York at Binghamton, who = sparked=20 Christopher M. Owen's enthusiasm for Nietzsche prior to his = medical=20 career.

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