Friederich Nietzsche and the seduction of Occam’s razor

Journal of Clinical Neuroscience 17 (2010) 966–969 Contents lists available at ScienceDirect Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn History Friederich Nietzsche and the seduction of Occam’s razor Helen V. Danesh-Meyer a,*, Julian Young b a b Department of Ophthalmology, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, New Zealand Philosophy Department, Wake Forest University, Winston-Salem, North Carolina, USA a r t i c l e i n f o Article history: Received 21 February 2010 Accepted 8 April 2010 Keywords: Friedrich Nietzsche General paresis of the insane Meningioma Neurosyphilis Occam’s razor syphilis a b s t r a c t Friedrich Nietzsche developed dementia at the age of 44 years. It is generally assumed that the cause of his dementia was neurosyphilis or general pareisis of the insane (GPI). Others have proposed frontalbased meningioma as the underlying cause. We have reviewed Nietzsche’s medical history and evaluated the evidence from the medical examinations he underwent by various physicians. We have viewed the possible diagnosis of GPI or meningioma in light of present neuro-ophthalmic understanding and found that Nietzsche did not have the neurological or neuro-ophthalmic symptoms consistent with a diagnosis of GPI. The anisocoria which was assumed to be Argyll Robertson pupil was present since he was six years of age. He did not have tongue tremor, lacked progressive motor features and lived at least 12 years following the onset of his neurological signs. Furthermore, the headaches that have been attributed to a frontal-based tumour were present since childhood and the pupil abnormality that has been interpreted as an ‘‘afferent pupillary defect” had the characteristics of an abnormality of the efferent pupillary innervation. None of the medical records or photographs suggest there was any ocular misalignment. We concluded that neither diagnosis of GPI nor frontal-based meningioma is convincing. It is likely that Nietzsche suffered from migraines, his blindness in his right eye was a consequence of high progressive myopia associated with retinal degeneration, his anisocoria explained by unilateral tonic pupil, and his dementia by an underlying psychiatric disease. Ó 2010 Elsevier Ltd. All rights reserved. 1. Introduction Friedrich Nietzsche (1844–1900) was a philosopher whose twin concepts of the ‘‘death of God” and the ‘‘will to power” marked the transition from nineteenth-century sentimentality to twentiethcentury realism. Poor vision and ill-health influenced the content and form of his philosophy. ‘‘Health”, both individual and social, became his central preoccupation. Because he was led to believe that prolonged reading and writing would render him completely blind, he wrote in short and seemingly disconnected aphorisms. This brevity has enabled interpreters, by judicious selection, to make of Nietzsche whatever they wanted: the Nazis, for example, regarded him a Nazi while post-modernists regard him a postmodernist. Nietzsche was transformed from a philosopher into a demi-god by the onset of dementia at age 44 years. Contemporaries such as Rudolph Steiner and Isadora Duncan suggested that he was not mad but ‘‘ascended”. What caused his poor health? The most common explanation is that he had neurosyphilis (that is general paralysis of the insane [GPI]).1,2 An alternative proposal is that, since childhood, he had suffered from a frontal-based meningioma.3,4 Here we review * Corresponding author. Tel.: +64 21 229 1840; fax: +64 9 367 7173. E-mail address: [email protected] (H.V. Danesh-Meyer). 0967-5868/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jocn.2010.04.004 Nietzsche’s symptoms in the light of modern neurology and conclude that neither diagnosis is convincing. 2. History of illness Nietzsche was born in 1844 in Röcken, a village in Prussian Saxony. Upon the death of his father when he was six years old, the family moved to nearby Naumburg where he gained admission to the Cathedral Grammar School. Despite blinding headaches that led to absences from school, he was able to maintain a rigorous study schedule, and in 1858 won a scholarship to Pforta, Germany’s most prestigious boarding school. During six years at Pforta, he was confined to the infirmary no less than 18 times, reportedly suffering from various kinds of ‘‘flu” accompanied by headaches with fortification. Nietzsche’s headaches appear to have been exacerbated by stress. During 1862 this formerly exemplary pupil entered a period of teenage rebellion: he wrote poems about drunks hurling bottles of schnapps at the crucified Christ, associated with the school’s subversive counter-culture, lost his status as a prefect on account of drunkenness, suffered from depression, and