Journal of Clinical Neuroscience 17 (2010) 966–969

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Journal of Clinical Neuroscience

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History

Friederich Nietzsche and the seduction of Occam’s razor

Helen V. Danesh-Meyer a,*, Julian Young b

a Department of Ophthalmology, Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, New Zealandb 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 2010Accepted 8 April 2010

Keywords:Friedrich NietzscheGeneral paresis of the insaneMeningiomaNeurosyphilisOccam’s razor syphilis

0967-5868/$ - see front matter � 2010 Elsevier Ltd. Adoi:10.1016/j.jocn.2010.04.004

* Corresponding author. Tel.: +64 21 229 1840; faxE-mail address: h.daneshmeyer@auckland.ac.nz (H

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 ofhis dementia was neurosyphilis or general pareisis of the insane (GPI). Others have proposed frontal-based meningioma as the underlying cause. We have reviewed Nietzsche’s medical history and evaluatedthe evidence from the medical examinations he underwent by various physicians. We have viewed thepossible diagnosis of GPI or meningioma in light of present neuro-ophthalmic understanding and foundthat Nietzsche did not have the neurological or neuro-ophthalmic symptoms consistent with a diagnosisof GPI. The anisocoria which was assumed to be Argyll Robertson pupil was present since he was six yearsof age. He did not have tongue tremor, lacked progressive motor features and lived at least 12 years fol-lowing the onset of his neurological signs. Furthermore, the headaches that have been attributed to afrontal-based tumour were present since childhood and the pupil abnormality that has been interpretedas an ‘‘afferent pupillary defect” had the characteristics of an abnormality of the efferent pupillary inner-vation. None of the medical records or photographs suggest there was any ocular misalignment. We con-cluded that neither diagnosis of GPI nor frontal-based meningioma is convincing. It is likely thatNietzsche suffered from migraines, his blindness in his right eye was a consequence of high progressivemyopia associated with retinal degeneration, his anisocoria explained by unilateral tonic pupil, and hisdementia by an underlying psychiatric disease.

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1. Introduction

Friedrich Nietzsche (1844–1900) was a philosopher whose twinconcepts of the ‘‘death of God” and the ‘‘will to power” marked thetransition from nineteenth-century sentimentality to twentieth-century realism. Poor vision and ill-health influenced the contentand form of his philosophy. ‘‘Health”, both individual and social,became his central preoccupation. Because he was led to believethat prolonged reading and writing would render him completelyblind, he wrote in short and seemingly disconnected aphorisms.This brevity has enabled interpreters, by judicious selection, tomake of Nietzsche whatever they wanted: the Nazis, for example,regarded him a Nazi while post-modernists regard him a post-modernist. Nietzsche was transformed from a philosopher into ademi-god by the onset of dementia at age 44 years. Contemporar-ies such as Rudolph Steiner and Isadora Duncan suggested that hewas not mad but ‘‘ascended”.

What caused his poor health? The most common explanation isthat he had neurosyphilis (that is general paralysis of the insane[GPI]).1,2 An alternative proposal is that, since childhood, he hadsuffered from a frontal-based meningioma.3,4 Here we review

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: +64 9 367 7173..V. Danesh-Meyer).

Nietzsche’s symptoms in the light of modern neurology and con-clude that neither diagnosis is convincing.

2. History of illness

Nietzsche was born in 1844 in Röcken, a village in Prussian Sax-ony. Upon the death of his father when he was six years old, thefamily moved to nearby Naumburg where he gained admissionto the Cathedral Grammar School. Despite blinding headaches thatled to absences from school, he was able to maintain a rigorousstudy schedule, and in 1858 won a scholarship to Pforta, Ger-many’s most prestigious boarding school. During six years at Pfor-ta, he was confined to the infirmary no less than 18 times,reportedly suffering from various kinds of ‘‘flu” accompanied byheadaches with fortification.

