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The Legend of Nietzsche's Syphilis: (Contributions in Medical Studies)

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This concise and well written book is a critical discussion of the widely accepted idea that Nietzsche died from neurosyphilis. The basic facts are known well. In his late 40s, Nietzsche had a psychotic episode from which he never recovered. Following a period of institutionalization, he was cared for by his family until his premature death. His psychiatric problems appear to have fluctuated some in the early phases of his illness but his later course was characterized by a progressive decline until he was profoundly demented and immobile. Schain, drawing to a large extent on the helpful compilation and publication of many relevant documents by the German physician Pia Volz, nicely surveys Nietzsche's medical history and the prior literature on this topic. Schain is appropriately critical of the neurosyphilis hypothesis. While this idea was apparently accepted widely by Nietzsche's physicians, including individuals such as the noted neuropsychiatrist and neuropathologist Otto Binswanger who were very knowledgeable about this topic, Schain shows well the defects of this conclusion. For example, Nietzsche's anisocoria was regarded as evidence of neurosyphilis but Schain provides evidence that it was actually a congenital phenomenon. Nietzsche probably contracted gonorrhea as a young man but had no clear history of primary or secondary syphilis. As Schain points out, only clinical diagnosis of neurosyphilis was possible in Nietzsche's time and neurosyphilis was clearly used as a 'waste basket' categorization of a variety of entities. Nietzsche never underwent neuropathologic evaluation and so this issue can never be settled definitively.

Schain's alternative diagnosis is schizophrenia and he makes a reasonable case for this diagnosis. There are, however, several problems with Schain's conclusions. Like others who have written on this topic, Schain is pursuing 'pathography', the idea that knowledge of illness can cast light on the life and work of the sufferer. Schain's conception of schizophrenia has a strong psychodynamic flavor. He sees Nietzsche's breakdown as the result of a conflict between Nietzsche's profoundly unconventional ideals and the realities of late Victorian society superimposed on a unstable personality structure. The latter idea is not defined well. Schain sees Nietzsche's illness as an organic extension of his critique and criticism of the Victorian world.

Schain's conception of schizophrenia, however, is inaccurate. Schizophrenia is not really a psychodynamice problem. It is, as suspected by 19th century German neuropsychiatrists, a brain disease, probably one resulting from abnormal brain development. Crucial features of Nietzsche's illness are not consistent with a diagnosis of schizophrenia. As Schain acknowledges, onset of psychosis and schizophrenia in the late 40s, while not unheard of, is definitely unusual. Schizophrenia does not account for Nietzche's subsequent decline and eventual death, which is more consistent with a neurodegenerative process than schizophrenia. This fact militates against other possible psychiatric diagnoses such as bipolar disorder or major depression with psychotic features, the latter being more common in the middle aged than new onset schizophrenia.

It seems most likely that Nietzsche suffered from some neurodegenerative disorder that presented with psychiatric illness. There are a lot of possibilities. None of them are common in the middle-aged. A number of very rare disorders, like prion diseases or Wilson's disease, are possible. Frontotemporal dementias, which are now appreciated as uncommon as opposed to rare, typcially have prominent behavioral features at onset and they do present at younger ages than more common dementias such as Alzheimer disease.

On statistical grounds, however, one cause would have to be favored. In a middle-aged Victorian man with a history of venereal disase presenting with psychosis followed by a progressive dementing disorder, neurosyphilis would be the most likely cause.