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Turin's breakdown: Nietzsche's pathographies and medical rationalities.

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. Janz (1) 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!" (1). 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 1930s (2). 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 21st 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

Aschheim (3) 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-siecle 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 spokesman (3). In 1902, Nordau's intuition was developed by Moebius (4), a celebrated physician who wrote the first specific pathography on Nietzsche and was later established by Lange-Eichbaum (5,6) in his respective works of 1930 and 1947. Both Moebius 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. Janz (1) 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" (7) and disastrous reading of his work.

In 1936, physician and philosopher Jaspers (8), 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]" (8). 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) (9-12) and "schizophrenia" (13,14). 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. Cybulska (11) and Young (12), 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, Holderlin, 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 Ubermensch--the Nietzschean notion of a controversial translation that refers to an overcoming of man (3). 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 Jaspers (15) in 1922, and by Ludwig Biswanger (16)--nephew of Otto Biswanger--in 1965) and via psychoanalysis ("James Joyce's case", analyzed by Lacan (17) 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 tumors (11,18-21); frontotemporal dementia (22,23); vascular dementia (11); CADASIL (24-26); MELAS (27)--is the one that remains apparently more neutral vis-a-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 mongering (28).

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" (29), 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) (30), 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) (31). 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, Cybulska (11) 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 study (32) 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 diseases (32).

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. Schain (14) 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 19th 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 conditions (33)--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 pathographers (11,14,21,34) 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 Podack (2) suggests, at that time, PGP was synonymous with syphilis with or without a previous history of contagion; furthermore, Schain (14) 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 Foster-Nietzsche also attributed to her brother's collapse: brain damage caused by overwork and drug abuse. In his clash with Moebius, Biswanger believed that as many as 70% of the cases of paralysis could be explained as a luetic infection (1). Schain (14) 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-desiecle, 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 paralytics (33).

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" (18,19)--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 treatment (1). 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. Safranski (35) 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 time (1); or when this same editor commissioned Heinrich Koselitz (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 18951. 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 consumerism (3). Nevertheless, as we have seen, the Nietzsche-celebrity diagnosis was confirmed in his first pathography, written by another celebrity, neurologist Paul Julius Mobius (4).

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 critics (14) 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" (36), 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 cases (37). 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 Schreber (38) --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 Shorter (39) 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 critics (40-46) have been questioning the diagnosis of schizophrenia that was attributed to him by eminent physicians of the belle epoque (47-50).

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. Janz (1) 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 Foster-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 honteuse (51)), associated with labor exhaustion, drug abuse, and Nietzsche's conflict with Christianity (1). 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" (29)--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 Volz (52), 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 it (53)--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 Schiffter (54). 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.

DOI: 10.1590/1413-812320182310.25602016

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Article submitted 26/03/2016

Approved 07/10/2016

Final version submitted 09/10/2016

Rogerio Paes Henriques [1]

[1] Centro de Educacao de Ciencias Humanas, Departamento de Psicologia, Universidade Federal de Sergipe. Av. Marechal Rondon s/n, Jardim Rosa Elze. 49100-000 Sao Cristovao SE Brasil. ruggerosph@gmail.com
Chart 1. Major recent diagnostic hypotheses (DH), published since
2000, alternatives to syphilis, attributed to Nietzsche as a causal
explanation for his collapse suffered in Turin.

HD                        AUTHORS

Meningioma type tumor     Sax (2003) (18)
                          Huenemann (2013) (21)

Other brain tumors        Cybulska (2000) (11)
                          Owen, Schaller & Binder (2007) (19)
                          Figueroa (2007) (20)

Frontotemporal dementia   Orth & Trimble (2006) (22)
                          Miranda & Navarrete (2007) (23)

Vascular dementia         Cybulska (2000) (11)

CADASIL                   Hemelsoet, Hemelsoet & Devreese (2008) (24)
                          Bosh & Hofer (2011) (25)
                          Perogamvros, Perrig, Bogousslavsky &
                          Giannakopoulos (2013) (26)

Melas                     Koszka (2009) (27)

MDP/BAD                   Young (2014) (12)

Schizophrenia             Schain (2001) (14)

Chart 2. Glossary.

Neurosyphilis   "Neurosyphilis (also known as general paresis [or
                progressive general paralysis]) appears 10 to 15
                years after primary infection with Treponema (...)
                and usually affects the frontal lobes, resulting in
                personality changes, irritability, and decreased
                self-care. Grandiose delusions develop in 10 to 20%
                of affected patients. The disease progresses with the
                development of dementia and tremor, eventually
                reaching bed confinement by parous
                neurosyphilis" (55).

