Abstract

At age 44, after suffering a breakdown in Turin, philosopher Friedrich Nietzsche was diagnosed with neurosyphilis. There was no necropsy on his body, so this medical diagnosis has been questioned over the time. We conducted a literature review on the medical diagnosis of Nietzsche, which emphasizes three genres of pathographies that emerged successively as alternatives explanations for Nietzsche’s breakdown in Turin: (1) narratives about syphilis (“demoniac-pathological”); (2) narratives about functional psychosis (“heroic-prophetic”); (3) other narratives about organic diseases, other than syphilis (“scientific-realistic”). The latter – which correspond to our study object in this work – undertake retrospective diagnostics, attempting to retrieve the “truth” underlying the disease and elucidate “Nietzsche’s affair”. We inquire this detective-like impetus, currently taken to the extreme by “evidence-based medicine”, and we denounce its anachronism. Syphilis has become a scientific fact only after the death of Nietzsche. We conclude that the diagnosis he received is shown to be consistent with the nineteenth-century medical rationality and the syphilis status as a cultural fact at that time.

Turin’s breakdown; Nietzsche; Pathographies

Introduction

On January 7, 1889, at the age of 44, stateless philosopher Friedrich Nietzsche, a German-born retired teacher due to health problems in Switzerland, already in his nomadic and lonely phase, collapsed as he wandered around Carlo Alberto’s Square during his stay in Turin, Italy. Janz¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016. reports that, sympathetic to the whipping of a horse, Nietzsche would have thrown himself onto the animal’s neck, hugging him, and would have later collapsed to the ground, thus embodying a Dostoevskian character. On January 10, 1889, he was hospitalized in a manic state at the Friedmatt psychiatric clinic – located in Basel, where he had previously taught – led by Dr. Ludwig Wille. At this institution, Nietzsche received the diagnosis of “progressive general paralysis” – PGP (neurosyphilis), later confirmed in the psychiatric clinic of the University of Iena, directed by Dr. Otto Biswanger, where he would be transferred at the request of his mother. Posterity would then assimilate such a medical diagnosis as an official explanation of his “breakdown” (Zusammenbruch, according to the expression found in the Nietzschean correspondences), after which, Nietzsche was afflicted by a degenerative dementia process from which he would never recover. His friend, Franz Overbeck, who transferred him from Turin to Basel, witnessing his devastation, stated days after the collapse: “Nietzsche is no more!”¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016.. He became consequently dependent on external care, rendered respectively by his mother and sister, until his death on August 25, 1900.

Nietzsche’s medical diagnosis was never a point of consensus among commentators, and its first significant criticism dates back to the early 1930s²2. Podach EF. L’effondrement de Nietzsche. Paris: Gallimard; 1931.. Since then, many authors have tried to call into question Nietzsche’s association with syphilis, thus giving rise to two alternative pathographies to the official diagnosis: (1) narratives about functional psychoses; (2) narratives about other organic diseases, other than syphilis. From the early 21^st century, critics have gained breath, especially from authors from the medical field who have been proposing new diagnostic hypotheses of Nietzsche’s organic diseases, other than syphilis. We aim to analyze here the recent pathographic critiques of medical authors about Nietzsche, not without presenting the first alternative genre previously mentioned and the pathography resulting from the official diagnosis.

According to the different existing pathographies, it can be seen that Nietzsche’s medical diagnosis, because it is not a point of consensus among the authors, determines the different possibilities of apprehending his textual production. That is, the reception of his philosophical work seems to be influenced by the presumption of his medical diagnosis. Thus, Nietzsche’s diagnosis would not be a mere addendum, but a matter of relevance for all who are concerned with his work.

Nietzsche’s pathographies

Aschheim³3. Aschheim SE. The Nietzsche legacy in Germany, 1890-1990. Berkeley, Los Angeles: University of California Press; 1992. reports that the battle of “Nietzschianism”, as he designates the multiple tendencies that claimed Nietzsche’s legacy between 1890 and 1914, revolved around two opposing modes of embracing of his work: “demonic-pathological” versus “heroic-prophetic”, respectively derived from medical eugenics linked to degeneration and the avant-garde fin-de-siècle movements. Besides their obvious opposition, both ways of receiving shared a mythical-existential language typifying Nietzsche in transhuman terms, wrapped in an aura of supernatural power. The pathographies associated with syphilis and functional psychoses derive respectively from this original binarism between Nietzsche’s detractors and worshipers, within the broader cultural context of the dispute over the Nietzschean heritage. Thus, by appropriating the terms proposed by Aschheim, we will designate pathographies associated with syphilis as “demonic-pathological”, while pathographies linked to functional psychoses will be called “heroic-prophetic”.

