ART IN MEDICINE: MUSICIANS, PHYSICIANS AND

PHYSICIAN-MUSICIAN JAMES J. CERDA GAINESVILLE, FL

INTRODUCTION According to Strohl (1) the profession of medicine and the art of music have been closely allied since ancient times. Apollo, according to Greek and Roman mythology, was the god of medicine, music, and poetry. To Homer, the greatest of poets, go the laurels for his successful use of music as a therapeutic agent in the field of surgery. It is only now after nearly 3,000 years that music is being used in surgery, though from a rather

different aspect than to check the flow of blood from a wound of Ulysses, as was originally done. In many operating rooms, classical music is available at the option of the surgeon and patient prior to and during the surgical procedure. At the Royal Victoria Hospital in Montreal, music therapy utilizing a trained music therapist is used in the palliative care of patients with advanced malignant disease (2). Recently, the International Journal of Arts and Medicine (IJAM) has emerged as an official peer-review journal to foster and research the therapeutic properties of music. Their goal is to help improve the management of patients through musical means by bringing together scientists, musicians, psychologists, and professionals from other disciplines and backgrounds who have an interest in music, medicine/music therapy, and related research (3). Musicians themselves seek medical care because of common and painful musculoligamentous overuse which can result in pain and loss of function in muscle groups and ligaments as a result of excessive or unaccustomed activity. This has been referred to as craft palsy (4). Probably one of the most famous musicians studied in this fashion was Gary Graffman, the renowned concert pianist, who was suffering from mysterious cramping and curling of the fourth and fifth fingers of his right hand. Examinations included complete musculoskeletal system evaluation, blood test to rule out immune system dysfunction or circulatory problems, conduction studies, videotapes and snapshots of many performances. It is of interest that 75% of the musician-patients are pianists, 15% are string players, and the remaining 10% comprise guitarists (steel and classical), woodwind and tuba players, and drummers (5). The nineteenth century was a period in which the association of medicine and music was especially great. The child prodigy, Fritz Kreisler, was born in Vienna in 1875. He won the grand prix of the Paris Conservatory at the age of 12, and was 228

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awarded the grand prix de Rome at the age of 20. At the completion of a successful tour of the United States as a concert violinist, he gave up his beloved music and began the study of medicine, culminating in his being appointed a medical officer in the Austrian Army. However, music was his first love and he subsequently abandoned his career in medicine, returning to his lifelong career as one of the great violin virtuosos of all time. In 1935 he revealed that a number of compositions he had played as compositions of old masters were actually his own (6). Herman Boerhaave (1668-1738) was educated with the hope that he would follow in the footsteps of his clerical father. He was considered the greatest clinician and medical educator of his time and was versed in a number of languages. Truly a Renaissance man, he was a distinguished chemist, physician, teacher, and practitioner, best known for the description of esophageal rupture (Boerhaave's syndrome). Less known is the fact that he developed the botanical garden in Leyden and is known as the first physician to cultivate chamber music (7). Hector Berlioz was the son of Louis Berlioz, a small-town physician who had little sympathy for a musical career for Hector. Louis Berlioz exerted every possible influence in order to direct Hector into a career in medicine, since not only Louis, but his grandfather and uncle had been physicians. Fortunately for music, Hector was easily recognized as a composer and child prodigy. It was fortunate that Bernard Vandiern, a great composer in his day, perceived Hector's potential. He stated that Berlioz had "with the sole exception of Mozart, the most stupendous gifts of the past century." Nevertheless, Berlioz entered medical school and in 1824 earned his Bachelor of Science degree in medicine. However, his desire to be a musician was stronger than his forced conscription into the medical profession. Against the advice of friends and his parents, (who threatened to cut off his allowance) he attended classes under the tutelage of Leseur. In fact, it was Leseur who commented after hearing Berlioz' mass, "You should not be a doctor or a druggist, or anything else, but a great musician." Stubbornly, his father held that Hector should continue to be a physician, but did allow him to continue to pursue his musical ambitions. However, Hector's lifestyle, including many unsuccessful love affairs, and lack of money were impediments. Nicolo Paganini recognized Berlioz' phenomenal ability and after the performance of "Harold" in Italy, paid tribute to Berlioz by getting down on his knee and congratulating him. It was through Paganini and Baron de Rothschild that Hector was able to complete "Romeo and Juliet" and, of course, his magnificent Symphony, "Fantastique," works which established him as a great composer (8). Paganini himself may have suffered from Marfan's syndrome, which probably contributed to his being considered the greatest violin virtuoso of all time, due to the manual dexterity

