Schumann's Illness (1972)

Schumann's Illness

In Robert Schumann: The Man and His Music, ed. by Alan Walker, London, Barrie & Jenkins, 1972

At the time when he made it, in 1906, Möbius's [1] suggestion that Schumann had suffered from 'dementia praecox' was a very reasonable one. It was at that time a very up‑to‑date diagnosis; since it was not very long after Kraepelin had succeeded in sorting out an important part of the ragbag of ill‑understood mental illnesses, and in distinguishing under the name of 'dementia praecox', those conditions which we now call schizophrenic. We now know much more about this group of illnesses, though we are still very ignorant of their causation. At the time Mobius wrote, the principal features recognized were: an onset commonly in adolescence or early adult life; progression by fits and starts, with periods of remission and partial recovery between whiles; symptoms in the form of hallucinations, delusions, unaccountable mood changes, and disorders of behaviour of sometimes a bizarre kind; and eventually successive decline to a state in which the personality is obliterated. All these features seemed to fit the case of Schumann fairly well. He had had nervous symptoms from adolescence onwards; he had had phases of illness and recovery; and finally his illness took a steep downward course to end in dementia and death.

    And yet the diagnosis made by Möbius will not do. It did not do in his own day, and its inadequacies were pointed out by Gruhle [2] in 1906. It is still less acceptable now. Gruhle argued that the facts adduced by Möbius, rightly con­sidered, led to a different conclusion, i.e. that during the earlier part of his life Schumann was cyclothymic (manic‑depressive), but that his last illness was an organic disease of the brain, most probably general paresis.

    Gruhle was one of the pioneers of the 'phenomenological' school of psychiatry, which made a great step forward in the understanding, and especially the diagnosis, of schizophrenia, by exact and detailed study of the symptomatology of all mental illness. Symptomatology was linked to the pathological causes where they were recognizable in, for instance, poisoning, infections and diseases of the brain; and, in the 'functional psychoses', to course and outcome. The two prin­cipal psychoses, schizophrenia and 'manic‑depressive insanity' could be distin­guished from one another by these means, and were also found in the main to run true to type in any affected family. Similar methods of study sufficed to distinguish the other main kinds of mental abnormality or disorder, i.e. mental subnormality, the neuroses and the personality disorders ('psychopathy'). This work was all going on at the turn of the century, when also Sigmund Freud was introducing revolutionary new ideas. Gruhle was one of the greatest phenomen­ologists then engaged in building up a rational taxonomy, one that remains basic for us today. It is not surprising that when he applied to Schumann's case the principles he had done so much to develop, it resulted in a radical reconsideration.

    This did not mean the end of the debate. The schizophrenic hypothesis has been revived since Gruhle's day, e.g. by Nussbaum [3] in 1923; and by Worner [4] in 1949; and a 'congenital schizophrenic‑type mental disease which ... might today be diagnosed as dementia praecox' is perpetuated by Joan Chissell [5] in the last edition of her biography of Schumann. But I am not aware of any revival of this hypothesis by a psychiatrist since the paper by Meyer and myself [6] in 1959.

    For basic source material we principally relied on the works by Litzmann [7, 8] and Wasielewski. [9] We overlooked two important sources: Boetticher [10] and Erler, [11] which will be mentioned below. Boetticher, while accepting the manic­depressive view put forward by Gruhle, thinks there is some schizoid admixture, [12] and emphasizes also obsessional symptoms, such as music running on in his head without letting him sleep. Our diagnostic analysis consisted in showing (a) that all the nervous symptoms which troubled Schumann in early life and up to the age of, say, forty‑two, were characteristically 'cyclothymic', that is, related to the manic‑depressive and not to the schizophrenic syndrome; (b) that Schumann survived repeated attacks of this kind of illness without any deterioration of personality (which was to be expected on the schizophrenic hypothesis); (c) that the last illness which led to his admission to the mental hospital at lEndenich began as a delirium or confusional state, typical of acute organic psychoses but very rare in schizophrenia; (d) that this illness progressed into a form of dementia unlike schizophrenic deterioration of the personality but typical of organic disease of the brain; (e) that the nature of this brain disease was most probably the late form of cerebral syphilis called general paresis or G.P.I.

