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The Unforgettable Neurosurgical Operations of Musicians in Last Century

Dr. rer. med. Mag. phil. Elena Romana Gasenzer, Ayhan Kanat, MD, AssistantProfessor, Univ.-Prof. Dr. Prof. h.c. Edmund Neugebauer

PII: S1878-8750(16)31303-1

DOI: 10.1016/j.wneu.2016.11.144

Reference: WNEU 4954

To appear in: World Neurosurgery

Received Date: 8 October 2016

Revised Date: 26 November 2016

Accepted Date: 28 November 2016

Please cite this article as: Gasenzer ER, Kanat A, Neugebauer E, The Unforgettable NeurosurgicalOperations of Musicians in Last Century, World Neurosurgery (2017), doi: 10.1016/j.wneu.2016.11.144.

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http://dx.doi.org/10.1016/j.wneu.2016.11.144

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The Unforgettable Neurosurgical Operations of Musicians in Last Century

Dr. rer. med. Mag. phil. Elena Romana Gasenzer (1)

Ayhan Kanat, MD, Assistant Professor (2)

Univ.-Prof. Dr. Prof. h.c.. Edmund Neugebauer (3)

1-Universität Witten/Herdecke, Campus Köln-Merheim, Köln, Institut für Forschung

in der Operativen Medizin, Fakulty of Health, Department of Medicine, Germany

2- RecepTayyip Erdogan University, Medical Faculty, Department of Neurosurgery,

Rize-Turkey

3- Witten/Herdecke University, Dean of Medical School Brandenburg Theodor

Fontane & Senior-Professur of Health Services Research, Universität Witten/Herdecke,

Fakulty of Health, Department of Medicine, Campus Neuruppin, Germany

Corresponding Author 1: Elena Romana Gasenzer

Universität Witten/Herdecke, Campus Köln-Merheim, Köln,

InstitutfürForschung in der OperativenMedizin, Fakulty o Health, Department of

Medicine

Phone: 0221-989-57-0

Mail: [email protected]

[email protected]

Corresponding Author 2: Ayhan Kanat, MD, Recep Tayyip Erdogan University,

Medical Faculty, Department of Neurosurgery 53100 Merkez Rize Turkey,

Mail to: [email protected] Phone: 90 5065855139 Fax 90 464 2140497

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Key words: musician, craniotomy, history of neurosurgery, tumor, traumatic brain

injury,George Gershwin, Maurice Ravel, Clara Haskil, Pat Martino

Abstract:

Background: there is no study for interesting craniotomies of famous musician in

history. This subject was investigated.

Material andMethods: The key words were “neurosurgery and music” and the names

of composers. We used digital catalogues like “pubmed” as well as the libraries of

universities.

Results: We found four musicians with different neurosurgical diseases who are

Maurice Ravel, George Gershwin, Clara Haskil, Pat Martino.from the 20th century eras.

Conclusion; Neurosurgical disease was leaded poor to the end of a musical career and

their lives in two of four musicians. Neurosurgeons today can understand the effect of limited

diagnostic tools such as MRI and CT at the timeon the poor outcome of two musician

I. Introduction

The brain is the locus of memory, compassion, logic, identity, and art 1. The practice

of surgical manipulation of the nervous systemand its coverings has been evident for more

than 12,000 years,and the settings in which these practices have been conducted, have

reflected the state of the art, science, and, indeed, purposeof these endeavors 1. However, at

the beginning of this century, neurosurgery was in its infancy as a surgical specialty 2. Today

the techniques and methods of neurosurgery are on a very high level 3-5.With the development

of modern diagnostic methods like CT, MRT or fMRT it is possible to discover neurological

disease in its early state. Disorders of the central and peripheral nervoussystem affect the

famous musician at some time during their lives with remarkable consequences their

craniotomies for the quality and outcomes of those lives 6,7. Overall, in terms of neuroscience,

musical activities of musicians are considered equal in terms of memory as well as perceptive,

cognitive and motor functions 6,8. However, there is no study for interesting craniotomies of

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famous musician in history, so we wanted to know what chances have musicians after

neurological surgery s to continue their musical activities.

II. Material and procedures

Methods were general biographical information, historical investigation, and general

research. Material was evaluated for historical and medical importance. The key words were

“neurosurgery and music” or and the names of composers.We used digital catalogues like

“pubmed” as well as the libraries of universities.

Results;

III. Neurosurgical cases from Music History

We found 4 musicians with neurosurgical disease in the 1930's to 1980's, they should

have said so. The cases of Maurice Ravel, George Gershwin, and Clara Haskil are good

examples of case reports of a neurosurgical operation in the first half of the 20th century.