Demonic-pathological pathographies

The first genre, consisting of “demonic-pathological pathographies”, confirms Nietzsche’s official diagnosis, drawing on the work Degeneration, published by Max Nordau in 1892. Physician and firm anti-modernist Nordau denounced then the supposed social degeneration of his time, of which Nietzsche would be an emblematic spokesman³3. Aschheim SE. The Nietzsche legacy in Germany, 1890-1990. Berkeley, Los Angeles: University of California Press; 1992.. In 1902, Nordau’s intuition was developed by Möebius⁴4. Möbius PJ. Über das Pathologische bei Nietzsche. Wiesbaden: Bergmann; 1902., a celebrated physician who wrote the first specific pathography on Nietzsche and was later established by Lange-Eichbaum⁵5. Lange-Eichbaum W. Nietzsche als psychiatrisches Problem. Deutsche medizinische Wochenschrift 1930: 1538.^,66. Lange-Eichbaum W. Nietzsche: Krankheit und Wirkung. Hamburg: Lettenbauer; 1947. in his respective works of 1930 and 1947. Both Möebius and Lange-Eichbaum, according to the worst psychobiographical literary tradition, would end up associating the philosopher’s life and work, pathologizing his writings in a captious and caricatured way. Thus, Nietzsche’s work would be a mere symptomatic reflection of his illness, and his (crooked) thought would reflect nothing more than his brain degenerated by the effect of syphilitic bacteria. Janz¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016. points out that the widespread reception of this “demonic-pathological” genre on Nietzsche hindered research on Nietzsche. It is a dubious bricolage between psychiatric pseudoscience about the “degenerate”⁷7. Serpa Júnior OD. O degenerado. História, Ciências, Saúde – Manguinhos 2010; 17(2):447-473. and disastrous reading of his work.

In 1936, physician and philosopher Jaspers⁸8. Jaspers K. Nietzsche. Einführung in das Verstandnis seines Philosophierens. Buenos Aires: Editorial Sudamericana; 1963. (Obra original publicada em 1936)., contemporary with Lange-Eichbaum, also confirmed the diagnosis of syphilis: “For the conception of Nietzsche... what is essential... is the fact that the mental illness in late 1888 was an organic brain disease, born of external causes, not an internal disposition. If you want diagnostics, we will say that most likely... it was a paralysis [PGP]”⁸8. Jaspers K. Nietzsche. Einführung in das Verstandnis seines Philosophierens. Buenos Aires: Editorial Sudamericana; 1963. (Obra original publicada em 1936).. In the reverse direction, however, he attempted to re-evaluate Nietzsche’s work by reintroducing the philosophical discussion to the “Nietzsche affair” – thereby opening up to “heroic-prophetic pathographies” – although the damage had already been done since posterity assimilated by semantic contagion the correlation between syphilis and the condemnation of Nietzsche’s philosophy. No wonder, post-Jarspersian “heroic-prophetic pathographies”, as we shall see, tend to reject the official syphilis diagnosis attributed to Nietzsche.

Heroic-prophetic pathographies

Let us turn to the “heroic-prophetic pathographies” on Nietzsche, linked to functional psychoses: “manic-depressive psychosis” (MDP)/“bipolar affective disorder” (BAD)⁹9. Kolle K. Nietzsche, Krankheit und Werk. Aktuelle Fragen der Psychiatrie und Neurologie 1965; 2:106-121.

10. Verrecchia A. La catastrophe di Nietzsche a Torino. Torino: Einaudi; 1978.

11. Cybulska EM. The madness of Nietzsche: a misdiagnosis of the millennium? Hosp. Med. 2000; 61(8):571-575.^-1212. Young J. Friedrich Nietzsche: uma biografia filosófica. Rio de Janeiro: Forense; 2014. and “schizophrenia”¹³13. Corman L. Nietzsche, psychologue des profondeurs. Paris: PUF; 1982.^,1414. Schain R. The legend of Nietzsche’s syphilis. Westport: Greenwood Press; 2001.. This genre eventually associated, with significant differences of degree among the authors, the “madness” (generic term given to the tragic experience, renamed “psychosis” in its description by psychodynamic psychiatry) to genius/creativity; this tradition dates back to Aristotle in his famous Problemata XXX, and also to Hippocrates in his discussion on the alleged madness of the philosopher Democritus of Abdera, whose historical revival facilitated the celebration of a kind of “heroic madness” and his normative capacity for self-improvement in Nietzsche, which would be confused with his own philosophical production. Cybulska¹¹11. Cybulska EM. The madness of Nietzsche: a misdiagnosis of the millennium? Hosp. Med. 2000; 61(8):571-575. and Young¹²12. Young J. Friedrich Nietzsche: uma biografia filosófica. Rio de Janeiro: Forense; 2014., for example, in very recent publications dating from 2000 and 2014 respectively, end their texts by celebrating allegedly bipolar creative geniuses such as Plato, Newton, Mozart, Wagner, Hölderlin, Coleridge, Schumann, Byron, John Donne, Van Gogh, Georg Cantor, Winston Churchill, Silvia Plath, John Lennon, Leonard Cohen, and so forth. According to this pathographic strand, the greatest goods also come to us through madness, divine gift – as we read in Plato’s Phaedrus, typified in the daimonion of Socrates.

