Franz Liszt and Alfred Graefe

 Ophthalmic surgery in 1886

 John G. O'Shea MD

 The evaluation and treatment of Franz Liszt’s failing vision gives us a fascinating insight into clinical ophthalmology of the late 19th century. Liszt was commonly regarded as the greatest pianist of  his century (1) ‘Liszt is the past, the present and the future of piano playing’ noted Wilhelm von Lenz in 1872, a locus classicus which aptly captures the singular prestige and aura of the great Hungarian virtuoso.


However, it was not until recent decades that the music of Franz Liszt has received adequate critical evaluation ,public performance and recording.  Humphrey Searle's pioneering  study of  Liszt's music (2) which dates from 1954 began a re-evaluation of the composer's oeuvre which continues to the present day.


Liszt's works have now been extensively recorded.  Interest in the recorded works of Liszt received impetus in Louis Kentner’s  and Alfred Brendel's recordings  of the 1950's.

In more recent years British-Australian pianist  Leslie Howard has undertaken  a complete recording of the solo piano music of Liszt ,an enormous undertaking which occupies more than 90 compact discs.(3)


Dr. Leslie Howard   MA D.Mus. AM


Suggested Listening- Howard, L  Liszt -the Complete Music for Solo Piano, Volume 11 The late Pieces  Hyperion Records  CDA66445  (1992)  

Howard's acclaimed  Liszt series reveals the extensive depth, breadth and variety of Liszt's many piano compositions.

Searle's catalogue of Liszt's work lists nearly 800 compositions, mostly for the piano, and many more have been discovered since then. Leslie Howard states that there are actually about 3500 compositions extant.

Professor Alan Walker of McMaster University, Ontario has recently completed the third volume of  his Liszt Biography. 

( Walker, A Franz Liszt Volume 3, The final years 1861-1886 1996 New York,  Alfred A Knopf )

Sir Thomas Beecham, Georg Solti, Simon Rattle and James Conlon have, inter alia,  revived interest in Liszt's compositions for the orchestra.

Franz Liszt was a central figure in nineteenth century music and the composer whose work, in the opinion of many scholars, most vividly anticipates the music of our own century.


Liszt's Eye Disease


Franz Liszt died in 1886 at the age of seventy-four years, like many of the elderly he was affected by multiple indispositions which were the ramifications of the age process and the habits and stresses of a lifetime.


According to Lina Ramann Liszt first sought medical care in 1881, he was suffering from "dropsy" and from " water on the lungs", these were early manifestations of cardiorespiritory disease which was to precipitate is death in Bayreuth in  July 1886.(  4  )


Liszt’s illness was prefigured by depression which was in part situational, two of his children ,who had shown great promise, had died young and he had not secured the appointment in Rome he had sought which would have given him access to an orchestra. He began to experience grief, regret and self-doubt .From this period comes the late music which prefigures the music of our own century, the music is the antithesis of romanticism and we hear the first echoing of the uncertainties of our own age (2 )


The sparse nature and economy of these compositions, the consistent use of the whole tone scale and the trend toward atonality prefigures both Bartok and Berg  . ( 2,3 )


Liszt began to drink cognac rather heavily and was warned to decrease his intake by his physicians.

( 4, 5 ) Liszt also smoked Havana cigars .




At about the same time he noted a gradual decline in the vision of the left eye. He had worn a presbyopic correction to read and to annotate music for many years, otherwise there was no past ocular history.


We know from Borodin’s correspondence that Liszt’s once phenomenal ability to sight read was impaired by 1882. He made several slips whilst score reading a Borodin symphony from manuscript due to his diminishing vision.  It is well docomented by Borodin and others that he now often played secundo piano as a concession to his failing vision.


Liszt consulted Alfred Karl Graefe, an ophthalmologist who practised at Halle. He made the trip from Weimar where he held yearly masterclasses for aspiring young pianists.