    A short explanation of the way in which syphilis affects the central nervous system may be found helpful at this point. There are three main syndromes: meningovascular syphilis, tabes dorsalis (locomotor ataxia) and general paresis. In the first condition, which may come on soon after the original infection, or at any time in later life, the blood vessels and membranes of the nervous system are principally involved. Symptoms include headaches, convulsions, and a great variety of pains if the posterior nerve roots are affected. The other two types are called late or tertiary syphilis, since symptoms appear from ten to twenty‑five years after the infection. In these conditions it is the nerve cells themselves which are attacked, in tabes the nerve cells of the spinal cord and in general paresis the nerve cells of the brain cortex, especially in the frontal and temporal regions; the membranes and small blood vessels are affected also. In tabes, as well as various forms of unsteadiness of the limbs, leading symptoms are the pains and abnormal sensations (paraesthesiae). Pains may take the form of severe stabbing, the so‑called 'lightning pains', which may be thought of as rheumatic pain; or girdle pains; or very severe crises of pain. In a typical case of tabes, with lesions confined to the spinal cord, mental changes do not occur. In general paresis, mental symptoms are the leading ones, and take many forms, e.g. a simple dementia, or a paranoid persecutory psychosis, or onset with an acute confusional or delirious state progressing later to dementia. Before the days of malarial and other fever therapies (or nowadays with penicillin), from diagnosis to death the illness usually only lasted two or three years. Although these three types of condition are dis­tinct, and most patients affected by tertiary syphilis of the nervous system tend to follow one clinical path or another, combinations are not infrequent. The combination of tabes with general paresis is recognized as tabo‑paresis.

    Schumann's clinical history was described in some detail by Meyer and myself (loc. cit.), and here can be quite briefly summarized. Covering the varying mood states which Schumann had all his life, we can draw up the following calendar, starting when he was eighteen: 

1828:    predominant mood melancholic.
1829:    one and a half years of almost continuous happiness, occasionally interrupted by quite short depressive          
            moods.
1830:    recurrence of melancholy in October.
1831:    persistently melancholic, psychically inhibited, with phases of agitation. Sudden recovery on 31 December.
1832:    excellent spirits throughout.
1833:    relapse into depression in the autumn; the fear comes that he might go mad.
1834:    by May almost well, and in August elated.
1836:    normal spirits pass into elation succeeded by a depressive phase.
1837:    depressive state in September.
1838‑9: up and down.
1840:    marriage, followed by several good years.
1842‑3: some months of nervous weakness and incapacity to compose, later passing into elated state.
1844:    very melancholic throughout the year, almost without intermission.
1845:    some depression in May.
1846:    May to July melancholic; then complete remission.
1848:    relapse in January and depressive mood predominating for most of the year.
1849:    in the best of spirits throughout the year.
1850‑1: minor mood changes only.
1852:    mild depression.
1853:    in good spirits throughout the year.
1854:    acute psychotic breakdown.
1856:    death.

     It is very typical of an 'endogenous' or manic‑depressive depression to cause a general slowing up of mental activity. This psychic inhibition, if it is at all severe, makes creative work impossible; and this is strikingly exemplified by Schumann (and even more so in the creative career of Hugo Wolf). The reactive type of depression arising from the losses and disappointments of life does not go so deep, and usually leaves creative powers untouched. In his depressions Schumann became almost incapable of the work of composition; and in 1844, his worst year, nothing was completed at all. He would even take weeks to write a letter. However, the opposite phase of the cyclothymic temperament, that of elation, commonly goes with increased productivity and, in the case of the greatly gifted, with creative work of the best. Very good years for Schumann in terms of prevailing mood state were 1840‑41, 1849, and 1853; these years were also his most productive ones, though the quality of his work in 1853 seems to have been far below his best, most probably because of the oncoming organic process.

    Schumann's depressions showed other features typical of the 'endogenous', as against the reactive, mood swing: a diurnal rhythm with mood state worst in the morning; feeling of physical malaise with hypochondriacal ideas; insomnia showing itself particularly in early morning waking; though usually gradual transition via a normal mood state, sometimes quite abrupt reversal into an elated phase. In his depressions Schumann would be full of fears and hopelessness, dead to any enjoyment, silent perhaps for days. In an elated phase, on the other hand, he felt full of strength and energy, radiantly happy, with free flow of imagination, wanting to take the world by storm. The elated phase was more likely to terminate by slipping into a depression than by a simple return to normality.

    In all the records available to us, we found no evidence of schizophrenic symptoms, e.g. delusions, hallucinations or paranoid symptoms, until the final psychotic phase 1854‑56. On the other hand the record is quite typically cyclo­thymic (manic‑depressive), with the colouring of symptomatology which one could have guessed from Schumann's romantic nature.