Although the roots of this genre trace back to the classical Greek ethos, this does not, however, imply a relationship of (linear and triumphant) historical continuity in its celebration of Nietzsche. Its rediscovery lies in the Expressionist movement – representative of German modernism until 1914 – which cultivates a trend similar to the “celebration of madness”, whose pathos supposedly providing an “enlightening” (prophetic) perspective would liberate from social conventions and oppressive laws. For late German expressionism, the madman would thus be the incarnation of the Übermensch – the Nietzschean notion of a controversial translation that refers to an overcoming of man³3. Aschheim SE. The Nietzsche legacy in Germany, 1890-1990. Berkeley, Los Angeles: University of California Press; 1992.. In experiencing and overcoming his madness, Nietzsche would enter into the pantheon of rare mad geniuses who would have succeeded in asserting his life as a work of art.

This “heroic-prophetic” pathographic genre on Nietzsche developed from the post-World War II European existentialist context with the psychodynamicization of psychiatry via comprehensive (phenomenological) and explanatory (psychoanalytic) psychopathologies around the narratives of “clinical cases” – what Freud called Krankengeschichten (literally, “history of the sick”). A positive conception of madness is resumed, as opposed to the deficient (and tutelary) perspective perpetrated by the organicist psychiatry at the time, to which Nietzsche was still attached. The speech of the madman is revived through a narrative-based listening clinic. It is inspired by the analyses of celebrated artists focusing on the relationship between madness and aesthetic creation, especially via phenomenology (“August Strindberg case”, analyzed by Jaspers¹⁵15. Jaspers K. Strindberg et Van Gogh, Swedenborg-Hölderlin. Paris: Les Éditions de Minuit; 1953. (Obra original publicada em 1922). in 1922, and by Ludwig Biswanger¹⁶16. Binswanger L. Délire. Grenoble: Jérôme Millon; 2010. (Obra original publicada em 1965). – nephew of Otto Biswanger – in 1965) and via psychoanalysis (“James Joyce’s case”, analyzed by Lacan¹⁷17. Lacan J. O Seminário, livro 23: o sinthoma, 1975-1976. Rio de Janeiro: Jorge Zahar; 2007. in 1975/1976). Besides the theoretical divergences arising from the conceptual framework resulting from these readings, they share an autopoietic perspective of the madman/psychotic man.

Scientific-realistic pathographies

The third and last genre of pathography on Nietzsche – which is appropriately our object of study in this work – associated with other organic pathologies other than syphilis – brain tumors¹¹11. Cybulska EM. The madness of Nietzsche: a misdiagnosis of the millennium? Hosp. Med. 2000; 61(8):571-575.^,1818. Sax L. What was the cause of Nietzsche’s Dementia? J Med Biogr 2003; 11(1):47-54.

19. Owen CM, Schaller C, Binder DK. The madness of Dionysus: a neurosurgical perspective on Friedrich Nietzsche. Neurosurgery 2007; 61(3):626-632.

20. Figueroa G. El último año de lucidez de Friedrich Nietzsche. Rev. Méd. Chile 2007; 135:661-665.^-2121. Huenemann C. Nietzsche’s Illness. In: Gemes K, Richardson J, editors. The Oxford Handbook of Nietzsche. Oxford: Oxford University Press; 2013. p. 63-80.; frontotemporal dementia²²22. Orth M, Trimble MR. Friedrich Nietzsche’s Mental Illness – General Paralysis of the Insane vs. Frontotemporal Dementia. Acta Psychiatr Scand 2006; 114(6):439-445.^,2323. Miranda M, Navarrete L. ¿Qué causó la demencia de Friedrich Nietzsche? Rev Méd Chile 2007; 135:1355-1357.; vascular dementia¹¹11. Cybulska EM. The madness of Nietzsche: a misdiagnosis of the millennium? Hosp. Med. 2000; 61(8):571-575.; CADASIL²⁴24. Hemelsoet T, Hemelsoet K, Devreese D. The neurological illness of Friedrich Nietzsche. Acta neurol belg 2008; 108:9-16.

25. Bosh OG, Höfer FXE. La Gaya Dementia: Nietzsche als Patient. Weimar – Jena: Die große Stadt 2011; (4)1:6-17.^-2626. Perogamvros L, Perrig S, Bogousslavsky J, Giannakopoulos P. Friedrich Nietzsche and his illness: a neurophilosophical approach to instrospection. J Hist Neurosci 2013; 22(2):174-182.; MELAS²⁷27. Koszka C. Friedrich Nietzsche (1844-1900): a classical case of mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) syndrome? J. Med. Biogr. 2009; 17:161-164. – is the one that remains apparently more neutral vis-à-vis Nietzsche’s work, seeking first to take ownership of his legendary figure to rewrite retrospectively the history of these diseases; it is less interested in Nietzsche and more in the self-promotion of new diseases, in favor of the so-called disease mongering²⁸28. Moynihan R, Heath I, Henry D. Selling sickness: the pharmaceutical industry and disease mongering. BMJ 2002; 324(7342):886-891..