These case reports document the possibilities of neurosurgical treatment in the middle of the

20th century as well as the effects of neurological diseases on musical activities and

performance. There are many speculative cases. For example yhe finding of a temporal

fracture on Mozart's skull 9, gives a way to speculations about the possibility of a chronic

subdural hematoma and its compressive effect on the temporal lobe 10,11. But, Mozart was not

operated for his disease, for that reason, we did not include in this paper.

IV. The Craniotomies of George Gershwin, Maurice Ravel, Clara Haskil, and Pat

Martino

IV. 1. The right temporal glioblastoma multiforme of George Gershwin

(1898- 1937)

Medical History:

George Gershwin; The “Rhapsody in Blue”, piano concerto in F and his opera “Porgy

and Bess” are his most famous works 12. In February 1937 during a concert in Los Angeles,

Gershwin had a focal seizure. He lost consciousness for a few seconds when he played the

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“Concerto in F”.13 After June 1937 his condition became worse. Gershwin was listless and

apathetic. He had strong headaches, ataxia and photophobia. On Wednesday, June 23,

Gershwin was brought to the Hospital, but the results of all medical examinations were

normal. One evening, he was unable to walk. He had chronic headaches and smelled burned

rubber 13-15. On the 9th of July he collapsed when he went to the bathroom Gershwin was

brought to the Hospital again. He fell into a coma.

Surgical procedure: Friends of Gershwin searched a neurosurgeon, immediately

called pioneering neurosurgeon Dr. Harvey Cushing in Boston, who, retired for several years

by then, recommended Dr. Walter Dandy, who was on a boat fishing in Chesapeake Bay with

the governor of Maryland. Friends of Gershwin then called the White House and had a Coast

Guard cutter sent to find the governor's yacht and bring Dandy quickly to shore. His friends

then chartered a plane and flew Dandy to Newark Airport, where he was to catch a plane to

Los Angeles; however, by that time, Gershwin's condition was judged to be critical and the

need for surgery immediate. At 3 o´clock the doctors performed a lumbar puncture; it

showered a pressure of 500 mm H2O. The spinal fluid was colorless and contained 30 mg of

protein. Also one cell was found 16. The intracranial pressure was be lowered from 400mm

H2O to 220mm H2O. Gershwin´s condition became a little bit better, but a short time later he

had bilateral Babinski-signs 13,14,16. The Neurosurgeons Dr. Carl Rand, Dr. Eugene Ziskind,

and Dr. Howard Nafziger began with the operation a short time after midnight. The operation

took five hours 13. The tumor was removed but it was a glioblastoma multiforme 14,17. After

the operation, Gershwin stayed out of consciousness and his body temperature increased to

41° C. He died on July, 11, 1937 16. W. E. Dandy wrote there was no chance for Gershwin to

survive, because it was impossible to remove a glioblastoma completely 12,14,17.

Diagnosis: The fact Gershwin died on a glioblastoma multiformeis documented. After

dura opening digital and visual examination were the only possibility to localize the tumor at

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that time, before MRT and CT scans era. What makes a GBM probable in Gerschwin´s case is

the short acute course, from the first psychiatric symptoms like, being nervous, feeling lonely,

depressions and listlessness in 1936, to his first epileptic seizure on 11 February 1937. This

seizure occurred when Gershwin practiced with the Los Angeles Philharmonic Orchestra.

During the concert in the evening of the same day, a further epileptic seizure occurred when

conducted his Concerto for piano in F-major. He played the solo part himself as soloist. He

suffered a petit-mal-seizure, lost his consciousness for 10 to 20 seconds, and missed several

bars of his piano solo. No spasmodic jerks occurred. A few seconds after that he continued

playing and conducting on the right bar 12,13,16,18. There is no record about the impact of the

disease on Gershwin’s musical performance, A special role plays Gershwin´s “composer´s

stomach”: his occasional abdominal problems,and abdominal pain possibly may be symptoms

of early focal seizures as a feeling of an epigastric aura.19,20. The epigastric aura is a typical

symptom of temporal focal seizures without loss of consciousness. If the size of the tumor

increased and surrounding brain structures are compressed the epileptogenic zone spread out

20. Mostly patients with low grade gliomas suffered from tumors associated epilepsy 20-22

IV. 2. The fatal craniotomy of Maurice Ravel (1875-1937)

Medical History: Maurice Ravel was one of the great composers of expressionism. At

the the early age of 25 he became famous 23-25 . In 1927 friends reported that Ravel had

difficulties to write 24. In 1929, he had an accident with a taxi and had some injuries and a

brain concussion 26. After the accident, his health became worse. 27. During a trip to the coast

in 1933, he had motor disturbances when he swam. It was apparently that symptoms of

neurologic disorder of Ravel developed, which affected the motor system and also his

cognitive abilities 28. Since that time, he had great difficulties to write, ataxia, and motor

aphasia 29.

