THE MADNESS OF DIONYSUS

Objective To examine the possibility that an intracranial mass may have been the etiology of the headaches and neurological findings of the philosopher Friedrich Nietzsche (1844-1900) and the cause of his ultimate mental collapse in 1889. Methods The authors conducted a comprehensive English and German language literature search on the topic of Nietzsche's health and illness, examining Nietzsche's own writings, medical notes from his physicians, contemporary medical literature, biographical texts, and past attempts at pathography. We also examined archived portraits and engravings of the philosopher from 1864 onward. An English language search in the modern literature on the topic of psychiatric presentations of intracranial mass lesions was also conducted. Results From his late 20s onward, Nietzsche experienced severe, generally right-sided headaches. He concurrently suffered a progressive loss of vision in his right eye and developed cranial nerve findings that were documented on neurological examinations in addition to a disconjugate gaze evident in photographs. His neurological findings are consistent with a right-sided frontotemporal mass. In 1889, Nietzsche also developed a new-onset mania which was followed by a dense abulia, also consistent with a large frontal tumor. Conclusion A close examination of Nietzsche's symptomatic progression and neurological signs reveals a clinical course consistent with a large, slow growing, right-sided cranial base lesion, such as a medial sphenoid wing meningioma. Aspects of his presentation seem to directly contradict the diagnosis of syphilis, which has been the standard explanation of Nietzsche's madness. The meningioma hypothesis is difficult, though not impossible, to prove; imaging studies of Nietzsche's remains could reveal the bony sequelae of such a lesion.