It emerges at the turn of the third millennium, with the apogee of neoliberal regimes of political management, in the context of sanitary efficacy tied to managerial rationale and the organization of “post-clinical” medical work, characterized by the parametrization of diagnostic and therapeutic procedures; as a consequence, the clinical-methodological pairing of medical practice with the epidemiological-statistical paradigm takes places. The rationality by which this narrative genre intends its position to be true rests genealogically on the notion of “scientific evidence”, whose core consists in considering only the knowledge referred to perfectly delimited objects (reductionism), and to permanent (positivism) and non-contradictory (formalism) materials. The “discourse of evidence” thus aims to become something of a metalanguage, through which contemporary biomedicine, a follower of the “end of the story”²⁹29. Fukuyama F. O fim da história e o último homem. Rio de Janeiro: Rocco; 1992., proposes to give the final word, transcending Nietzsche’s diagnostic quarrel and thus aborting the narrative polyphonies in favor of its “last version”. This trend is currently illustrated in the psychiatric field by the Research Domain Criteria (RDoC) project of the National Institute for Mental Health (NIHM)³⁰30. Zorzanelli R, Dalgalarrondo P, Banzato CEM. O projeto Research Domain Criteria e o abandono da tradição psicopatológica. Rev. latinoam. psicopatol. fundam. 2014; 17(2):328-341., the main funding body for mental health research in the United States, which aims to anchor the psychiatric diagnosis in pathophysiology, reducing the “mental” to “cerebral”. Based on the neuroscientific perspective adopted, this project expands and exacerbates the ongoing biological reductionism in psychiatry, which the American Psychiatric Association (APA) hitherto sought to keep veiled and in “water bath” in its outspokenly nosological “neo-Kraepelinian” work via the Diagnostic and Statistical Manual of Mental Disorders (DSM)³¹31. Henriques RP. A psiquiatria do DSM: pílulas para que te quero. São Cristóvão/SE: Editora UFS; 2015.. As a result, this pathographic genre, which we will call “scientific-realist” (since it is based on a realistic interpretation of science), disregards Nietzsche’s philosophy, reduces his biography to clinical data of anamnesis and adheres to the objectivity of the disease, and no longer to the “clinical case”.

Chart 1 systematizes the main diagnostic hypotheses recently attributed to Nietzsche, accompanied by a glossary of technical medical terms. Some authors assume the existence of comorbidities and, therefore, propose several diagnostic hypotheses for Nietzsche. Thus, for example, Cybulska¹¹11. Cybulska EM. The madness of Nietzsche: a misdiagnosis of the millennium? Hosp. Med. 2000; 61(8):571-575. points out that BAD is a reasonable hypothesis to explain the affective symptoms that Nietzsche would have manifested throughout his life; however, this diagnostic hypothesis would not, single-handedly, account for his degenerative process after the collapse in Turin, which would, therefore, be explained by vascular dementia; besides, this author does not exclude a possible nonspecific brain tumor as a possible cause of Nietzsche’s collapse and later decline.

In the next topic, we will show Fleck’s case study³²32. Fleck L. La génesis y el desarollo de un hecho científico. Madrid: Alianza Editorial; 1986. concerning the construction of syphilis or lues (plague) as a dated scientific fact as the basis for examining the recent criticisms of Nietzsche’s diagnosis, linked to “scientific-realistic pathographies”.

Styles of thought linked to syphilis

Let us first take the Fleckian notion of “style (structure or group) of thought” and apply it to the pathographic discussions on Nietzsche. Syphilis has been perceived and conceived in various ways throughout history, according to the styles of thought then in force, that is, according to the different a priori socio-historical ones that determine in the speaking beings corresponding ways of thinking, feeling and acting. In the fifteenth century, for example, it was first described as a nosological entity tied to “venereal disease”, and was indistinguishable from gonorrhea and soft cancer. It was associated with chastisement/punishment for lust, one of the capital sins, whose determinant was the influence of the stars:

Most authors assume that the conjunction of Saturn and Jupiter on November 25, 1484, under the sign of Scorpio and in the House of Mars, was the cause of venereal evil (Lustseuche). The good Jupiter succumbed to evil planets Saturn and Mars. The sign of Scorpio, to which the sex parts are subjected, explains why the genitals were the first point affected by the new diseases³²32. Fleck L. La génesis y el desarollo de un hecho científico. Madrid: Alianza Editorial; 1986..

Gradually, another perception/conception came to overlap with that of venereal evil and coexisting with it, in which syphilis would be perceived and conceived as an empirical-therapeutic nosological entity so defined: that non-specific mercury-reactive condition. It would then be associated with the syphilitic blood whose determinant was the Hippocratic-Galenic theory of bodily humor. Schain¹⁴14. Schain R. The legend of Nietzsche’s syphilis. Westport: Greenwood Press; 2001. points out that Nietzsche himself, as an internal high school student in Pforta, before any suspicion of syphilis, received care compatible with the theory of humor, and was treated by the doctor of that college (Dr. Zimmermann) with leeches and Spanish flies against strong headaches, which would effectively launch him into the “health circuit”.