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Surgical Procedure: In the autumn of 1937, his condition became dramatically worse.

The surgeon Thierry de Martel recommended a neurosurgical operation 30. On 17th December,

Ravel was brought to one Hospital. The Neurosurgeon Dr. Clovis Vincent (1879-1948) and

the neurologist Alajouanine suspected either a brain tumor or hydrocephalus. Clovis Vincent

(1879-1948) was the founder of neurosurgery in France 31. On 19th December, Dr. Vincent

performed a right frontal craniotomy 32. But he could not find a tumor. The brain tissue

looked normal, and there was no atrophy 33. A few hours after the operation, Ravel woke up

and called for his brother. Later he fell into coma. He died in the morning on the 28th of

December.

Differential Diagnosis:The exact diagnosis of Ravel´s disease is not known 34. Some

authors diagnosed a traumatic hydrocephalus, Pick-Disease, a Wiplash syndrome 35,

Alzheimer´s disease 36 or a corticobasal degeneration 37. Some musicologists believe the

special style in his last works, specially the Bolèro, are a symptom for his amusia and

neurologic disease 38, because the Bolèro is “Music with nothing” 32. Amusia is occasionally a

consequence ofbrain damage, and often is coupled with aphasia. It is notable in thecase of the

Russian composer V.Y. Shebalin (1902–1963), who continued to compose after a left-

hemisphere stroke causinghemiplegia and severe aphasia 39. He worked with verry reduced

musical material and the orchestra repeat only the same theme. The only enhancement in the

musical expression will be reached with loudness and the instrumentation 23. His difficulties

to write go with his special expression in his last works. Because of a brain injury or disease,

the disability of writing may occur, without lost of musical abilities 24. Also the role of the

asymmetry of the hemispheres was discussed 40. Special the right hemisphere should be

preferred to process musical patterns. Some authors developed the theory that Ravel´s illness

would have affected primarily the right hemisphere 41. A broad range of events and factors

can lead to a wrong-site craniotomy 32,42 Probably,the most dramatic wrong-site craniotomy in

the neurosurgical literature. Many of these preoperative checks had been done before the

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deadly a wrong-site craniotomy performed on Maurice Ravel by Clovis Vincent. Although the

opinion of doctors and his friendswas divided, it was decided that it was better to try to

dosomething to rescue him rather than to let him continueas as he was 32,42. Before the

craniotomy, Ravel’s friends did not want him to be frightened when his hair was to be cut off

for the intervention, and they suggested that this was another radiologic examination. The

composer was clearly aware of what was going on, saying, “Not at all: I know exactly that

they will cut of my head.” Ravel underwent an exploratory craniotomy. After the surgery,

Ravel lapsed into coma, and on December28, 1937, he died 32,42

IV. 3. The first awake craniotomy in music history; The suprasellar tumor

surgery of Pianist Clara Haskil in 1942 43,44

Medical History: Clara Haskil (1895-1960) became famous because of her wonderful

interpretations of Mozart´s piano concerts 45. Her style and the expression of her piano

playing are also today a standard of high level piano playing 46. In her youth Clara Haskil

suffered from congenital scoliosis, which deteriorated seriously during her years at the

Conservatoire. She had to give up the violin for this reason as early as 1914. In the same year

her uncle sent her to a famous nursing home for bone diseases in Berck-sur-Mer 47. In 1942,

she complained about strong headaches and impaired vision. Based on headache and

bitemporal hemianopsia, several doctors diagnosed a brain tumor.

Surgical Procedure: Awake craniotomy with local anaesthesia. The Parisian

Neurosurgeon Dr. Marcel David (1898-1986) performed a right-sided craniotomy on Clara

Haskil.3 under local anaesthesia within four hours and without complications 48. Until 1939

Marcel David an assistant of Clovis Vincent at the Pitié. She had no neurological problem(s)

after this surgery. It´s not known whether Dr. David always used local anaesthesia in such

surgery or as a general rule used available sedation techniques2,48-50. Since the end of 19th

century chloroform anaesthesia was standard for surgical interventions of any kind 51, later

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nitrous oxide was preferred. Because of the World War II and the occupation by the

Germans, the medical care was difficult in France 1942. Therefore, it cannot be assumed that

Dr. David had the latest techniques of anesthesia and surgical management available. Possibly

Marcel David used a sedation with nitrous oxide to open the skull, and performed the

intervention under slight sedation or local anesthesia due to a lack of material and equipment.