Alfred Graefe (1830-1899) belonged to the distinguished Grafe family of Prussian and Polish origins. His cousin was the Alfred von Graefe of Berlin (1828-70) whose untimely death from tuberculosis was a great tragedy to ophthalmology.(  6 )


Graefe examined Liszt and told him that he had a cataract (the contemporary term used in Lina Ramann's Lisztiana (5) is grauer star {German} which is synonymous with cataract ). He declined to operate, presumably because of the problem of unilateral aphakia. The most satisfactory result for both patient and doctor was the removal of cataracts which severely diminished acuity and which were bilateral. There was also some cataract and  present in the right eye, these were typical senile cataracts. Grafe wisely advised a conservative approach to the problem.


Graefe saw the composer on occasion, it was not until 1886 that Liszt's vision had declined to such an extent that operation became imperative. the operation was scheduled for September 1886, Liszt wrote that he found the idea of an eye operation extremely  "disagreeable." Liszt died in Bayreuth on 31 July 1886 and the operation did not take place.( 5)


The composers seventy-fifth birthday would have fallen on October 22 1886 , for Liszt this was an occasion of great celebration and he toured Europe extensively to mark the event.


Liszt's health had markedly declined, his vision was poor. In London in 1886 Jenny Churchill wrote that she had to help Liszt eat asparagus at a public banquet because he could not see the plate! He cold write and notate music only with greatest difficulty. When he played he was often lead to the concert platform on the arm of another person- his mobility was poor due to his vision and ''dropsy" (pedal oedema) and probably also to osteoarthritis of the hips.


As with Handel's blindness the public was touched by the great musician's determination in the face of profound disease. We are reliably told that Liszt still played remarkably well and people were often moved to tears by the great pianist's playing .( 4  )


The influence of Liszt's declining vision on his playing was probably confined to his impaired score reading, there is much testimony that Liszt scarcely looked at the keyboard whilst playing at other times. Weingartner does however say that Liszt adopted a hand position closer to the keys than that of his youth, a possible concession to declining vision. (5)


External Eye Disease


In the last year of Liszt's life their was a new component to his eye disease namely a severe type of blepharitis, we are told that it made his eyes stream profoundly, especially in cigar smoke filled rooms. His eyes looked red, and the condition was aggravating. Graefe prescribed drops, of the antibacterial sublimate which he characteristically used as a prophylactic for endophthalmitis (q.v) and Liszt was advised to avoid cigar smoke which exacerbated the blepharitis, characteristically he ignored the advice preferring to smoke copiously.


The external eye disease is seen if one looks carefully at late photographs of the composer.


The famous photographs by Louis Held and by Paul Nadar show thickening, blunting and discolouration of the lid margin. These are high quality portraits which have been well produced ( 7,8  )


Nadar's photographs of March 1886 also show arcus senilis and in profile one see peripheral corneal lesions presumably due to staphylococcal hypersensitivity keratitis. a small left exotropia is present, presumably due to the cataract. ( 8 )


Contemporary Extracapsular Cataract Surgery:


The clinical approach to Liszt's eye problem illustrates much about the Graefes and their approach to ophthalmology.


The approach was conservative and scientifically based.



Graefe's technique of cataract extraction was based upon that of his cousin, namely he performed an extracapsular extraction with a  broad or sector iridectomy. (6)


The main complication being retained soft lens matter. Anterior uveitis was also relatively common. If the posterior capsule opacified postoperatively or there was axial soft lens matter left behind after the operation a secondary capsulotomy was performed using  a fine needle.


The spatulate Graefe knife and the approach to the anterior chamber are still well known. These were also developments fostered by Albrecht von Grafe.


Local anaesthesia was widely used by 1886. This was in the form of cocaine drops. (5)  Initially adopted by Karl Koller in 1884 their use in German ophthalmology became almost universal after the famous Heidelberg conference.


Sections were almost never sutured with the consequence that post operative astigmatism was usually against the rule.  The ab externo with the Graefe knife aproach usually used ensured good wound construction and minimal astigmatism given the limited technology of the time.


Edward Nettleship (1845-1913), a contemporary British ophthalmologist, succinctly outlined the technique of extracapsular cataract extraction in of the Graefe's now widely in use throughout Europe his Students Guide to the Diseases of the Eye (1884)..