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conferred by being born with long fingers and the hyperextensive joints of Marfan's syndrome (9). Herman Ludwig Ferdinand von Helmholtz (1821-1894) was professor of physiology at Konigsberg. A physician by training and teacher by profession, Helmholtz became Germany's foremost physicist, succeeding to the chair of physics at the University of Berlin. His contributions to our knowledge of acoustics nearly equaled those he made to physiologic optics. Among his greatest accomplishments in medicine during nineteenth century was the ophthalmoscope invented in 1850. He was a skilled pianist and musician, having studied the theory of music as required at that time for a proper musical education. His first paper on physical acoustics appeared in 1849 and his most famous group of works, "On the Sensation of Tones as a Physiological Basis for the Theory of Music," became a fundamental textbook in its field (10). Theodor Billroth was born on the island of Rugen in 1829. Billroth's contributions to surgery of the digestive tract gained him international recognition. It was, however, in music that his ambitions really lay. His earliest hopes were to study music. Nevertheless, his parents opposed this career and insisted he study medicine. It was at Zurich that Billroth met Johannes Brahms where they formed a lifelong friendship. In fact, virtually all of Brahms' chamber music was played for the first time in Billroth's home. Leading musicians of Vienna gathered at his home for evenings of music with Billroth performing on the piano or violin. As if this were not enough, Billroth wrote extensively and entitled a book, "Wer ist Musicalich?", attempting to develop a physiologic theory of music appreciation. Furthermore, he was recognized as a critic of music and wrote musical reviews for the music magazine, "New Zuricher Zietung" (11). Aleksandr Borodin was born in St. Petersburg, Russia in 1833. It was the ambition of his mother that he aspire to become a physician, so at the age of 15 he was enrolled in the St. Petersburg Academy of Medicine. Like Billroth, Borodin was able to combine his great interest in science with his musical avocation. He became a Professor at Petersburg Academy of Medicine. Borodin became a member of the "Russian Circle of Five," who had a single mission: to create a national art in their composition. The group was composed of Balakrieve, a mathematician; Borodin, a physician; Cui, a professor of fortification in the Engineer's Academy; Moussorvsky, a military officer; and Rimski-Korsakov, a former naval cadet (12). Early in his youth, Albert Schweitzer became a lover of music. He became a pupil of Eugene Munch, one of Germany's most illustrious organists. It was under Munch's tutelage that Schweitzer developed as a great organist and as an outstanding interpreter of Bach. It is of interest

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to note that the late director of the Boston Symphony Orchestra, Charles Munch, was the nephew of Eugene Munch. Schweitzer then entered the University of Strasbourg in 1893 where he studied philosophy, theology, and music. In 1900 he was ordained a Lutheran minister and began to write extensively in theology. In 1905 he read a magazine article in which the president of a Paris missionary society pleaded for workers in Africa. This was Schweitzer's inspiration to serve as a medical missionary. He enrolled in the University of Strasbourg to prepare himself for his future work as a physician in French Equatorial Africa. His work in Africa is legendary, and led to his winning the Nobel prize. Despite failing health he continued to give lectures and concerts in many European countries, using the money to fund his hospitals in Africa (13). There has also been a considerable interest in musicians and their diseases. Of great importance was the celebration last year of the bicentennial of Mozart's death at the age of 35. In the United States and abroad, virtually hundreds of commemorative concerts were given during 1991, "the year of Mozart." The movie, Amadeus, may have won the Oscar for best movie, but it wins no awards for medical accuracy since it was probably kidney disease after a lifetime of illness and not his envious rival court composer Antonio Salieri that ultimately did in the Austrian wunderkind, christened Johannes Chrysostomus Wolfgangus Theophilus Mozart (14). Despite, or perhaps because, of a large amount of medical speculation, the actual cause of Mozart's death remains somewhat uncertain. It has been variously attributed to typhoid fever, tuberculosis, and glomerulonephritis. It was Barraut, quoted by Biancolli, who stated that: "Two factors hastened Mozart's death. The first was a chronic cause dating from his earliest years and increasing every day. This was simply excessive work, continual fatigue and profound misery. It was at that moment that the disease which carried him off laid hold of him. If we considered his rapid emaciation, his difficulty in breathing, his faintings, the swelling of his legs and hands, paresis, and if we remember that when young he had scarlatina, we are indeed led to the conclusion "nephritis." Mozart, in our opinion died of Bright's disease, and if one considers the extreme weakness when he felt the first attacks of this malady, one can really understand that the disease only took six months, from July to December, to exterminate a man who throughout his life had been obliged to fight in order to have bread to eat" (15). According to Yu (16), Mozart's skull was acquired by the Mozarteum at Salzburg, where it is presently held. A group of French scientists has recently carried out extensive examinations on the skull. Of particular note was the finding of premature synostosis of the metopic suture, a rare congenital anomaly associated with a characteristically shaped cranium. When they superimposed im-