had his first serious row with his mother. The year 1862 saw him confined four times to the infirmary, eventually being sent home to convalesce.5 Later life records reveal many occasions on which a period of stress was H.V. Danesh-Meyer, J. Young / Journal of Clinical Neuroscience 17 (2010) 966–969 immediately followed by an attack: for instance, the death in 1883 of his former ‘‘Master” (but now bitter enemy) Richard Wagner, sent him to bed in a darkened room for several days.6 Conversely, happiness and excitement seem to have alleviated his symptoms: in 1882 his closest friend, Franz Overbeck, was amazed by his appearance of vibrant good health as he pursued the brilliant and beautiful Lou Salomé in the (unfulfilled) hope of marrying her.7 In 1869, aged 24 years, Nietzsche was appointed assistant professor of classics at the University of Basel, becoming full professor the following year. After a symptom-free hiatus of several years, his condition deteriorated. Frequent bouts of headaches, nausea, and visual disturbances led to incapacitation lasting four to nine days. The symptoms were usually right-sided, though one letter of 1873 describes a friend who was taking dictation by acting as his ‘‘left eye” as well as his ‘‘right hand”.8 Although these symptoms persisted during his decade in Basel, Nietzsche remained highly productive during this time. Illness, plus the desire to devote himself to philosophy full-time, forced Nietzsche to retire in 1879. Believing that his good health required a constant temperature of between 9 °C and 12 °C, he spent summers in the Swiss Alps and the winters on the Italian or French Riviera. He continued during these years to oscillate between periods of relative health and days of incapacitating attacks of ‘‘the usual litany”. He suffered repeated bouts of depression that brought him close to suicide, including one that lasted the whole of 1887. At other times he experienced episodes of elation, grandeur and megalomania. There were suggestions of labile affect: Lou Salomé observed in 1882 that he was subject to ‘‘violent mood swings”.9 It is not known precisely when Nietzsche became psychotic. He increasingly believed that he was a messiah, possessing the power to alter the world at will. Erwin Rohde and Paul Deussen, two of his old friends, commented on significant changes in his personality in June 1886 and September 1887, respectively. Rohde describes an atmosphere of strangeness, ‘‘as if he came from a country where nobody else lives”.10 Nietzsche exhibited a furious streak of creative activity between October 1888 and January 1889 completing not only his quasiautobiography Ecce Homo but also Nietzsche contra Wagner, Twilight of the Idols, (written in 10 days) and The Antichrist. Ecco Homo’s chapter titles, however – ‘‘Why I am So Wise,” ‘‘Why I am so Clever”, ‘‘Why I am a Destiny” – reveal his increasing grandiosity. At the beginning of January 1889, Nietzsche wrote a series of extraordinary letters that reveal intensification of the delusions of grandeur. He signed them ‘‘The Crucified One”, ‘‘Dionysus” or ‘‘Nietzsche Caesar”. A letter to King Umberto of Italy, whom he addressed as his son, announced that he would be arriving in Rome and looked forward to his meeting with the Pope. By this time his delusions were well-formulated: he believed he had deposed both the Pope and the German Emperor, and that he was, as he wrote to Jakob Burchhardt: ‘‘God”. He was taken to the Basel psychiatric asylum where a Dr Wille diagnosed neurosyphilis, a diagnosis confirmed by Dr Binswanger in the Jena asylum to which he was transferred a week later. In the Jena asylum he sometimes smeared the walls with faeces, drank his own urine, and asked for a pistol to defend himself against those he thought wished to assassinate him.11 On 12 May 1890 his mother took him home to Naumburg where she cared for him until her death in 1897. After a stroke in 1898, and a more serious one the following year, he died of pneumonia on 25 August 1900. 2.1. Family history Nietzsche had an aunt and sister who suffered from migraines. Two maternal uncles were afflicted with depression, one eventually drowning himself. Nietzsche’s father died after a sudden ill- 967 ness in July 1849, with a report of softening of one-quarter of his brain (although the autopsy report was lost).12 2.2. Social history Nietzsche visited brothels in Cologne and Leipzig between 1865 and 1869 where he admitted to acquiring gonorrhoea (though he claimed never to have had syphilis). Apparently on medical advice, he paid visits to brothels in Naples in 1877.13 2.3. Examination findings Nietzsche’s first recorded visit to a physician was for an ophthalmic examination performed by Professor Schellbach of Jena, when he was aged five years.14 Schellbach found