Clara Haskil played mentally Mozart’s piano concerto in E-flat Major KV 271 throughout the

operation 47, to test her memory as well as a distraction. Some studies shown, that Mozart´s

music has positive effects on brain functions, called Mozart effect. After listening of Mozart´s

sonata in D-Major for two pianos (KV 448) blood pressure was lower and the IQ temporally

rise up about 8 or 9 points 52,53. In a group of 29 patients with epileptic seizures, in 23 cases

the epileptiform activity decreased. In one comatose patient with status epilepticus the amount

of ictal activity decreased from 62 % to 21% during listening Mozart´s piano sonata D-Major

KV 448.54,55 To “play” the Mozart piano concerto E-flat Major KV 271 mentally by heart.

The case report Clara Haskill is the first reported awake craniotomy of a famous musician 44.

Today as well as in the past awake craniotomies were performed, when it is to hazardous for

the patient to perform general anesthesia 56,57. Specially when the tumor is located in frontal

lobes, language or memory areas, near the motor cortex, or in case of epilepsy surgery awake

craniotomy is a safety method to preserve high functional areas by a most completely removal

of the tumor or epileptic focus 58.

Differential Diagnosis

Since 1942 Clara Haskil complained of headaches which grew in frequency and

intensity, accompanied by impaired vision. Because of her headache and

bitemporalhemianopsia, several physicians finally diagnosed a brain tumor, mostly a pituitary

tumor. Headaches and increasing visual impairment are a characteristic symptom of a

suprasellar tumor as well as a tuberculum sallae meningioma pressing on the chiasma

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opticum. Headaches are a sign if the tumor has grown to a certain size 59. Clara Haskil often

suffered severe headache, so it´s probably that she suffered by chronic headache. A supra- or

parasellar tumor can cause cluster headache because of increasing intracranial

pressure,cerebrovascular problems, neuro-endrocrine changes or an activation of the

trigeminovascular system. 60. Pituitary tumors may also provoke hormone disorders. Specially

a influences the secretion of pituitary hormones such as ADH or TSH 61, prolactin. In the case

of Clara Haskil is unlikely because she hadn´t symptoms of hormone disorders. Other

differential diagnosis would be a Rathke cleft cysts, which may also be located in the sellar

and suprasellar regions and may produce symptoms like headache, visual loss, and/or

endocrine dysfunction 62. Craniopharyngiomas can spread along an axis from the third

ventricle to the pituitary gland 63, but they are a typical nonglial brain tumor of childhood (6 -

8% of all pediatric brain tumors)64 Thus makes a craniopharyngioma in case of a 47 years old

woman unlikely.

Traumatic brain injury, and skull fracture of Clara Haskil

On 6th December 1960, Clara Haskil went to a concert in Brussel 65 On the stairs at

the Brussels central-station she fell down and bruised her head on a stair. For short time, she

lost consciousness. They brought her to a hospital, a few hours later to another one. There, she

was diagnosed with a head trauma with skull fracture and an intracranial hemorrhage. She lost

consciousness again. Doctors performed a trepanation. Clara Haskil died six hours later in the

early morning hours of December 7, 1960 59,66,67. The short course is typical of such

accidents. She was able to speak and she expressed a fear she might have injured her hands.

Briefly, she regained consciousness, and orientation. She lost consciousness again at the

second hospital she was taken. Her condition deteriorated dramatically. The “lucid interval ”

is a distinctive sign of epidural haematoma. It is at least as likely to accompany a subdural as

an epidural hematoma 68.

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There is no documentation of the surgery, which Dr. David performed on her in 1940,

possibly lost in the turmoil of war. Some documents about her medical treatments received

are in private hands today. Increased intracranial pressure or brain edema may be causes of

her death.

IV. 4: AVM Surgery of Pat Martino

Pat Martino was born in Philadelphia in 1944. He started playing guitar when he was

12 years old. He left school at that age to pursue a music career 7. Before his 18th birthday, he

became an icon in the jazz scene, signed as a leading artist for Prestige Records at age (20).

His key albums during this period included “Strings!,” “Desperado,” “El Hombre,” and

“Baiyina,” one of the first successful jazz ventures in psychedelic music.This musician

underwent surgery to treat an intracerebral hemorrhage resulting from acerebral arteriovenous

malformation , requiring a wide left temporal lobectomy7. Before surgery, Pat Martino had

a history of epilepsy 69 associated with manic depression 70,71 but no abnormalities in his

musical capabilities. After surgery, he had an almost complete memory loss, showing

the expected effect of an extensive injury to the left temporal lobe 72,73. He completely lost his

musical capabilities including theory, technique, and skills.However, the musical capabilities

of Pat Martino completely recovered even when much of the left temporal lobe has been

removed.