Finally, at the close of the 19^th century, syphilis would be conceived as a biomedical nosological entity linked to bacteriological science, whose specific condition was determined by the Treponema pallidum and whose natural history would become known. Neisser and Ducrey, who isolated the causative agent of gonorrhea in 1879 and chancroid in 1889, and Wassermann, who established the serological test for syphilis in 1906 provided their inputs on this subject. It should be noted that the scientific diagnosis of syphilis based on the Wassermann test did not correspond to a scientific treatment of syphilis, which would only occur after the introduction of penicillin as a drug in 1941.

Therefore, at the time of diagnosis of progressive general paralysis (PGP (neurosyphilis) to Nietzsche at the Basel and Iena clinics in 1889, when bacteriology was incipient, there was some correlation for the nineteenth-century medical reason between syphilis, gonorrhea, and chancroid around the style of thought linked to venereal evil and mercury.

Recent criticisms of Nietzsche’s medical diagnosis

Recent criticisms of Nietzsche’s diagnosis undertaken by medical researchers adhering to “scientific-realistic pathographies” focus mainly on questioning the status of syphilis as a nineteenth-century nosological entity and Nietzsche’s status as a patient at the time of his collapse in Turin.

The status of syphilis in the 19th century

Since the late nineteenth century, syphilis has been a source of great concern for the presumption of its growing morbid influence, in the framework of a “total disease”, which would make it something of general etiological principle, perceived/conceived as the cause of a wide range of symptomatic conditions³³33. Carrara S, Carvalho M. A sífilis e o aggiornamento do organicismo em psiquiatria: notas a uma lição do doutor Ulysses Vianna. História, Ciências, Saúde – Manguinhos 2010; 17(2):391-399. – among them, dementia in middle-aged men. Nietzsche’s collapse in Turin was the episode responsible for the unleashing of his irreversible insanity, and occurred at age 44 when he was in the so-called middle age; thus, the carapace would have served him. In other words, criticism starts from the idea that the diagnosis of syphilis would be the typical “misconception” of that time, of which Nietzsche would have been a victim.

Recent biographers and pathographers¹¹11. Cybulska EM. The madness of Nietzsche: a misdiagnosis of the millennium? Hosp. Med. 2000; 61(8):571-575.^,1414. Schain R. The legend of Nietzsche’s syphilis. Westport: Greenwood Press; 2001.^,2121. Huenemann C. Nietzsche’s Illness. In: Gemes K, Richardson J, editors. The Oxford Handbook of Nietzsche. Oxford: Oxford University Press; 2013. p. 63-80.^,3434. Astor D. Nietzsche. Porto Alegre: LP&M; 2013. have stated that Nietzsche has generally confessed to having become infected twice when he was admitted in January 1889 at the Basel psychiatric clinic. Critics diverge over the analysis of this personal “confession”: some claim that Nietzsche referred to gonorrhea – which he actually contracted in his student days – rather than to syphilis; others take such a “confession” as the only (not at all obvious) fact that supports the diagnosis of syphilis, denouncing the alleged error of physicians by believing naively or opportunistically in the anamnesis of a patient with an altered (manic) mental state.

However, this “confession” of Nietzsche may not have had this all-important relevance. Contrary to what Podack²2. Podach EF. L’effondrement de Nietzsche. Paris: Gallimard; 1931. suggests, at that time, PGP was synonymous with syphilis with or without a previous history of contagion; furthermore, Schain¹⁴14. Schain R. The legend of Nietzsche’s syphilis. Westport: Greenwood Press; 2001. explains it was believed that the milder cases of syphilis – in which the contagion went unnoticed, and the first two phases were mild – were precisely those that evolved into their fearsome tertiary phase (with brain damage). The exception was the director of the Iena clinic, Otto Biswanger, who disagreed that all cases of PGP were due to syphilis, and in a publication of 1894, he argued that some of these cases were due to “brain overload” – an explanation close to the cause that Elisabeth Föster-Nietzsche also attributed to her brother’s collapse: brain damage caused by overwork and drug abuse. In his clash with Möebius, Biswanger believed that as many as 70% of the cases of paralysis could be explained as a luetic infection¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016.. Schain¹⁴14. Schain R. The legend of Nietzsche’s syphilis. Westport: Greenwood Press; 2001. wonders whether it would not have been the experience with Nietzsche as a patient that led Biswanger to such a point of view. Anyway, this idea of Biswanger would not avenge, and at the time of Nietzsche’s death in 1900, there was already a consensus in the medical field that understood PGP as synonymous with syphilitic brain disease. The responsible for the consensus on PGP’s syphilitic origin thesis was Alfred Fournier, the most consecrated syphilograph of the fin-de-siècle, who received the credit of Emil Kraepelin, considered the father of modern psychiatry. This thesis was indeed confirmed in 1913 when researchers at the Rockefeller Institute for Medical Research announced that they had found the Treponema pallidum in the brain of paralytics³³33. Carrara S, Carvalho M. A sífilis e o aggiornamento do organicismo em psiquiatria: notas a uma lição do doutor Ulysses Vianna. História, Ciências, Saúde – Manguinhos 2010; 17(2):391-399..