Nietzsche’s headaches appear to have been exacerbated bystress. During 1862 this formerly exemplary pupil entered a periodof teenage rebellion: he wrote poems about drunks hurling bottlesof schnapps at the crucified Christ, associated with the school’ssubversive counter-culture, lost his status as a prefect on accountof drunkenness, suffered from depression, and had his first seriousrow with his mother. The year 1862 saw him confined four timesto the infirmary, eventually being sent home to convalesce.5 Laterlife records reveal many occasions on which a period of stress was

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immediately followed by an attack: for instance, the death in 1883of 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 hisappearance of vibrant good health as he pursued the brilliant andbeautiful Lou Salomé in the (unfulfilled) hope of marrying her.7

In 1869, aged 24 years, Nietzsche was appointed assistant pro-fessor of classics at the University of Basel, becoming full professorthe 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 ninedays. The symptoms were usually right-sided, though one letterof 1873 describes a friend who was taking dictation by acting ashis ‘‘left eye” as well as his ‘‘right hand”.8 Although these symp-toms persisted during his decade in Basel, Nietzsche remainedhighly 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 healthrequired a constant temperature of between 9 �C and 12 �C, hespent summers in the Swiss Alps and the winters on the Italianor French Riviera. He continued during these years to oscillate be-tween periods of relative health and days of incapacitating attacksof ‘‘the usual litany”. He suffered repeated bouts of depression thatbrought him close to suicide, including one that lasted the whole of1887. At other times he experienced episodes of elation, grandeurand megalomania. There were suggestions of labile affect: Lou Sal-omé observed in 1882 that he was subject to ‘‘violent moodswings”.9

It is not known precisely when Nietzsche became psychotic. Heincreasingly believed that he was a messiah, possessing the powerto alter the world at will. Erwin Rohde and Paul Deussen, two of hisold friends, commented on significant changes in his personality inJune 1886 and September 1887, respectively. Rohde describes anatmosphere of strangeness, ‘‘as if he came from a country wherenobody else lives”.10

Nietzsche exhibited a furious streak of creative activity betweenOctober 1888 and January 1889 completing not only his quasi-autobiography Ecce Homo but also Nietzsche contra Wagner, Twi-light of the Idols, (written in 10 days) and The Antichrist. Ecco Homo’schapter titles, however – ‘‘Why I am So Wise,” ‘‘Why I am soClever”, ‘‘Why I am a Destiny” – reveal his increasing grandiosity.

At the beginning of January 1889, Nietzsche wrote a series ofextraordinary letters that reveal intensification of the delusionsof grandeur. He signed them ‘‘The Crucified One”, ‘‘Dionysus” or‘‘Nietzsche Caesar”. A letter to King Umberto of Italy, whom he ad-dressed as his son, announced that he would be arriving in Romeand looked forward to his meeting with the Pope. By this timehis delusions were well-formulated: he believed he had deposedboth the Pope and the German Emperor, and that he was, as hewrote to Jakob Burchhardt: ‘‘God”. He was taken to the Basel psy-chiatric asylum where a Dr Wille diagnosed neurosyphilis, a diag-nosis confirmed by Dr Binswanger in the Jena asylum to which hewas transferred a week later. In the Jena asylum he sometimessmeared the walls with faeces, drank his own urine, and askedfor a pistol to defend himself against those he thought wished toassassinate him.11 On 12 May 1890 his mother took him home toNaumburg where she cared for him until her death in 1897. Aftera stroke in 1898, and a more serious one the following year, he diedof 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 eventu-ally drowning himself. Nietzsche’s father died after a sudden ill-

ness in July 1849, with a report of softening of one-quarter of hisbrain (although the autopsy report was lost).12

2.2. Social history

Nietzsche visited brothels in Cologne and Leipzig between 1865and 1869 where he admitted to acquiring gonorrhoea (though heclaimed 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 oph-thalmic examination performed by Professor Schellbach of Jena,when he was aged five years.14 Schellbach found that Nietzschehad 6 diopters of myopia in the right eye, a very high degree ofmyopia for a child. He also noted that the right pupil was signifi-cantly larger and constricted more slowly to light than the left pu-pil. This anisocoria had been observed by Nietzsche’s mother whenhe was a small child. There was no abnormality documented withthe left pupil. During his 24th year, in Basel, his right eye under-went a progressive loss of visual acuity. By age 30, he was essen-tially blind in his right eye.14