"All operators for hard cataract agree in the following points(1) an incision is made in the cornea at the junction of the cornea and sclerotic ,or even slightly in the sclerotic, large enough to give exit to the crystalline lens unbroken , but not altered in shape. The knife now almost universally employed is the narrow thin straight knife of Von Graefe(2) The capsule is freely opened with a small ,sharp pointed instrument(cystitome or pricker)(3) The lens is removed through the rent in the capsule( the latter structure remaining behind) either by pressure and manipulation outside the eye or by means of a traction instrument (scoop or spoon) passed into the eye just behind the lens.  Most operators have abandoned the use of the scoop , reserving it for certain emergencies  and special cases (4)Iridectomy is very often performed as the second stage, not with the primary object of facilitating the exit of the lens , but to lessen  the after risks of iritis.(10)


Nettleship, incidentally, was a pioneer of domiciliary cataract extraction using cocaine drops. The favoured mydriatic was atropine. Nettleship writes that visual rehabilitation takes about six to eight weeks.(10)


His post operative regimen, designed to minimalise astigmatism and to facilitate wound healing consisted in the following . Three days of  bed rest were followed by  two weeks of nursing in a darkened room. The patient was then allowed to ambulate and was allowed to go outside wearing dark glassses. After about eight weeks glasses were prescribed.  These were aphakic glasses which incorporated a cylinder. The problems of aphakia were well described by Donders and others, and by the late nineteenth century these glasses incorporated a cylinder.( toriodal lenses)

It is also interesting to note that extracapsular cataract extraction, proposed initially by Albrecht von Graefe of Berlin, fell out of favour for senile cataract and was replaced with intracapsular cataract extraction. The technique was revived by Mr. Harold Ridley of London in 1949 to facilitate intraocular lens implantation and has remained popular since then.


Alfred Graefe of Halle


To return to Liszt’s ophthalmic surgeon it is interesting to reflect that Liszt was the progenitor of a musical dynasty through his second daughter Cosima who married Richard Wagner. The Graefe family, of  Polish and Prussian extraction, were no less illustrious in the field of medicine.


Graefe was born on November 23 1830 in Martinskirchen on the Elbe. He studied medicine at Halle, Heidelberg Wurzburg Leipzig and Prague.


He graduated as Doctor of Medicine in Halle in 1854 with the thesis  De canalulorum lacrymalium natura. He was appointed asssistant physician at his cousin Albrect von Graefe’s clinic in Berlin in order to perfect his knowledge of ophthalmology.


At this time he married the daughter of a city counsellor of Halle and lived an exceedingly happy domestic life.


Alfred Karl Graefe was the co-author with Theodor Saemisch of the multi-volume lexicon  Handbuch der Gesamten Augenheilkunde which became the prototype of the many large works which characterise our speciality, most notably Sir Stewart Duke Elder's System of Ophthalmology.(9) The first edition of this seminal work appeared in 1854.


Graefe is recorded as being one of the most outstanding ophthalmologists and skilful surgeons of all  times. All who worked with him stressed both his humanitarian and unselfish nature. Amongst his extraordinary original work in ophthalmic surgery are included the following contributions which are still pertinent to modern ophthalmology.


Alfred Graefe and Cataract Wound Closure


Graefe was a pioneer of aseptic ophthalmic surgery. The Greeks in antiquity had recommended clean bandages when dressing the eye. It wa an Arabic maxim that if you operate cleanly you will have success.


Lister dressing could not be applied to the eye and so a search for an improved method of  wound closure and  dressing was made. The rate of endophthalmitis was ~3% of  lens extractions prior to Graefe.



The search to find improvements in wound closure involved many contemporary ophthalmologists, these included not only Graefe but Leber, Desmarres, Horner and Jacobson of  Konigsberg. A “current controversy in ophthalmology” clearly demanding rapid international attention. In the event it was Graefe who developed the best solution to the problem.