Therefore, it is necessary to relativize the heuristic value of this personal “confession” in the establishment of the medical diagnosis of syphilis to Nietzsche. Moreover, as we have seen, gonorrhea – which Nietzsche would have contracted – and syphilis belonged to the same discursive semantic complex around the venereal disease, which in itself could justify its diagnosis of syphilis in the nineteenth-century medical view, given the indistinction between the two nosological categories. Such a diagnosis could only be considered a “misconception” from a retroactive perspective, which sees the past through the lens of the present, which is misinterpreted because it is anachronistic.

The status of Nietzsche as a patient

Some authors have argued that at the time of his collapse in Turin, Nietzsche was a “second-class patient”¹⁸18. Sax L. What was the cause of Nietzsche’s Dementia? J Med Biogr 2003; 11(1):47-54.^,1919. Owen CM, Schaller C, Binder DK. The madness of Dionysus: a neurosurgical perspective on Friedrich Nietzsche. Neurosurgery 2007; 61(3):626-632. – Nietzsche was not yet famous as a writer, neither he nor his family had sufficient financial resources to acquire care. Nietzsche was, in fact, hospitalized in the second class on account of his meager resources as a retired teacher in Basel for the funding of his expenses with the asylum treatment¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016.. It is a very seductive argument, since in line with that of anti-psychiatry, which currently gains a politically correct contour. However, we aim to launch our analysis beyond the vulgar denunciation around the known iatrogenic effects of the asylum model, insufficient when applied to Nietzsche’s case. Such authors have argued that the symbolic and financial irrelevance of Nietzsche – deposited in an asylum wing for the poor – would have provided the supposed misunderstanding (the hasty diagnosis of syphilis) that they seek to mend. However, whether at the end of his life or after his death, when Nietzsche had already gained the air of a “celebrity”, this situation did not change his medical diagnosis. Safranski³⁵35. Safranski R. Nietzsche: biografia de uma tragédia. São Paulo: Geração Editorial; 2011. points out that, between 1890 and 1914, “Nietzsche’s name became a sign of recognition (...) Nietzschianism became so popular that, as early as in the 1890s, the first parodies, satires and slanderous texts about him appeared” (p. 294). An emblematic example of the early days of Nietzsche’s transformation into celebrity occurred in early 1891, when the editor of his writings (Naumann) strove to add Nietzsche’s pictures to the fourth part of his Zarathustra, which was in print, which was uncommon in publications of that time¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016.; or when this same editor commissioned Heinrich Köselitz (Peter Gast) in mid-1893 to write a biography of Nietzsche to organize the first volume of his complete works and to get rid of the letters that compelled him to answer questions about Nietzsche’s life; Elisabeth would eventually respond to Naumann’s request by writing the first biography about her brother, published in April 1895¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016.. It is worth mentioning Nietzsche’s progressive penetration in German artistic culture (music, theater, architecture, painting, and so forth), besides its related areas (philosophy and literature) concurrently with his illness process, which would lead to the dissemination of an authentic “worship of Nietzsche” along the lines of mass consumerism³3. Aschheim SE. The Nietzsche legacy in Germany, 1890-1990. Berkeley, Los Angeles: University of California Press; 1992.. Nevertheless, as we have seen, the Nietzsche-celebrity diagnosis was confirmed in his first pathography, written by another celebrity, neurologist Paul Julius Möbius⁴4. Möbius PJ. Über das Pathologische bei Nietzsche. Wiesbaden: Bergmann; 1902..

We questioned whether Nietzsche’s diagnosis was more closely related to the nineteenth-century style of thought about syphilis, supported by the medical reason of the time around the semantic-discursive complex “venereal evil-mercury”, than to questions related to the fault or bias of medical-professional conduct addressed to him. Consistent with nineteenth-century medical reasoning, one of the recent critics¹⁴14. Schain R. The legend of Nietzsche’s syphilis. Westport: Greenwood Press; 2001. of syphilis diagnosis curiously notes that Nietzsche was treated with mercury at the Iena clinic by his assistant physician, Dr. Theodor Zieher. In the nineteenth century, syphilis was a cultural fact matched by medical reason, and not a scientific fact, yet to be invented by the style of thought attached to the Wassermann test.