that Nietzsche had 6 diopters of myopia in the right eye, a very high degree of myopia for a child. He also noted that the right pupil was significantly larger and constricted more slowly to light than the left pupil. This anisocoria had been observed by Nietzsche’s mother when he was a small child. There was no abnormality documented with the left pupil. During his 24th year, in Basel, his right eye underwent a progressive loss of visual acuity. By age 30, he was essentially blind in his right eye.14 In October 1877, Nietzsche was examined by a Frankfurt physician, Otto Eiser, and an ophthalmologist, Dr Gustav Krüger. Eiser found no focal neurological signs and consequently excluded the possibility of any kind of brain tumour. The gist of the combined diagnoses was that Nietzsche’s headaches and convulsive attacks were caused partly by damage of unknown origin to the retinas of both eyes and partly by ‘‘a predisposition in the irritability of the central organ i.e. the brain, originating in the philosopher’s ‘excessive mental activity’”. He was noted to have considerable fluid in the right retina and was documented to be almost completely blind in the right eye. He was recommended to lead a quiet life, wear blue lens spectacles, refrain from spicy food, wine, coffee and tea. The most devastating proscription, however, was the warning that unless he gave up all reading and writing for several years he would become completely blind.15 There are only a few neurologic reports on Nietzsche after his mental decline. In 1889, the admitting physician in the Basel asylum noted that he could stick out his tongue without a tremor. The doctor wrote: ‘‘Tongue heavily furred; no deviation, no tremor!” Indeed, the only abnormal physical finding was an asymmetry in the size of the pupils: the right pupil was larger than the left, and reacted sluggishly to light. Despite the lack of other signs, however, his physician diagnosed syphilis. When Nietzsche was transferred to Jena, he underwent an examination by Otto Binswainger, a neurologist, who also documented pupillary abnormalities: ‘‘Pupils right wide, left rather narrower, left contracted with slight irregularity, all reactions normal on left, on right only reaction to convergence, consensual reactions only on left . . .”. He also confirmed the lack of tongue tremor: ‘‘symmetrical smile, tongue non-tremulous with deviations to right . . . Romberg negative . . . screws left shoulder up spasmodically when walking . . . slight ankle clonus on left . . . head percussion not sensitive, facial nerves sensitive”. 3. The evidence against syphilis Neurosyphilis (or GPI) is the standard explanation for Nietzsche’s dementia.16 It was the default diagnosis for middle-aged men in 1889. The admitting physician of the asylum apparently made this diagnosis largely on the basis of anisocoria and the presence of grandiose delusions. However, the history that the anisocoria had been present since childhood was not elicited. In retrospect, 968 H.V. Danesh-Meyer, J. Young / Journal of Clinical Neuroscience 17 (2010) 966–969 there are other possible alternative explanations for the anisocoria. This sign may have been an unilateral tonic pupil – a pupil that reacts poorly to light but somewhat better to near stimuli. In relation to his mental state, the admitting physicians of the asylum did not elicit the history of severe bouts of depression punctuated by increasing grandiosity a decade before his general collapse. Furthermore, if one considers the clinical features associated with GPI it becomes apparent that Nietzsche exhibited none of them. The sine qua non of GPI is an uncontrollable trembling tongue and Argyll Robertson pupil. Both of the admitting physicians distinctly commented on lack of tongue tremor and their surprise over its absence.17 In addition, the description provided by both neurologists regarding his pupils would be inconsistent with an Argyll Robertson pupil, in which both pupils are small.18 There are other distinctive signs of GPI: an expressionless face, hyperactive tendon reflexes, tremor of facial muscles, impairment of handwriting, and slurred and confused speech.19 Nietzsche exhibited none of these. There is evidence for his continued ability to play and improvise on the piano in the asylum. Peter Gast wrote: ‘‘Oh if you had been listening! Not one wrong note! Interwoven tones of Tristan-like sensitiveness . . . Beethoven like profundity . . . it beggars description. Oh, for a phonograph!”16 His facial expressions remained lively while he was in the asylum and his reflexes were reported as normal. Nietzsche’s handwriting in the weeks and months after his collapse was at least as good as it had been in previous years. His speech was fluent, although the content was often bizarre. Nietzsche