    Premonitory symptoms of organic disease of the nervous system can be sus­pected in 1843 when there were the first complaints of giddiness, or 1844 when auditory symptoms began in the form of tinnitus, a singing or a roaring in the ears, and a distressing effect by which noises became musical tones. These symp­toms would come and go. The commonest cause, Menière's disease, can be excluded since Schumann never lost his hearing. Otherwise, one cannot be sure how they were caused, though the symptoms are compatible with syphilis of the nervous system.

    According to Boetticher[13] there were painful attacks of 'rheumatism' affecting the feet in 1852, and recurring again in 1852. At the end of August 1852 there were burning sensations at the back of the head, and a succession of prickling nervous sensations, especially in the backbone and the finger‑tips. More definite signs that the brain was being affected also appeared in 1852, first with clumsiness of speech and then with what seems to have been a convulsive attack. Schumann had to give up his conducting. In July 1853 he had some kind of attack which was regarded by Nussbaum as a cerebral vascular stroke; congestive attacks, with the clinical features of very temporary strokes, are common in the early stages of general paresis. The physician, Dr Kalt, who saw him seems to have made this diagnosis, since he said he had 'Gehirnerweichung' (brain softening)[14], which was the synonym in common parlance. In August there were speech disturbances; and in November more auditory symptoms.

    The final psychotic stage, which began with an acute delirium, came on quite abruptly on the night of Friday, 10 February 1854, with an attack of tinnitus, developing in a few days into musical tones and on the night of Friday, 17 February, into angelic music. The next morning the angel voices changed to the voices of devils. They told him he was a sinner and would be thrown into hell. He saw them round him in the shapes of tigers and hyenas. A continuous, or nearly continuous, state of auditory and visual hallucination continued for over a week; consciousness, though presumably clouded, was at least partially pre­served and he could recognize and speak to his wife. On Sunday 26th he was rather better, but in the evening said lie must go to the asylum, and went and laid out all the things he would want to take with him. The next day he was deeply melancholic and told Clara that he was not worthy of her love. Without the others realizing it, he went out of the house into stormy rain without protec­tion against the weather. An hour later he was brought home again, having thrown himself into the Rhine; he had been seen and rescued.

    Clara was not allowed to see him again after this before he was taken to hospital. He left a week later, on Saturday, 4 March, going off with two male nurses without asking after his wife or children. He settled happily into asylum life, and took an immediate liking to his personal nurse. It seems that by this time all delirious symptoms must have passed off, leaving a placid emotional state, and fairly normal affective rapport. However in succeeding weeks he would have periods of agitation in which he would walk up and down his room or kneel and wring his hands. On 31 March Clara recorded with sorrow that Robert asked for flowers, but never for news of her. In April there was another acute psychotic phase with hallucinations and confused talk. At the end of May he was unusually cheerful, and on 21 July Clara received flowers Robert had sent her.

    About this time Brahms paid a visit which he describes in a letter to Clara dated 13 August 1854. He found Robert looking well and strong; he was clear and sensible and not confused. Dr Peters told Brahms that he was very changeable and that periods of clarity and confusion followed one another. The day before, while drinking his wine, he had suddenly stopped, said there was poison in it, and had thrown the rest on the floor. He wrote much, but illegibly. The doctor commented on his weakness of memory, and his incapacity to remember what he had done an hour ago.

    There seems to have been no consistent change in the winter of 1854‑55; musical hallucinations continued to occur. On 23 February 1855 Brahms wrote Clara a letter describing a second visit, not a very happy one. There were trouble­some defects of memory, an incapacity to recognize or to admit them, patho­logical obstinacy and pathological emotional lability. However it seems his general emotional responsiveness was maintained and natural. On 5 May 1855 Robert wrote Clara his last letter, still affectionate but quite fragmentary and incoherent. By this time intellectual impairment must have reached an advanced stage.

    Brahms paid a further visit in April 18 6 when Schumann received him with pleasure but could only express himself in single inarticulate words. From this time deterioration was rapid, physically and mentally, and he died on 29 July 1856 after a day of almost continuous convulsion.

    A report on the case by Richarz, the medical superintendent at Endenich, in 1873 is quoted by Wasielewski. On clinical aspects, he says that spells of hallucin­ation were repeated again and again. The gradual and progressive impairment of intellectual powers was very slow and never reached an extreme degree. Postmortem examination showed atrophy of the brain, thickening of the lepto­meninges, i.e. the fine membranes wrapping round the actual tissue of the brain, and their adherence to the cerebral cortex in several places. These are the changes one expects with general paresis.