A critique of recent criticisms of Nietzsche’s diagnosis

Recent critics – more specifically those who adhere to “scientific-realistic pathographies” – have been performing retroactive (anachronistic) readings, updating Nietzsche’s pathography in the light of current nosographies, in an attempt to take ownership of this thinker, since contemporary medical reason (whose style of thought focuses on “evidence-based medicine” – EBM) allows for such a movement of retrospective search for a “truth” underlying the disease to be revealed. EBM relies on the “indiciary paradigm”³⁶36. Ginzburg C. Sinais. Raízes de um paradigma indiciário. In: Ginzburg C. Mitos, emblemas, sinais: morfologia e história. São Paulo: Companhia das Letras; 1989. p. 143-179., an old acquaintance of medical practice, taking it to the extreme and recreating the professional profile of the physician-researcher (in the style of Sherlock Holmes) in his obsessive quest for clues leading to correct elucidation of the cases³⁷37. Nordenstrom J. Medicina baseada em evidências. Seguindo os passos de Sherlock Holmes. Porto Alegre: Artmed; 2008.. Demanding this same “detective” stance of the nineteenth-century physicians who treated Nietzsche and denouncing his alleged misconceptions from this demand is at least an anachronism and an unreasonable charge. The EBM applied to the Nietzsche case purports to undo now the presumed neglect of the past, when Nietzsche’s attending physicians would have been exempt from the ethical-professional duty of elucidating this case by the objective means available at that time, namely, expert autopsy.

What “scientific-realistic pathographies” adepts do not elucidate is: if Nietzsche had received a diagnosis other than syphilis, would his medical treatment have been more qualified, taking into account the eighteenth-century parameters? Did the “first-class” patients receive differential treatment from the nineteenth-century physicians? If so, what might a “first-class” medical treatment reflect at the time?

Let us have a look at that. Daniel Paul Schreber³⁸38. Schreber DP. Memórias de um doente dos nervos. Rio de Janeiro: Paz e Terra; 1995. (Obra original publicada em 1903). – the famous high-ranking jurist, an authentic “first-rate” patient admitted three years after Nietzsche, who would spend nearly a decade in three German psychiatric institutions – does not appear to have received more qualified medical care than Nietzsche did. Psychiatry historian Edward Shorter³⁹39. Shorter E. A history of psychiatry: from the era of the asylum to the age of prozac. New York: John Wiley and Sons; 1997. reports that the eighteenth-century German mental hospitals worked according to the “university psychiatry” model (founded by Griesinger), directed at experimental research, to the detriment of clinical care. It should be noted that the search for the “truth” behind his illness has been occurring with Schreber as well and, since the 1980s, several critics⁴⁰40. Koehler KG. The Schreber Case and affective illness: a research diagnostic reassessment. Pscychol Med 1981; 11(4):689-695.

41. Lipton AA. Was the “nervous illness” of Schreber a case of affective disorder? Am J Psychiatry 1984; 141(10):1236-1239.

42. Rinsley DB. Schreber’s Illness: dementia paranoides or affective disorder? Int J Psychoanal. Psychother 1984-1985; 10:377-382.

43. Kendler KS, Spitzer RL. A reavaluation of Schreber’s Case. Am J Psychiatry 1985; 142(9):1121-b-1122.

44. Grotstein JS. The Schreber Case revisited: schizophrenia as a disorder of self-regulation and of interactional regulation. Yale J Biol Med 1985; 58(3):299-314.

45. Nydes J. Schreber, Parricide, and Paranoid-Masochism. Int J Psycho-Anal 1963; 44:208-212.^-4646. Kushner HI. Freud and the diagnosis of Gilles de la Tourette’s Illness. Hist. Psychiatry 1988; 9(33):1-25. have been questioning the diagnosis of schizophrenia that was attributed to him by eminent physicians of the belle époque⁴⁷47. Freud S. Observações psicanalíticas sobre um caso de paranoia (Dementia Paranoides) relatado em autobiografia (“O Caso Schreber”). In: Freud S. Obras Completas. São Paulo: Companhia das Letras; 2010. v. 10. p. 13-107 (Obra original publicada em 1911).

48. Bleuler E. Dementia Praecox: el grupo de las esquizofrenias. Buenos Aires: Paidos; 1960. (Obra original publicada em 1911).

49. Jung CG. Símbolos da transformação. Análise dos prelúdios de uma esquizofrenia. Petrópolis: Vozes; 1986. (Obra original publicada em 1912).^-5050. Jaspers K. Psicopatologia geral. Rio de Janeiro: Atheneu; 1979. (Obra original publicada em 1913)..

This “return to illness” movement became possible only from the style of thought adopted by contemporary medical reason, linked to the EBM, and to the consequent resurgence of the indiciary paradigm and the investigative stance of the professional profile of the detective physicians, which ontologizes the disease by deontologizing the patient.

Since the end of the twentieth century, the EBM has gradually been implanted as a new paradigm or style of thought to reduce the emphasis on intuition, non-systematic clinical experience, and physiopathological justification in medical decision-making. A hierarchy of the types of studies worthy to be considered as providers of evidence is proposed: (1) first, the meta-analyses of randomized comparative research; (2) at least one randomized comparative study; (3) at least one non-randomized controlled study; (4) at least one quasi-experimental study; (5) non-experimental, descriptive, comparative studies; (6) expert reports, opinion of authorities. In short: the scientific method was reduced to the experimental method, and are practically synonymous now.