In October 1877, Nietzsche was examined by a Frankfurt physi-cian, Otto Eiser, and an ophthalmologist, Dr Gustav Krüger. Eiserfound no focal neurological signs and consequently excluded thepossibility of any kind of brain tumour. The gist of the combineddiagnoses was that Nietzsche’s headaches and convulsive attackswere caused partly by damage of unknown origin to the retinasof both eyes and partly by ‘‘a predisposition in the irritability ofthe central organ i.e. the brain, originating in the philosopher’s‘excessive mental activity’”. He was noted to have considerablefluid in the right retina and was documented to be almost com-pletely blind in the right eye. He was recommended to lead a quietlife, wear blue lens spectacles, refrain from spicy food, wine, coffeeand tea. The most devastating proscription, however, was thewarning that unless he gave up all reading and writing for severalyears he would become completely blind.15

There are only a few neurologic reports on Nietzsche after hismental decline. In 1889, the admitting physician in the Basel asy-lum noted that he could stick out his tongue without a tremor.The doctor wrote: ‘‘Tongue heavily furred; no deviation, notremor!” Indeed, the only abnormal physical finding was an asym-metry in the size of the pupils: the right pupil was larger than theleft, and reacted sluggishly to light. Despite the lack of other signs,however, his physician diagnosed syphilis.

When Nietzsche was transferred to Jena, he underwent anexamination by Otto Binswainger, a neurologist, who also docu-mented pupillary abnormalities: ‘‘Pupils right wide, left rather nar-rower, left contracted with slight irregularity, all reactions normalon left, on right only reaction to convergence, consensual reactionsonly on left . . .”. He also confirmed the lack of tongue tremor:‘‘symmetrical smile, tongue non-tremulous with deviations toright . . . Romberg negative . . . screws left shoulder up spasmodi-cally when walking . . . slight ankle clonus on left . . . head percus-sion not sensitive, facial nerves sensitive”.

3. The evidence against syphilis

Neurosyphilis (or GPI) is the standard explanation for Nietz-sche’s dementia.16 It was the default diagnosis for middle-agedmen in 1889. The admitting physician of the asylum apparentlymade this diagnosis largely on the basis of anisocoria and the pres-ence of grandiose delusions. However, the history that the anisoco-ria had been present since childhood was not elicited. In retrospect,

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there are other possible alternative explanations for the anisocoria.This sign may have been an unilateral tonic pupil – a pupil that re-acts poorly to light but somewhat better to near stimuli. In relationto his mental state, the admitting physicians of the asylum did notelicit the history of severe bouts of depression punctuated byincreasing grandiosity a decade before his general collapse.

Furthermore, if one considers the clinical features associatedwith GPI it becomes apparent that Nietzsche exhibited none ofthem. The sine qua non of GPI is an uncontrollable trembling ton-gue and Argyll Robertson pupil. Both of the admitting physiciansdistinctly commented on lack of tongue tremor and their surpriseover its absence.17 In addition, the description provided by bothneurologists regarding his pupils would be inconsistent with an Ar-gyll 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, impairmentof handwriting, and slurred and confused speech.19 Nietzscheexhibited none of these. There is evidence for his continued abilityto play and improvise on the piano in the asylum. Peter Gast wrote:‘‘Oh if you had been listening! Not one wrong note! Interwoventones of Tristan-like sensitiveness . . . Beethoven like profundity. . . it beggars description. Oh, for a phonograph!”16 His facialexpressions remained lively while he was in the asylum and his re-flexes were reported as normal. Nietzsche’s handwriting in theweeks and months after his collapse was at least as good as ithad been in previous years. His speech was fluent, although thecontent was often bizarre. Nietzsche also lacked the motor andneurological features of a progressive syphilitic central nervoussystem infection and developed none of the following: ataxia, spas-tic paralysis and seizures.20 Headaches are rare symptoms of GPI,and, when they do occur, they typically begin only a few weeksor months, before a general collapse. By contrast, it is known thatNietzsche’s headaches commenced in childhood.