Big Tragedy of a Picture

Picture 2 shows a scene from birthday party honoring Maurice Ravel in New York

City, March 8, 1928.From left: Oskar Fried; Éva Gauthier; Ravel at piano; Manoah Leide-

Tedesco; and George Gershwin. The cases of George Gershwin 14,74-76 and Maurice Ravel

23,32,42,77-79 demonstrated the first cases of neurosurgical treatment in music history. Both died

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after fatal craniotomy in 1937. George Gershwin died on July, 11, 1937. Maurice Ravel died

on on December 28, 1937.

VI Discussion:

What we have learned from Unforgettable craniotomies of famous musician in

last century?

Unfortunately, in Ravel’s, Gershwin’s, Haskil’s day there were no modern

neuroimaging methods, such as CT, MRI, functionalMRI, SPECT, or PET. “What is the

worst that could happen if neurosurgeons do something? What is the worst that could happen

if neurosurgeons do nothing?”42. Those were likely questions of their surgeon. Today,

neurosurgical practice is confronted by an explosion of technology 80-83. Only neurosurgeons

can understand the feelings of neurosurgeons in that time, who had limited diagnostic tools.

At that time of Ravel and Gershwin, neurosurgical operations were risky for the patient 2.

The first medical textbooks about neurosurgical techniques and procedures were published

between 1930 and 1950 by the pioneers of neurosurgery 84 like, H. Cushing 85, W. E. Dandy 86

or P. Bailey 87 in USA as well in Europe. The case of Clara Haskil is very interesting 44.

She had her first operation in the middle of the 20th century when operation microscope and

microsurgery were not avaible. Her tumor was possibly a meningioma of the suprasellar

region. Perhaps Dr. David used the method by Krause or Frazier of a right-frontal trepanation

88. She recovered completely. Her great career as a pianist began after this surgery. But she

died after a second operation in 1960 when modern neurosurgery had begun 3,89.

What about the surgery of jazz guitarist Pat Martino?

Pat Martino underwent a left temporal lobectomy in 1980.After surgery, he presented

with severe retrograde amnesia and complete loss ofmusical interest and capabilities. His

musical abilities, including theory, technique, and skills, were completelylost. It is known that

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musicians use the lefthemisphere more;The patient’s musical abilities recovered overtime, and

he regained his previous virtuoso status 7 The surgery of Pat Martino shows the possibility of

an unusual degree ofcerebral plasticity and reorganization of professional musicians.

Musicians with enhancedmotor skills possess greater capacity forplasticity because of

enriched interhemisphericconnections 90 and structuralasymmetry of relevant brain areas 91. It

is known that musicians use the left hemisphere more 90,91 This knowledge favors that

theasymmetry of the left planum temporale islower than in the general population.

This“symmetry” of his hemispheres related tomusic exposure possibly influenced the

recoveryand further development of musicalabilities in Pat Martino.

Limitations;

This review faces important limitations. Firstly, we could only investigated the

musician, which appeared in literature. It is obvious, that many musicians who were operated

but not appeared in literature. Secondly, we aware that, in this paper, there is only a spotty

discussion of how each of the musicians' musical prowess was affected by her/his disease.

The aim of study is uncover the interesting craniotomies of famous musicians, not affection

musical prowess by neurological disease. In future, we want to write an article about this

subject.

Conclusion:

The neuronal plasticity of musician‘s brain may be different than nonmusician, 92,93

The succesfull cranial surgery of Pat Martino and Clara Haskil may be example for

recovering damaged functions of brain of musicians. Our review will lead to remember these

interesting craniotomies in future. It will lead to publish more case report in this subject, and

open new horizons of about recovering of musician after neurosurgery,

Competing interests: The authors declare that they have no competing interests.

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Legends

Picture 1:Clara Haskil (7 January 1895 – 7 December 1960) was aclassical pianist,

renowned as an interpreter of the classical and earlyromantic repertoire.

Picture 2 shows a scene from birthday party honoring Maurice Ravel in New York

City, March 8, 1928. From left: Oskar Fried; Éva Gauthier; Ravel at piano; Manoah Leide-

Tedesco; and George Gershwin.

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ACCEPTED MANUSCRIPTAbbreviations:

CT: computed tomography

fMRT : functional Magnetic Resonance Tomography

MRI: Magnetic resonance imaging

PET: Positron emission tomography

SPECT: Single-photon emission computed tomography

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