Robert Schumann in Endenich: The Diagnosis and Course of His Illness and His Illness-Related Experiences

The composer Robert Schumann (June 8, 1810–July 29, 1856) is one of the most important representatives of German Romanticism in all genres of music. He spent the last two-and-a-half years of his life in the private psychiatric hospital in Endenich near Bonn. The treating physicians, i.e. the owner Dr. Franz Richarz and his assistant Dr. Eberhard Peters, kept a journal with detailed medical records for the entire duration of his treatment. Their journal was believed lost until 1991, when a fourth generation descendant of the Richarz family gave it to the Academy of Arts in Berlin. The records were released in the same year, 135 years after Schumann’s death, in the hope that some of the controversial, speculative, and prejudiced statements about him in the literature would be corrected, the nature of his illness would be better defined, and the involvement in his illness of people close to him, especially Clara Schumann and Brahms, would become clearer. However, this hope was not entirely fulfilled [1,2].


Introduction
The composer Robert Schumann (June 8, 1810-July 29, 1856) is one of the most important representatives of German Romanticism in all genres of music. He spent the last two-and-a-half years of his life in the private psychiatric hospital in Endenich near Bonn. The treating physicians, i.e. the owner Dr. Franz Richarz and his assistant Dr. Eberhard Peters, kept a journal with detailed medical records for the entire duration of his treatment. Their journal was believed lost until 1991, when a fourth generation descendant of the Richarz family gave it to the Academy of Arts in Berlin. The records were released in the same year, 135 years after Schumann's death, in the hope that some of the controversial, speculative, and prejudiced statements about him in the literature would be corrected, the nature of his illness would be better defined, and the involvement in his illness of people close to him, especially Clara Schumann and Brahms, would become clearer. However, this hope was not entirely fulfilled [1,2]. Appel [1] published the records, together with text passages from letters and diary entries of people close to Schumann that reported about his status. The psychotic episode began on February 10, 1854, with verbal and musical hallucinations [3]. In her diary, Clara Schumann described the illness experience of her husband in a touching way that was also fairly clear as regards the psychopathology of his illness [1,2]. After a suicidal attempt, Robert was admitted to Endenich on March 4, 1854, at his own request. The journal with Richarz and Peters' medical records originally comprised 22 pages. However, six pages covering the dates March 4 to April 5 and April 28 to September 6, 1854, were lost in the chaos of war in 1945 in Berlin. These pages reported the findings at admission and medical anamnestic data, so that this information unfortunately is missing [1]. The remaining pages contained 753 medical entries. They were analyzed separately, as were the 315 text passages originating from Schumann's social environment.

