Nietzsche's Diagnosis Of The Insane

Friedrich Nietzsche (1844-1900) left a provocative philosophical work. Also, the diagnosis of his protracted illness became a controversial issue. After a particularly productive period (1888), Nietzsche suffered a mental breakdown. The diagnosis of general paresis of the insane (GPI) was made by the medical director of the Basel asylum, Ludwig Wille1. In Jena, Otto Binswanger, the institution's director, and his staff, upon consistent examination, corroborated GPI. The diagnosis was never contested by anyone of his physicians: as late as 1920 Binswanger, who met him twice after his release, reasserted categorically the diagnosis1. After January 1889, Nietzsche never recovered. The disoriented, agitated and delirious patient entered a slow

His right eye was functionally blind by age 301,2,3. Central chorioretinitis was diagnosed in 1878 (severe myopia? toxoplasmosis?). Severe headaches set in from school years on1,2,3,4. They were asymmetric (mainly right-sided), frontal/supraorbitary, and accompanied by photophobia and nausea/vomiting, becoming more severe in adult life. After recurrent sick leaves from his professorship chair at Basel (1871, 1876), Nietzsche retired in 1879. During the 1880s, he used to take a variety of medicines against numerous complaints: stomach cramps, constipation, retching, headaches and severe insomnia, against which he took, apparently in high doses, chloral

However, anisocoria was present since childhood and typical signs, such as dementia, ataxia, and hand and tongue tremor, were absent. Nietzsche admitted having had gonorrhea (“Tripper”) twice in his twenties1. It is, however, worth noting that, in 1865-7, to tell gonorrhea from syphilis would have needed a doctor1. Anyway, if asymmetrical findings (e.g., left ankle clonus), and the very long course before death speak against neurosyphilis, lancinating headaches and orbital pain, aniso/dyscoria and a subacute mental breakdown in a middle-aged patient with a history of remote venereal infection comprise a coherent cluster pointing to the diagnosis of neurosyphilis. In fact, motor problems are a relatively late feature in most cases of GPI and would not necessarily be expected at presentation. Asymmetrical manifestations are common, and strokes resulting in hemiplegia not rare. (ref Merrit.). The usual course led to death in 3-4 years and “a few cases” 5-6 years5. Kraepelin refers to “a genuine case of paresis confirmed by autopsy, with a remission of twenty years”4,5 and to “some cases of so-called arrested paresis”5, even not dismissing the “mooted question” of recoveries from paresis5. Binswanger, too, was not impressed by Nietzsche’s