If we are to come to any final opinion about the nature of Schumann's illness, we must first try to decide what it was that killed him. There can, we think, be no reasonable doubt that when Schumann was in Endenich he was suffering from organic disease of the brain. When, twelve days after the onset of acute psychotic symptoms, he voluntarily went to the asylum, he was in a fatuously euphoric state, entirely forgetful of his wife and family. From the letters of Brahms we get a clear picture of Schumann in hospital retaining his emotional responsiveness, even when intellectual failure had become profound. Gross failure of memory was reported by the doctor as present a few months after his admission to hospital. In course of time intellectual failure reached the point of not being able to speak or write coherently, and it was succeeded by increasing physical weakness and emaciation, decubitus, incapacity to carry out ordinary voluntary movements, and death in convulsions. During the earlier part of his stay there were hallucinatory episodes and short-lived delusional ideas; a prominent feature of these states is their transitory nature, and they have every appearance of being organically determined phenomena. The existence of some form of organic disease of the brain seems to be beyond dispute. Going back into the past, we find the first mention of symptoms characteristic of an affection of the nervous system not earlier than 1844. In that year there is the first mention of attacks of giddiness, and Dr. Helbig reports "Gehörstäuschungen." We do not know exactly what was meant by this word, but it seems improbable that it meant auditory hallucinations. It is much more probable that some form of tinnitus was intended, since that is the auditory symptom which is more precisely described later. Giddiness recurred in 1845, and tinnitus in 1846. It is then described in unmistakable terms as a constant singing and roaring in the ears, and an effect by which noises became musical tones.

    From this time until 1852 there is a gap, and no symptoms of a characteristically organic kind are recorded. In 1852, however, they reappeared in more ominous form, first as a dreamy apathy and disturbance of speech, then the occurrence of a “convulsive" attack. From that time deterioration was steady. There were more speech difficulties and more auditory symptoms in 1853; and in February 1854 there came the sudden outbreak of a florid psychosis. In the course of a week Schumann was reduced from normal mentality to a state of raving.

    Of this state the first sign was an intense tinnitus, which was soon translated into a continuous and vivid auditory hallucinosis. It is interesting that the hallucinations took at first a musical form, only later to become voices. One might suppose that stimulation of the auditory centres by pathological stimuli caused this reaction in his case because so much of his normal mental activity was musical rather than verbal. In this delirium‑like psychosis, it is not easy to say how large a part was played by clouding of consciousness. At times at least it was not wholly clouded over, since he could recognise his wife at his side; but there is a suggestion of a twilight state with a varying degree of clouding. The hallucinosis, also, was variable in degree, and at times passed off. We hear of his getting quieter, getting up and setting about the correction of manuscript, of writing business letters, and still later receiving and entertaining a visitor. Other symptoms were fleeting delusional ideas and sudden impulsive actions. The total picture is a very familiar one, that of a delirious state, an exogenous organic reaction.

    We agree with Gruhle that dementia paralytica is by far the most probable diagnosis, and accounts for the entire course of the illness from 1852 onwards. There are other possibilities, such as presenile and arteriosclerotic dementia, hypertensive encephalopathy, vitamin deficiency (pellagra, aneurin deficiency or related deficiencies which are known to occur in depressives or after chronic alcoholism), a deep‑seated new growth, etc. MacMaster (1928) thought of (obviously atypical) tuberculous meningitis. But on careful consideration none of these alternatives fits all the facts as well as syphilitic disease.

    Relating this hypothesis with his productivity, we can say that an organic psychosis, such as dementia paralytica, would explain the failure of Schumann's musical powers in 1852 and later. Furthermore, the type of failure is consonant with organic changes. Schumann was quite productive in 1852 and 1853. All critics are agreed that these later works are without merit, the last occasions when he reached his old mastery being the violinsonatas of 1851. Of the work of 1853, Chissell notes that mental tiredness and emotional apathy were accompanied by an unhesitating flow. It seems very probable that organic psychotic changes were making their effects felt in 1852, and unlikely that their onset was any earlier than 1851. We have, then, to account for the tinnitus and giddy attacks which appeared much earlier, i.e., in 1845. Consistently with the diagnosis of dementia paralytica, these may be attributed to a luetic infection. A combination of cerebrospinal syphilis and dementia paralytica, though rare, is well known to occur; and, following Lange‑Eichbaum, there seems to have been a similar sequence in the illness of Nietzsche. An exceedingly far‑fetched suggestion is also, perhaps, just worth mentioning, that of a lesion such as a tumour of the temporal lobe. The later appearance of gustatory and olfactory hallucinations might be thought to fit in with this, but otherwise there is nothing to support it. Ménière's disease, as a cause for tinnitus and giddiness, can be excluded, since there is no evidence that Schumann ever became deaf.

    Having reached this point, we now have to consider the nature of the depressive and anxiety states which afflicted Schumann from the age of eighteen onwards. We believe that any impartial examination of the self‑descriptions, such as those we have quoted, leads irresistibly to the conclusion that these were cyclothymic in nature. Let us, however, first consider the alternative hypothesis, which is so constantly repeated, that Schumann was schizophrenic.

    The whole basis for a diagnosis of schizophrenia depends on a schizophrenic interpretation of the final psychosis of 1854‑56, and a determination to regard earlier symptoms as caused in the same way. This was the position taken by Möbius, who said, in a paragraph which has often been quoted:

    "Angst und Verstimmung, wunderliche Manieren, Neigung zur Stummheit, Misstrauen, Gehörstäuschungen, schwere Sprache, allmähliches Abnehmen der Geisteskräfte, alles schubweise hervortretend und langsam, aber unaufhaltsam zunehmend, das ist die Krankheit, die jetzt Dementia praecox genannt wird."