Finally, Nietzsche lived at least 12 years following the onset ofhis major symptoms, an extremely prolonged period for a man un-treated for GPI in the 1880s (18–24 months was a typical intervalbetween symptom onset and death). According to a study reportedin the late nineteenth century, 229 of 244 patients with GPI diedwithin five years of diagnosis; all but two died within nine yearsof diagnosis.21

4. The case against meningioma

Since 1926, it has been proposed that Nietzsche’s symptomsand signs could be explained by the presence of a brain tumor,such as a large, slow-growing, frontal cranial base tumor (such asa meningioma near the optic canal, superior orbital fissure, cavern-ous sinus, and medial portion of the sphenoid wing). Such a diag-nosis is proposed to explain the right-sided frontal headaches, ‘‘anafferent pupillary defect”, and loss of visual acuity in the right eye.3

Photographs have been used to provide support for the diagnosis ofa meningioma by suggesting that his eye position demonstratedboth cranial nerve VIth and IIIrd nerve palsy. It has been arguedthat a fronto-temporal tumour could cause psychiatric symptoms,including mania, and could also account for the emotional labilityand depression, that Nietzsche developed two years after his manicpresentation and maintained until his death in 1900.22,23

Current understanding of the characteristics of meningiomasmakes this diagnosis untenable. First, for meningioma to explainNietzsche’s symptoms, it would have to have been present sincechildhood as his pupillary abnormalities were known at the ageof six years and he had a history of headaches throughout his child-hood. The proponents of the meningioma theory have interpretedhis 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 aniso-coria. Rather anisocoria is caused by an abnormality of the efferentpathway controlling pupillary responses. For a meningioma tocause an efferent pupillary abnormality to account for the anisoco-ria characterized by the right pupil being large and poorly reactiveto light stimulation, it would have to damage the IIIrd cranial nerveor the ciliary ganglion. However, in this circumstance, one wouldexpect both some degree of ocular misalignment and ptosis or atleast its development over the years. However, none of Nietzsche’sphysicians or his friends documented any ocular misalignment norptosis at any stage of his life, and the many photographs takenthroughout his life provide no evidence that he had a paralysis ofthe right IIIrd nerve.

Additionally, intracranial meningiomas (or a similar tumoursuch as glioma) in childhood are rare and may be associated withneurofibromatosis (NF). Nietzsche had no features of NF. A largefronto-cranial tumour present since childhood may also be ex-pected to produce some symptoms of its large mass. Nietzsche,however, was never known to have any symptoms of chronic in-creased intracranial pressure such as tinnitus or transient visualobscurations at any stage of his life. The lack of any focal neurolog-ical signs, even until his adult years, is also inconsistent with thenatural history of a sphenoid wing meningioma. However, thereare some suggestions that Nietzsche may have had a protrudingright eye. It is reported that his eyelid would not close over his eye-ball in his coffin. This would be consistent with proptosis caused bya meningioma; however, it would be equally consistent with uni-lateral high myopia producing pseudo-proptosis.24 As mentionedabove, it is well documented that Nietzsche had high unilateralmyopia as a young child. The natural progression of 6-diopter myo-pia at age five would be myopia of at least 9 diopters – and prob-ably more of the order of 12 diopters – by adulthood. Indeed,progressive high myopia could explain both the unilateral pseu-do-proptosis as well as the degenerating vision (as a consequenceof myopic retinal degeneration or retinal detachment), although itwould not explain the anisocoria.