also lacked the motor and neurological features of a progressive syphilitic central nervous system infection and developed none of the following: ataxia, spastic paralysis and seizures.20 Headaches are rare symptoms of GPI, and, when they do occur, they typically begin only a few weeks or months, before a general collapse. By contrast, it is known that Nietzsche’s headaches commenced in childhood. Finally, Nietzsche lived at least 12 years following the onset of his major symptoms, an extremely prolonged period for a man untreated for GPI in the 1880s (18–24 months was a typical interval between symptom onset and death). According to a study reported in the late nineteenth century, 229 of 244 patients with GPI died within five years of diagnosis; all but two died within nine years of diagnosis.21 4. The case against meningioma Since 1926, it has been proposed that Nietzsche’s symptoms and signs could be explained by the presence of a brain tumor, such as a large, slow-growing, frontal cranial base tumor (such as a meningioma near the optic canal, superior orbital fissure, cavernous sinus, and medial portion of the sphenoid wing). Such a diagnosis is proposed to explain the right-sided frontal headaches, ‘‘an afferent pupillary defect”, and loss of visual acuity in the right eye.3 Photographs have been used to provide support for the diagnosis of a meningioma by suggesting that his eye position demonstrated both cranial nerve VIth and IIIrd nerve palsy. It has been argued that a fronto-temporal tumour could cause psychiatric symptoms, including mania, and could also account for the emotional lability and depression, that Nietzsche developed two years after his manic presentation and maintained until his death in 1900.22,23 Current understanding of the characteristics of meningiomas makes this diagnosis untenable. First, for meningioma to explain Nietzsche’s symptoms, it would have to have been present since childhood as his pupillary abnormalities were known at the age of six years and he had a history of headaches throughout his childhood. The proponents of the meningioma theory have interpreted his pupillary abnormalities as a relative ‘‘afferent pupillary defect” which would be present with a unilateral optic nerve meningioma. However, a relative afferent pupillary defect does not cause anisocoria. Rather anisocoria is caused by an abnormality of the efferent pathway controlling pupillary responses. For a meningioma to cause an efferent pupillary abnormality to account for the anisocoria characterized by the right pupil being large and poorly reactive to light stimulation, it would have to damage the IIIrd cranial nerve or the ciliary ganglion. However, in this circumstance, one would expect both some degree of ocular misalignment and ptosis or at least its development over the years. However, none of Nietzsche’s physicians or his friends documented any ocular misalignment nor ptosis at any stage of his life, and the many photographs taken throughout his life provide no evidence that he had a paralysis of the right IIIrd nerve. Additionally, intracranial meningiomas (or a similar tumour such as glioma) in childhood are rare and may be associated with neurofibromatosis (NF). Nietzsche had no features of NF. A large fronto-cranial tumour present since childhood may also be expected to produce some symptoms of its large mass. Nietzsche, however, was never known to have any symptoms of chronic increased intracranial pressure such as tinnitus or transient visual obscurations at any stage of his life. The lack of any focal neurological signs, even until his adult years, is also inconsistent with the natural history of a sphenoid wing meningioma. However, there are some suggestions that Nietzsche may have had a protruding right eye. It is reported that his eyelid would not close over his eyeball in his coffin. This would be consistent with proptosis caused by a meningioma; however, it would be equally consistent with unilateral high myopia producing pseudo-proptosis.24 As mentioned above, it is well documented that Nietzsche had high unilateral myopia as a young child. The natural progression of 6-diopter myopia at age five would be myopia of at least 9 diopters – and probably more of the order of 12 diopters – by adulthood. Indeed, progressive high myopia could explain both the unilateral pseudo-proptosis as well as the degenerating vision (as a consequence of myopic retinal degeneration or retinal detachment), although it would not explain the anisocoria. 