    In the light of the description which has been provided, this clinical summary can be seen to be inaccurate. There were numerous phases of illness from youth on, always with complete recovery and no indication of progression until the 1850's. The speech difficulties and mental impairment are confined to the last years, and are organic in nature. The auditory symptoms are peripheral in nature, until the delirious state of February 1854 brings genuine hallucinations. The only "hallucina­tory" experience before that time is the hypnagogic hallucination of February 1838. Evidence for mistrust or a paranoid reaction at any time in life is very scanty: at Düsseldorf Clara was more mistrustful than Robert. The states of anxiety and de­pression are, surely, characteristic of cyclothymia and not of schizophrenia.

    The "Neigung zur Stummheit," which Nussbaum also calls "Mutismus," is worth a little more discussion. There can be no doubt that in the course of his married life Schumann became very taciturn; yet evidence is lacking that his taciturnity was pathological. At times, especially in an intimate circle, he would be very talkative, when the subject discussed was one which interested or moved him. Nussbaum's "Schnauzkrampf" and Möbius' "wunderliche Manieren" appear both to be over­statements of a position of the lips at rest suggestive of whistling, and of a habit Schumann had of walking up and down in his room on tiptoe. Both of these would appear to fall well within the range of normal mannerisms.

    The family history is a point which counts in favour of schizophrenia. The mental illnesses of both his sister and his son have been diagnosed as schizophrenic; this diagnosis seems very probable in the case of the son, less so in the case of his sister Emilie. However this is a point which cannot carry great weight. We have to diagnose schizophrenia by the clinical features shown by the patient himself, and to do so with any justification we have to show the presence of at least one or two incontestably schizophrenic symptoms. We can find no evidence of any schizophre­nic symptoms in the illness itself; and the most that can be safely asserted is that Schumann's basic personality, which of course lent an individual colouring to the features of the illness, was not of an exclusively cyclothymic kind. His unrealistic idealism, his dreaminess and romanticism are certainly character traits which are not typical of the cyclothymic extravert, and could perhaps, together with his manner­isms, be regarded as schizoid. In such qualities as these one might justifiably trace the influence of the familial predisposition. The fact remains that Schumann never showed any overt symptom, and that the whole course of his illness is of a totally different kind.

    The portraits of Schumann (figs. 1 to 3) show a markedly pyknic habitus, with soft, rounded, almost feminine features. His personality also had qualities which might be called soft or feminine. In youth he was extremely extraverted, gay, active, and sociable, without a sign of schizoid sensitivity or withdrawal. In his married life he changed much, in a way which can be accounted for by the increasing predominance of depressive moods, and by the domesticating influence of Clara. Schumann was, of course, a complex personality, to which his classification as cyclothymic does not do full justice.



    However, the course of the mood changes is characteristically cyclothymic. There were depressive phases in 1828, 1830, 1831, 1833, 1836, 1838, 1839, 1842, several such in 1844 taking up nearly the whole of the year, 1847, 1848. In 1829, 1832, 1833, 1836, 1838, 1843, 1849 and 1851 there were phases of marked eleva­tion of mood, sometimes of a rather extreme degree. On two or three occasions, Schumann recorded in self‑descriptions emotional states of a mixed kind ("tot und selig zugleich," "so arm und reich, so matt und kräftig, so abgelebt und so lebenslustig" ). There is a suggestion of correlation of mood changes with the seasons. Many of the down‑swings took place in the autumn, with a number of others in the spring; the principal up‑swings also occurred in the months February to June. However there was no consistent regularity; the main mood changes in 1836, 1842 and 1848 were in December.

    If one examines a chart of Schumann's production against the years, the inhibi­tory effect of his depressive phases and the excitatory effect of the elevated phases are made strikingly obvious (Table 2). 1840 and 1849 were his peak years, and in both of them he was in a consistently elevated mood throughout the year. In most of the other years he had some weeks or months of depression, not enough to distin­guish one year from another on the chart; but the year 1844 was remarkable for low spirits practically throughout the entire year. It is also noteworthy that, regardless of quality, his production was consistently high in the four years 1850‑53. Despite the onset of symptoms of an organic type, he was unusually free from depressive and hypochondriacal moods during these years, apart from a phase of depression in April and May 1852. The fact that the organic symptoms themselves had no inhibitory effect on his productivity is confirmatory evidence that the earlier and the later psychiatric illnesses were different in nature.

    Gruhle laid stress on two signs which he regarded as pathognomonic of endoge­nous depression, both shown by Schumann to a conspicuous degree; the inhibitory effect of the depression on mental life, and the subjective experience of intense physical malaise. There are other points which we may add. In his depressions Schumann suffered from an intractable insomnia, which Dr. Helbig said had resisted all previous medicines; from Clara's account of finding her husband in the morning awake and drowned in tears, it would seem that the insomnia was of that type, with early morning waking, which is most characteristic of endogenous depression. Helbig also observed a marked diurnal rhythm, with the morning hours being the worst, a feature which is again typical of the endogenous depression. Psychogenic precipita­tion for the depressive phases is not easily to be found, and in general these moods do not appear to be of the reactive type. They could not be alleviated by distrac­tions, and, until they spontaneously remitted, Schumann was hypochondriacal, oppressed by irrational fears and bodily malaise, dependent and self‑reproachful. The evidence of a manic‑depressive constitution could hardly be more complete.