    It does not seem possible to doubt the organic nature of the final psychotic phase from 1854 to 1856. The acute delirious state with massive hallucination and prominence of visual hallucinations which came on abruptly on the night of io February 1854 must have been due to some physical cause, but could be due to any one of a great range, poisoning, infection, vascular catastrophe, etc. The later slowly progressive course, with numerous ups and downs, is quite a typical course for tertiary syphilis of the central nervous system, i.e. general paresis, and typical of nothing else; other possibilities, not easily to be totally excluded, such as presenile or arteriosclerotic dementia, or brain tumour, rarely run such a wavering course. Kerner[15] suggests arteriosclerosis rather than general paresis as the cause, on the grounds that Clara's pregnancies, apart from one miscarriage, were normal, and that there was no deterioration in the last stages of Schumann's illness. This does not do justice to the facts, and arteriosclerotic syndromes are in any case unlike Schumann's illness in symptomatology or course. The chronic illness is typically organic (i.e. not schizophrenic), with its heavy incidence on intellectual capacities, especially memory. Finally the rapid physical deterioration to extreme wasting, with muscular paresis and gross speech disorder, leading to death in convulsions, fit the picture of general paresis as no other disease.

    We conclude, then, that, had he been burdened only with the cyclothymic disposition, almost as much of an advantage as a handicap in musical creation, Schumann could have very well lived on into old age and a life of happiness with his family and sustained achievement. But little more than half‑way through his life he was smitten down by an organic disease of the brain. This, then, was a kind of accident, an 'act of God', and in no way to be attributed to such a chain of cause and effect which lead us to think of character as destiny. The most likely explanation is that of syphilis, acquired in youth, and manifesting as brain disease in middle age after an interim latent phase of twenty years or so. Schumann did in fact lead rather a wild life as a very young man, and hypomanic mood states which predominated in 1829 and again in 1833 may have been a contributory factor leading to indiscretion. If he acquired syphilis at this time, latency till 1852 would be quite in the order of the day, especially if he had treatment.

    It is only if he had treatment that Clara could have escaped infection from him if he had it; but treatment, while rendering him non‑infective, would still have left him open to a continuing latency of the infection. In a brilliant piece of biographical research, Eric Sams[16] has shown that the 'injury' to Schumann's finger which he incurred in the early 18 3os, and which has long been a mystery, could very well have been a side effect, in the form of muscular paresis, of treat­ment by mercury, which was the standard treatment for syphilis in that era.

    Partially successful treatment could account for the fact that there is no history of stillbirths or miscarriage among Robert and Clara's eight children. Three of them lived to a ripe old age. But did they all escape? It is not very easy to answer this confidently, since we also have to take into account the fact that manic­depression tends to run in families.

    There was a family history of mental or nervous illness in Robert's family. His father seems to have had melancholic phases; and his sister Emilie is said to have become mentally ill at seventeen; she is also said to have drowned herself at nineteen. Möbius thought she was schizophrenic, but her illness could quite possibly have been manic‑depressive. One of Robert and Clara's eight children, Emil, died in infancy. Felix and Julie both had lung trouble and died in their twenties, Julie dying in childbirth. Ferdinand died after years of ill‑health at forty­two. Ludwig, born in 1848, began to show signs of mental illness by the age of twenty, and two years later was regarded as incurable. He died in a mental hospital at the age of fifty‑one. He, also, has been regarded as a schizophrenic. But it is highly suggestive that in June 1870 he was diagnosed by his doctors as not only insane but 'Rückenmarkkrank', i.e. suffering from a disease of the spinal marrow.[17] This, then, could conceivably have been a late manifestation of syphilis, this time acquired congenitally.

    Of course one will never be able to be quite sure of the nature of Schumann's affliction, since no theory can be submitted to a decisive test. Nevertheless, an obscure and complex problem has yielded little by little to attempts to solve it; and by successive stages from the Möbius‑Gruhle debate in 1904‑6, we have arrived at a rational and intellectually satisfying explanation of all the facts at our command.