Graefe noted that antiseptic dressing of the lids was the most important part of antibacterial prophylaxis, he also used a sublimate solution  so that he had reduced his rate of post operative infection such that in a series of 440 lens extractions he had not  a single case of endophthamitis. Graefes’ clinical work was soundly based upon the contemporary scientific experimentation of Koch and Sattler.


Evisceration  versus Enucleation


Graefe reported two cases of fatal meningitis following enucleation, both died on the fifth postoperative day. A post-mortem revealed that inflammation extended via the pial sheaths to the central nervous system. Graefe recommended evisceration as an alternate procedure to relieve the pain of panophthalmitis and that after evisceration his antibacterial sublimate be instilled into scleral remnant of  the eye.


Other contributions to Ophthalmology


These include descriptions of essential blepharospasm, of paralytic strabismus, retinal infarction, hemianopia, luetic iritis, intraocular tumours, latent strabismus, accomodative disturbance and asthenopsia, torticollis and head postures. There is also an early dissertation of the horopter concept. The diverse work of an unusually fertile, precise and far reaching mind. Graefe’s original monograph on strabismus, written as an assistant physician only 28 years old, is regarded by many as an original contribution to ophthalmology ranking with Donders work on refraction.


Students and Successors.


Graefe’s later years were marred by presbyacusis which impaired his conversations and made consultations slow and difficult. Graefe retired to Weimar shortly before his death a town forever associated with the artistic glories Goethe, Schiller and of his former patient, Franz Liszt.


Graefe’s distinguished students and colleagues included Carl Schweiger, Konrad Frolich, Eugen von Hippel and Paul Bunge.



When Liszt died in 1886 there was a heartfelt outpouring of grief throughout Europe .In his obituary to Liszt  Hugo Wolf wrote poignantly ,"the eye of this brilliant phenomenon is forever closed,  but it was the eye of an immortal.'' (11,13)



Professor Kunht wrote of  Alfred Graefe in a similar vein  in his obituary (1899).


‘Only rarely will nature combine in such a harmonious way intellect, temperament and a fascinating personality in order to create the model of a true physician as it was in the case with Alfred Graefe”


Liszt’s ophthalmic problems are illustrative of many features of late 19th century ophthalmic surgery. (13) An era, like our own, of rapid innovation, improvement and change. The meeting of Alfred Graefe and his distinguished patient Franz Liszt is also a fortuitous meeting of two of mankind’s most brilliant, generous and productive benefactors. Parallel lives of extraordinary productivity in both music and medicine.



British Liszt Society
Mrs A. Ellison.135 Stevenage Rd
Fulham, London SW6 6BP

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1 von Lenz ,W  The Great Piano Virtuosos of  Our Time  New York, Schirmers (1899) 11-26


2 Searle, H    The Music of Liszt  London, Williams and Norgate   (1954)   99-123


3 Howard, L  Liszt -the Complete Music for Solo Piano, Volume 11 The late Pieces  Hyperion Records  CDA66445  (1992)


4. O'Shea, J G  Music and Medicine London, JM Dent and Son (1990) 155-171


5 Ramann , L  Lisztiana Mainz, Schott (1983)


6 Duke Elder ,S   System of Ophthalmology  London H Kimpton (1966) Volume 11, 248-263


7 Schroter ,WG  Weimar um 1900- photographien von Louis Held Leipzig, VEB Fotokinoverlag (1984) 55-61


8 Burger E  Franz Liszt , Eine Lebenschronik in Bildern und Dokumenten Munchen , List Verlag (1986)  309-333


9 Gurlt E and Wernich A (editors) Biographisches Lexicon der Hervorragenden Arzte Munich (1962)


10 Nettleship E The Student's Guide to the Diseases of the Eye 3rd Edition,  J&A Churchill London (1884)


11 Hirschberg J ( translated by F C Blodi ) The History of Ophthalmology Volume 11 ( Part 1-B) The reform of Ophthalmology Bonn J P Wayenbourg Verlag 1992 41-8


12 Williams  A  1886: Liszt's Last Months and Death Liszt Society Journal (1986)



13 O’Shea  JG Franz Liszt’s eye disease J R Soc. Med  1995 ; 88 : 562 -564