In 1918, Ives suffered a series of what he called "heart attacks". The episodes left lasting physical and psychological damage: he never fully regained his health, was later diagnosed with diabetes, and in 1927 found himself unable to compose. He produced very little thereafter, and, owing to a trembling hand, outsourced most (if not all) of his writing to his wife, Harmony. Autograph material is thus quite uncommon, and this shaky signature evidences the debilitating health problems Ives faced in his final decades.