Nietzsche’s diagnosis was made from the weakest evidence for the current parameters of EBM: the clinical judgment of medical experts, authorities on the subject – precisely what EBM proposes to be replaced by scientific evidence, from the hierarchy. We witness a clash of distinct thought styles. Hence the vehement current contestations made to Nietzsche’s diagnosis.

However, what is the heuristic value of the physicians’ clinical judgment at stake? In the specific case of Nietzsche, would it be possible to ignore the vast clinical experience of doctors such as Wille, Biswanger, and Ziehen? Such experienced doctors do not seem to have questioned with conviction – other than Biswanger, transiently, as we have seen – their diagnosis of syphilis. Attributing such a diagnostic consensus to the supposed lack of interest of such doctors in Nietzsche is a naive oversimplification. Janz¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016. voids this complaint by stating that “We cannot (...) claim that the two doctors [Biswanger and Ziehen] did not understand their special patient [Nietzsche]”. Instead, one should try to portray the nineteenth-century medical rationality about syphilis, which supported – coherently, in our view – the diagnosis of Nietzsche.

Final considerations

We presume a certain “syphilophobia” in the pathographic tradition about Nietzsche, since the genre associated with syphilis, at least in its early stages, has completely disqualified his philosophical work. Thus, the repeated confrontation of this official medical diagnosis has been confused with the salvation of Nietzsche’s work of such defamation. Such a diagnostic clash, until then, seems to be the only possible way of doing justice to his philosophical work. His sister, Elisabeth Föster-Nietzsche, aimed to shift Nietzsche metonymically from the semantic-discursive complex associated with the venereal evil and, therefore, clear the name of her family; to this end, she constructed diagnostic hypotheses unrelated to syphilis (conceived at that time, and to some extent, currently, as la maladie honteuse⁵¹51. Arruda E. Patografia de Friedrich Nietzsche. Estudo ontológico-fenomenológico. Rio de Janeiro: Fundação Universitária José Bonifácio; 1985.), associated with labor exhaustion, drug abuse, and Nietzsche’s conflict with Christianity¹1. Janz CP. Friedrich Nietzsche: uma biografia, volume III: os anos de esmorecimento, documentos, fontes e registros. Petrópolis: Vozes; 2016.. On the other hand, the authors who intend to shift metonymically Nietzsche from the syllable-discursive complex associated with syphilis, linking it to functional psychoses and other organic diseases, aim to, respectively: (1) clear the name of his work and extol his “Great Health” (triumphant heroic madness); (2) clear the name of medicine, refitting it to the EBM paradigm applied retrospectively to Nietzsche. The same moral judgments of Elisabeth seem to have spread among Nietzsche’s alternative pathographic genres.

While Nietzsche’s “demonic-pathological pathographies” sought to denigrate his philosophical work by associating it with degeneration, the “heroic-prophetic pathographies”, in turn, resuming the classical Greek tradition that associated madness and genius, sought to revalue his work; on the other hand, the “scientific-realist pathographies” would retain a neutrality in their work, in an apparent advantage over the previous ones. However, this neutrality about Nietzsche’s work implies disregarding his word, reflecting a narcissism of this contemporary medicine practiced by those who think that he is “the last man”²⁹29. Fukuyama F. O fim da história e o último homem. Rio de Janeiro: Rocco; 1992. – as if it were possible to undertake a neutral diagnosis of Nietzsche’s disease, without considering it as a “clinical case”, that is, without taking into account his life and work, unrelated to any historical-cultural context. As we have seen, the EBM is nothing more than another narrative to be added to the historical flow of Nietzsche’s pathographies, and not some “last version”, as its adherents claim.

We agree with Volz⁵²52. Volz PD. Nietzsche im Labyrinth Seiner Krankheit: Eine medizinisch-biographische Untersuchung. Würzburg: Königshausen und Neumann; 1990., whose work still represents the most extensive review of Nietzsche’s medical registries and records, that syphilis remains a fair diagnostic hypothesis – nothing short of that: a “suspicion”, as Klopstock would have it⁵³53. Klopstock T. Friedrich Nietzsche und seine Krankheiten: kein ausreichender Anhalt für MELAS. Nietzsche-Studien 2013; 42(1):293-297. – to explain the collapse of Turin, especially when one takes into account contextually the style of thought and the medical rationality that served as its foundation. This same diagnostic opinion was recently endorsed in the journal Nietzsche-Studien by Schiffter⁵⁴54. Schiffter R. Friedrich Nietzsche Krankheiten: eine unendliche Geschichte. Nietzsche-Studien 2013; 42(1):283-292.. Let syphilis not bring any demerit to the intriguing and admirable Nietzschean philosophical work! It would be inappropriate to discuss his medical diagnosis biased by moral judgments, as seems to be the case with alternative pathographies, when in fact Nietzsche and his work have long since transcended good and evil.

Chart 2 presents a glossary.

References

Publication Dates

History