5. Conclusion Syphilis or brain tumours are diagnoses that have been made to provide a single explanation for the multiple manifestations of Nietzsche’s ill-health. However, a review of the documented examination findings provides a paucity of evidence to support either hypothesis. Nietzsche’s madness highlights developments in medicine that occurred around and after his lifetime. The ophthalmoscope was invented in 1854, at which time there was still minimal experience and knowledge of the retinal findings related to various disorders. It is highly probable that the fluid that was noted in the retina of Nietzsche’s right eye was a retinal detachment caused by his high myopia. In the mid-1800s Douglas Argyll Robertson described how some patients with syphilis had small pupils that constricted poorly to light yet constricted promptly to accommodation (‘‘light-near” dissociation). It was not until the twentieth century, however, that Holmes Adie and others25 discovered that some young patients without clinical or serological evidence of syphilis had pupillary light-near dissociation. By the middle of the twentieth century many patients previously diagnosed with Argyll Robertson pupil were re-classified as having Adie’s tonic pupils.26 We now know that the Argyll Robertson pupils are small, almost always bilateral, irregular and show light neardissociation. Tonic pupils on the other hand tend to be unilateral (the condition becomes bilateral in 4% of patients per year), larger, with segmental paralysis of the iris sphincter on detailed examination.27,28 In retrospect, Nietzsche’s pupillary signs were more consistent (based on the available observations) with a tonic pupil, H.V. Danesh-Meyer, J. Young / Journal of Clinical Neuroscience 17 (2010) 966–969 although these differences had not been identified during his lifetime. In the nineteenth century GPI was the most common diagnosis put forward to account for patients with depressive or pseudodepressive illnesses who went on to develop dementia. However, patients so diagnosed often recovered and there are historical cases that suggest some were suffering from depressive pseudodementia. The definition of GPI was so extensive that a review of case reports during this period suggested that at least one in three patients was actually suffering from functional or organic psychoses.21 This misclassification was a consequence of the widespread disagreement concerning the clinical domain, course and even histopathology of GPI. Furthermore, it was not until the early 1900s that it was considered possible that the ‘‘combined insanities” of ‘‘mania” and ‘‘melancholia” could be seen in the same individual.29 Because of the belief that affective symptomology (either depressive or manic) was a manifestation of GPI, this was the label given to patients with bipolar disorders and various schizo-affective disorders. Nineteenth century neurology was not equipped to provide the necessary information for a definitive diagnosis, as it was the era before the discovery of Treponema pallidum (1905 by Frit Schaudinn and Paul Hoffman) or the Wasserman test for its diagnosis (1907). Neuroimaging of any form did not exist. The routine use of reflex examination was only institututed in 1886. Before the 1890s, neurological texts did not contain descriptions of detailed cranial nerve examinations. As the prevailing diagnoses for Nietzsche’s condition are in doubt, alternative possibilities should be considered. Indeed it is entirely possible that Nietzsche suffered from three concomitant and common disorders: migraines, a tonic pupil with his poor vision being explained by myopia. Because of the lack of clinical notes regarding his psychiatric disorder, it is difficult to provide a conclusive alternative diagnosis. However, the reports available suggest many features of bipolar disorder. Other, more extravagant theories have been suggested. Nietzsche, at one point, blamed his afflictions on listening to the ‘‘nerve shattering music” of Wagner. Many people who knew Nietzsche, such as Cosima Wagner (Wagner’s wife), predicted Nietzsche would go mad long before he showed obvious signs. Nietzsche himself raised this possibility. As a schoolboy he suggested that Hölderlin’s madness was moulded by his study of Empedocles and mused, later on, about the possibility that he might follow in his ‘‘favourite poet’s” footsteps. Occam’s razor, devised by the medieval philosopher William of Ockam, is invoked by physicians in all disciplines. It is the rule of diagnostic parsimony: one should not look for multiple causes when a single one provides a suitable explanation. However, a 969 reflection on Nietzsche’s madness suggests that not all constellations of symptoms can be reduced to a single, parsimonious root cause and when the clinical features are atypical for a single diagnosis, it is important to look more closely. In some cases, therefore, Hickman’s dictum (‘‘patients can have as many diseases as they please”) may actually prevail. 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