Results
The daily entries document the knowledge and treatment principles of the treating physicians; both their understanding of the illness and their approach to treatment correspond exactly with the information given in the text books of Griesinger [4] and Guislain [5] (the latter was translated from French into German by Laehr). The treatment of Robert Schumann's illness was typical [6] for the mid-19 th century treatment of what was at first considered to be "melancholy with delusions" but rapidly modified to the feared differential diagnosis of a "general (incomplete) paralysis. " The main features of his treatment were as follows: • Complete shielding from stimuli, which included all professional matters and exciting information and most importantly meant absolutely no contact with his family and close friends, i.e. no visits, letters, or anonymous gifts that would allow him to recognize the sender. The theory behind this approach was that it would allow the destroyed mind to return to its normal functions by ensuring it was not stimulated by the environment. • Forced participation in physical procedures such as baths, spending time outdoors and taking walks. The so-called "fontanelle, " a deliberately induced wound that was kept festering in order to induce a "removal by pus" of harmful substances, was applied to Schumann several times. The method was not further recommended in the 1861 textbook by Griesinger [4]. • Dietetic considerations were the general basis of the treatment [6].
These were perhaps a last remnant of the pre-Enlightenment period, a relic of the 2000-year-old four humors theory about changes in the composition of the blood, the elimination of harmful substances, and excretion. These considerations were behind the many different dietary measures, the regulation of defecation and some of the procedures such as the "fontanelle. " Medication given as part of the dietetic treatment was intended to regulate digestion and excretion and included mainly laxatives and sedatives. Stool inspections were therefore a fixed component of the dietetic treatment regime, as was the frequent administration of an enema.
Richarz was a follower of the Conolly "no restraint" movement. He had an empathetic attitude towards Schumann and showed appreciative interest in him also beyond his death. In his medical reports, letters, and later publications [7], his writing does not use any terminology that unconsciously belittles the patient or implies that he was an annoying object.
The "paralysis" became a certainty in the course of Schumann's paranoid-hallucinatory symptoms. He showed cerebro-organic characteristics of dementia together with severe agitated states, differences in pupil size, and increasing speech disturbances. The journal describes a dramatic illness course that fluctuated somewhat but overall showed a continuous worsening of the mental and physical state [8]. In the medicine of the time, syphilis was just emerging as the suspected cause, and the term "progressive paralysis" was coined to describe the typical course of this symptomatic triad, which still forms the basic symptomatology of today's diagnosis of Lues IV.
The main result of the autopsy of Robert Schumann [1] was a general atrophy of the cerebrum and "the pituitary gland … surrounded by a fairly large amount of a yellowish, slushy mass that in part has the consistency almost of fibrocartilage." The finding, similar to a syphilitic gumma in the basal brain, most likely suggests at least a local intracerebral tumorous irritation. Schumann describes a venereal infection in his diary at the age of 21 and mentions it to the treating physicians in a guilt-like, self-blaming episode on September 12 [1]. Today, we cannot be absolutely certain what kind of venereal disease he had. Treponema pallidum was not discovered until 1905, the serologic reaction was not available until 1906, and the effective antibiotic treatment with penicillin was not started until 1942 [6]. Treponema pallidum is no longer contagious after about five years [8].
Robert married Clara Schumann, nine years his junior, in 1840, so that Clara and the couple's 7 children were at no risk of being infected.
People close to Robert, in particular his wife Clara and the circle of friends around Brahms and Joachim, cared deeply for him and suffered under the forced therapeutic isolation [9]. Clara and the physicians wrote letters to each other on a weekly basis. After a partial easing of the strict isolation measures in September 1854, Clara wrote to Robert and received replies. Robert's writings and utterances contain no indication at all that Clara was present in Robert's hallucinatory delusions that he was a sinner and neglected by other competitors in music or in his delusional self-accusations [1,2].
Robert was visited several times by close friends, mainly Brahms and Joachim. Clara was not permitted to visit Robert until just days before his death. During the difficult time of Robert's illness, in winter 1854, the 35-year-old pianist Clara Schumann, who was famous in her own right, resumed her concert activities in order to feed her seven children. Because she expressed her financial concerns several times, we can assume that she decided to actively counteract her misfortune through work rather than passively waiting for her husband to recover or for catastrophe to strike [2].
Brahms, who in the autumn of 1853 as a 20-year-old young musician was welcomed with open arms into Robert and Clara's circle of admired, congenial, young musician friends, played a supportive and helpful role that mitigated the family's suffering. During Robert's time in Endenich, he mentions his affection especially for Brahms and Joachim almost five dozen times [1,2]. There is no evidence for a delusional, reproachful attitude towards Brahms or that he accused him of anything. In 50 surviving documents, Brahms expresses himself only in an admiring, acknowledging, and affectionate way towards Robert. Noticeable competitive behavior to gain Clara's favor is not apparent in the documents of the time. Nevertheless, the fact that Brahms had a special position of trust with Clara, apparently more so than Joachim-with whom she went on concert tours-can almost certainly be described not only as mutual appreciation for musical things but also as mutual affection.
The medical records and illness-related letters show the concern of all during the unfavorable course of the illness and contradict strongly the theory that Schumann was disposed of by being put into the psychiatric hospital. The lines of argument that claim that Clara, Johannes Brahms, and the profit-pursuing Richarz played a causative role in Schumann's illness [10][11][12][13][14] are characterized by misunderstood, deep psychology attempts at causality. Those interpretations were strongly misleading also before the appearance in 1991 of the Endenich journal describing Schumann's severe organic disease [14]. Clara's affection for Robert and the love that is obvious in the couple's many letters to each other are still present and unchanged in the texts after his admission to Endenich in February 1854.
A fair amount of literature on Schumann deals with the interdependency between his creative work as a musician and his illnesses, for example depression, a neurosis, and assumed high blood pressure [10,14,15]. Depending on the zeitgeist, the pathographic literature highlights almost all conceivable psychiatric and also organopathological illnesses [14,15]. Today, he is mainly analyzed from the perspective of theorists looking for an interdependence of creativity and bipolar disorder [16]. However, the medical records provide almost no evidence for such interpretations. Schumann often experienced a depressive mood, and as is the case in almost all people who create something, he stopped working for a certain period, mainly in 1843/44, when he went through a severe depressive phase. The theory that his outstanding productivity in 1840 and 1849, a time in which he published numerous compositions, could be due to a hypomanic drive cannot to be substantiated from the texts and seems to serve no purpose. In 1840, Robert and Clara had to convince Friedrich Wieck (Clara's father) and even a civil court involved in the decision whether the then 21-year-old bride Clara should be permitted to marry that he was a successful and renowned musician and composer who was able to support a family. In 1949, he successfully obtained the position of music director at Düsseldorf. These are examples of quite normal, productive behavior, for example of anyone who is trying to pass a dissertation examination or obtain a good position at a university [17].
Schumann's final illness of course influenced his work. He worked less and then, as the severity of his illness increased, simply stopped altogether. According to the medical knowledge of Schumann's time, the prodromal symptoms and the first part of the course of "general (incomplete) paralysis" [4,5] by no means made it an illness that prevented all activities. Exactly this feature, i.e. the co-existence of normal and impaired functions, made it possible to distinguish it from other "paralyses" after strokes, tumors, etc. Despite his psychotic experiences, Schumann still performed music-related work in Endenich, e.g he corrected his works, harmonized Paganini caprices and wrote sensible business letters to his editors; however, his performance of all these tasks decreased markedly until his activities completely petered out one year before his death [17][18][19].

Conclusion
The "genius and madness" discussion is followed still today, even in molecular genetic lines of argument. At the moment, the discussion is concentrated on literary creativity and its alleged close link to depressive disorders [2,17,18]. However, the triple jump between the categories of a "brilliant" creative performance, an intrapsychic motivation together with talent, and a possible modification through somatic or mental illness [20] still appears to be insurmountable. Nobel Prize winning novelist Thomas Mann saw through this jumping between categories in an exceptional way. In his Doctor Faustus (1947), with the help of syphilis the devil makes a genius out of the composer Adrian Leverkühn. Thomas Mann lets his hero then invent the twelve-tone technique, which he does not like at all and which also is assumed to have been somewhat at the expense of Arnold Schoenberg. With his well-known masterly and ironic distance, Mann criticizes the "genius and madness mythology" and takes it ad absurdum, at least for the arts [21].