5. Conclusion

Syphilis or brain tumours are diagnoses that have been made toprovide a single explanation for the multiple manifestations ofNietzsche’s ill-health. However, a review of the documented exam-ination findings provides a paucity of evidence to support eitherhypothesis. Nietzsche’s madness highlights developments in med-icine that occurred around and after his lifetime. The ophthalmo-scope was invented in 1854, at which time there was stillminimal experience and knowledge of the retinal findings relatedto various disorders. It is highly probable that the fluid that wasnoted in the retina of Nietzsche’s right eye was a retinal detach-ment caused by his high myopia. In the mid-1800s Douglas ArgyllRobertson described how some patients with syphilis had smallpupils that constricted poorly to light yet constricted promptly toaccommodation (‘‘light-near” dissociation). It was not until thetwentieth century, however, that Holmes Adie and others25 discov-ered that some young patients without clinical or serological evi-dence of syphilis had pupillary light-near dissociation. By themiddle of the twentieth century many patients previously diag-nosed with Argyll Robertson pupil were re-classified as havingAdie’s tonic pupils.26 We now know that the Argyll Robertson pu-pils are small, almost always bilateral, irregular and show light near-dissociation. 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 examina-tion.27,28 In retrospect, Nietzsche’s pupillary signs were more con-sistent (based on the available observations) with a tonic pupil,

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although these differences had not been identified during hislifetime.

In the nineteenth century GPI was the most common diagnosisput forward to account for patients with depressive or pseudo-depressive illnesses who went on to develop dementia. However,patients so diagnosed often recovered and there are historicalcases that suggest some were suffering from depressive pseudo-dementia. The definition of GPI was so extensive that a review ofcase reports during this period suggested that at least one in threepatients was actually suffering from functional or organic psycho-ses.21 This misclassification was a consequence of the widespreaddisagreement concerning the clinical domain, course and even his-topathology of GPI. Furthermore, it was not until the early 1900sthat 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 depres-sive or manic) was a manifestation of GPI, this was the label givento patients with bipolar disorders and various schizo-affective dis-orders. Nineteenth century neurology was not equipped to providethe necessary information for a definitive diagnosis, as it was theera before the discovery of Treponema pallidum (1905 by FritSchaudinn and Paul Hoffman) or the Wasserman test for its diag-nosis (1907). Neuroimaging of any form did not exist. The routineuse of reflex examination was only institututed in 1886. Before the1890s, neurological texts did not contain descriptions of detailedcranial nerve examinations.

As the prevailing diagnoses for Nietzsche’s condition are indoubt, alternative possibilities should be considered. Indeed it isentirely possible that Nietzsche suffered from three concomitantand common disorders: migraines, a tonic pupil with his poor vi-sion being explained by myopia. Because of the lack of clinicalnotes regarding his psychiatric disorder, it is difficult to provide aconclusive alternative diagnosis. However, the reports availablesuggest many features of bipolar disorder. Other, more extravaganttheories have been suggested. Nietzsche, at one point, blamed hisafflictions on listening to the ‘‘nerve shattering music” of Wagner.Many people who knew Nietzsche, such as Cosima Wagner (Wag-ner’s wife), predicted Nietzsche would go mad long before heshowed obvious signs. Nietzsche himself raised this possibility.As a schoolboy he suggested that Hölderlin’s madness was moul-ded by his study of Empedocles and mused, later on, about the pos-sibility that he might follow in his ‘‘favourite poet’s” footsteps.

Occam’s razor, devised by the medieval philosopher William ofOckam, is invoked by physicians in all disciplines. It is the rule ofdiagnostic parsimony: one should not look for multiple causeswhen a single one provides a suitable explanation. However, a

reflection on Nietzsche’s madness suggests that not all constella-tions of symptoms can be reduced to a single, parsimonious rootcause and when the clinical features are atypical for a single diag-nosis, it is important to look more closely. In some cases, therefore,Hickman’s dictum (‘‘patients can have as many diseases as theyplease”) may actually prevail. One may end up cutting oneself ifone wields Occam’s razor too readily.

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