Appendix

Kerner considers Schumann's history from a medical point of view, but onewhich is not in any way instructed psychiatrically. He adopts the hypothesis put forward by H. Kleinebreil (Der kranke Schumann, dissertation Univ. Jena, 1943) which was also accepted by W. Schweisheimer ('War Robert Schumann geisteskrank?', Artzl. Praxis, p. 840, 1959). I have not been able to consult these works, and it is possible that the arguments are stronger there than as they are presented by Kerner. Kerner believes that Schumann was subject to essential hypertension, which eventually resulted in a paranoid‑hallucinatory involutional psychosis, schizophreniforrn in type, which necessitated asylum care for the last years of his life. The physical basis was cerebral arteriosclerosis; and the psychosis was released by a severe conflict situation from which Schumann saw no way out. The conflict situation was not unconnected with Clara, and was also contributed to by his failing musical powers. The affectiessness shown in letters to Clara from Endenich (which has beeen attributed to schizophrenic personality change, but in my view is a typical result of organic changes in the frontal area of the brain) according to Kerner may have had personal causes ('sehr persönliche Ursachen').

    Kerner argues against and rejects both schizophrenic and manic‑depressive diagnoses. If any children of Robert and Clara succumbed to schizophrenia, this was only because the children of creative personalities are in special danger, as the appearance of a genius in a family often heralds that family's downfall (!). As for the manic‑depressive hypothesis, evidence of depression can be accounted for by the many misfortunes of Schumann's life, and also by the romantic sorrowfulness and suicidal imaginings of the age of Werther.

    His diagnosis of essential hypertension is supported by symptoms coming on fairly early in life, such as giddy feelings, attacks of shortness of breath and cardiac anxiety. To the present writer they look more characteristic of simple anxiety states. Kerner does not give any consideration to the history of mood swings throughout earlier life, extending into hypomanic as well as depressive directions, which are so characteristic of cyclothymia.

    Those of Schumann's symptoms which are clearly organic in nature Kerner puts down to cerebral arteriosclerosis, rejecting the diagnosis of general paresis. His discussion is a long one, with much that is not relevant, but reduces itself to the following points: (1) none of the children of Robert and Clara suffered from anything suggestive of congenital syphilis; (2) if Schumann had had an irregularity of the pupil, or unequal pupils, or small pupils, this would have been noticed by the painter Laurens, who portrayed him several times in his last years; (3) Schumann's history does not show progressive impairment of mental faculties. On this last point he quotes from an article Richarz contributed to the Kölnische Zeitung of 15 August 1873: 'Sein Selbstbewusstsein war geknickt, doch nicht zerstört, sein Ich nicht sich selbst entfremdet, nicht umgewandelt. Bis zuletzt behaupteten sich die geistigen Fähigkeiten... auf einer verhältnissmässig grossen Höhe.' That is, mental faculties had suffered, but had not been reduced to the lowest level by the time he died. True enough; two days before he died he was able to recognize Clara, though not able to speak a coherent sentence to her. Nevertheless, dementia was quite advanced more than a year earlier, as can be seen from his letter to Clara dated May 1855; and it continued to progress by infinitesimal degrees up to his death.

    These arguments, as it seems to me, do not carry much weight. The children could well have been spared a congenital syphilis, if Robert had received medical treatment rendering him uninfective. The point about the pupils is an interesting one. Perhaps the most characteristic of all signs of tertiary syphilis of the brain are pupils unreactive to light but reactive to accommodation, e.g. in focusing the eyes, a sign first described by a Scottish physician, Argyll Robertson (1837‑1909). Such pupils are usually small, but may be large, or unequal, or irregular in shape. Kerner says that Schumann's pupils were large; if they were consistently large, even in a good light, this would probably be from loss of the light reflex. This looks like a point in favour of the diagnosis of cerebral syphilis.

    Kerner's diagnosis of an essential hypertension causing symptoms about the age of forty calls for a malignant condition which would probably have proved fatal in one to two years. One would have expected more definite symptoms of dizziness and vertigo, severe occipital headaches worse in the morning, and almost certainly eye symptoms, such as scotomata, blurred vision, even partial or one­sided blindness. Cardiac and renal symptoms, as well as cerebral ones, would be expected. On the other hand a benign hypertension would only be expected to produce cerebral symptoms much later; cerebral arteriosclerosis is a disease of later life, and not early middle age. The disease progresses by causing a succession of small or larger strokes, from which recovery is incomplete, so that progress downhill is in a series of steps. Some of these strokes would produce a definiteparesis or aphasia; and gross neurological changes, such as would be missed by no competent doctor, would be inevitable. Richarz was certainly competent. His formulation of the case is compatible with general paresis‑and this is what he probably thought it was‑and not with cerebrovascular disease.