Dementia        This is a syndrome characterized by multiple
                impairments in cognitive functions without
                consciousness impairment. Cognitive functions that
                may be affected in dementia include general
                intelligence, learning, and memory, language,
                problem-solving, orientation, perception, attention
                and concentration, judgment, and social skills. The
                patient's personality is also affected" 55. Vascular
                dementia "is usually the result of cerebral
                infarctions from vascular diseases, including
                hypertensive cerebrovascular disease. Infarcts are
                usually small, but cumulative in their effect" 56.
                Frontotemporal dementia, described only in detail in
                the last two decades 22, is the most common subtype of
                "frontotemporal dementia", a category that gathers
                several diseases that cause damage to the frontal and
                lateral regions of the brain.

Meningioma      it is a tumor, usually benign and slow-growing, of
                the meningeal membranes that involve the central
                nervous system (CNS). According to Sax's 18
                hypothesis: "If a meningioma of the right optic nerve
                were present in this [Nietzsche's] case, a regular
                mass size increase would have effectively led to a de
                facto frontal lobotomy. Such an effect would be
                responsible for the subsequent deterioration of
                Nietzsche's state of mind between 1889 and 1900
                [post-collapse]".

CADASIL         Acronym of "Cerebral Autosomal Dominant Arteriopathy
                with Subcortical Infarcts and Leukoencephalopathy".
                It is a hereditary autosomal dominant disease of
                small and medium blood vessels transmitted by the
                paternal lineage, whose characteristic is the tetrad
                dementia, psychiatric disorders, headache and
                frequent cerebral vascular accidents. This disease
                causes repeated ischemic attacks and is related to
                mutations in the NOTCH3 gene. According to
                Perogamvros et al. 26: "Nietzsche evidenced all the
                major clinical manifestations of CADASIL (young age
                [< 50 years old], migraine, strokes, mood disorders,
                subcortical dementia, [paternal] family history)".

MELAS           acronym of "mitochondrial encephalomyopathy, lactic
                acidosis, and stroke-like episodes". It is a rare,
                multisystem neurodegenerative disease of maternal
                transmission, of progressive development and with a
                very variable clinical phenotype, which usually
                appears in childhood (usually between 2 and 10 years
                of age; in rare cases, it may appear later, up to 40
                years or even later). Koszka 27 concludes his article
                by stating that "when considering the entire clinical
                history available on Nietzsche (onset of disease in
                childhood, maternal inheritance, typical symptoms and
                complications, disease development) and his family,
                his probable diagnosis is MELAS syndrome or MELAS
                overlap syndromes".

MDP/BAD         Formerly known as "manic-depressive psychosis"
                (Kraepelin) and reclassified as "bipolar affective
                disorder" (Leonhard). It is characterized by the
                cyclic alternation between manic or hypomanic phases
                (mood exaltation) and depressive phases (mood
                relegation), interspersed by intermittent periods of
                complete recovery. Given the lack of a demeaning and
                deteriorating course 55, it may even be used as an
                explanation for some aspects of Nietzsche's affective
                life, but never as a causal criterion for his
                collapse and consequent ruin, as Cybulska (11)
                correctly points out.

Schizophrenia   formerly known as "early dementia" (Kraepelin), then
                renamed as "schizophrenia" (Bleuler 48). Its
                symptomatology covers positive (delusions,
                hallucinations, language disorders, etc.) and
                negative (affective dullness, apragmatism,
                self-neglect, etc.) psychotic symptoms. Depending on
                the specific subtype, there are predominant positive
                (paranoid schizophrenia) or negative (hebephrenic
                schizophrenia and catatonic schizophrenia) symptoms,
                and these are the most common subtypes in the
                Nietzsche era. It develops by outbreaks, acute
                episodes that tend to leave a sequel and--when
                untreated, as was customary at the turn of the
                nineteenth to the twentieth century--lead to
                deterioration of the personality. Among mental
                disorders, this is the only one that may have acted
                as a causal factor in the Turin collapse, although
                the recent advocate of this hypothesis, namely,
                Schain 14, has not specified the subtype in question,
                more in keeping with the supposedly triggering
                psychogenic aspects of Nietzsche's many crises.
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Title Annotation:FREE THEMES
Author:Henriques, Rogerio Paes
Publication:Ciencia & Saude Coletiva
Date:Oct 1, 2018
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