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ages of the skull on a contemporary (1778) portrait of Mozart, they demonstrated that the features of both coincided closely. Given this, Yu goes on to state that other studies would be intriguing, including positive identification by DNA fingerprinting, diagnostic molecular analysis, utilizing polymerase chain reaction (PCR), trace metal analyses, and radiographic analyses, to provide evidence for renal osteodystrophy. A complete review of the various theories can be found in an excellent article by Guillery (17). The most famous instance of deafness is the case of the composer Ludwig van Beethoven. Beethoven suffered through a wide variety of other diseases, including "rheumatism" which may have been gout, and probably infectious hepatitis. In early 1825 he had a severe attack of colitis and was glad to have survived it. He wrote the adagio, a minor quartet as a "hymn of thanksgiving to God" by an "invalid on his convalescence," which inspired the sonnet: Bereft of love and wearied out with life, Too torn to weep, yet wishing to be wept Upon and loved; beset with sorrows rife, I lay alone through tortured nights unslept. And all the world's outside was vilely stenched By man's insensate brutishness, and stocked With micro-men for macro-tests. How wrenched Was my poor heart to see dear peace so mocked! Thus wrenched I then heard a song above, Sublime, transcendent music! Starsward soared This pure abstraction, prayer for peace and love Transfigured wine from fragile chalice poured All cares seemed naught when Beethoven could still Give thanks to God though deaf, alone and ill (18). His health continued to dissipate and after composing one of his masterpieces, the string quartet in C sharp minor in 1826, his health took a sudden turn for the worse, including symptoms such as chills, fever, and pleuritic pain. He had diarrhea and became jaundiced. After seeing his physician, Dr. Waruch, he continued to try to keep up his spirits. Beethoven was said to have looked at his many bottles of pills and whisper, "Pity-too late!" These were his final words. For two days he remained in hepatic coma, expiring shortly after 5:00 p.m. on March 26, 1827 (19). In summary, it would appear that music is an art to which many physicians are attracted. Whether as performers or as listeners, a considerable number of people in the medical sciences have had some sort of interest in music. The reason for this affinity between medicine and music is hard to explain and will continue to be an interesting topic for

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speculation, and with validation of therapeutic goals through interdisciplinary research involving physiology, psychology, and applications of music and medicine. Organizations such as the International Arts-Medical Association, and the International Society for Music and Medicine will play important roles. At the University of Florida a working group has been established called "Art in Medicine (AIM)" a concept which is not new, but whose application may be new. The purpose of our program is designed to encourage caring and humanistic communication between health professionals and patients through art and music and to provide artists a new dimension to express their art as an integral part of the healing process. This cooperative effort hopes to: (1) Improve and increase the practice of humanistic communications among health professionals toward each other and patients. (2) Encourage health professionals to find a form of expression through the arts by exposing the group to local, national and international figures in the health and science disciplines who are known for their artistic pursuits in addition to their scientific professions. (3) Create awareness in both groups of the symbiotic relationship of the arts of self expression and human physiology in the prevention of illness and healing processes by means of seminars conducted by artists, patients, scientists and experts in such new areas of scientific exploration as Psychoneuroimmunology and associated fields. (4) Form a dedicated group of those artists and scientists to interact with patients suffering terminal or chronic illness to encourage them to express through some form of art or art appreciation, their pain, fear, and hopes in order to provide an approved quality of life and acceptance of self. (5) Collect pertinent data relative to the response of patients, artists, and health professionals involved in the program. Much needs to be done.

ACKNOWLEDGEMENT The author wishes to thank Mrs. Patricia R. Vance for expert technical assistance. REFERENCES 1. Strohl, EC, Jamieson, RW, Diffenbaugh WG. Physicians-Musicians. Perspectives in Biol Med Winter 1974; 267. 2. Munro, S, Bount B. Music Therapy in Palliative Care. Can Med Assn J 1978; 119: 3.

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3. Spintge R, Droh R. The International Society for Music in Medicine. IJAM (1) Fall 1991; 8. 4. Fry, HJH. The effect of overuse on the musician's technique: a comparative and historical review. IJAM (1), Fall 1991; 46. 5. Hein, D. Musician Doctors. OMNI, Nov 1983; 20. 6. The Great Instrumentalists. Ed J Camner. New York: Dover Publ, 1980: 75. 7. Fleisehli, DJ. Boerhaave Syndrome. JAMA 198; 1966; 172. 8. Cross, J. Encyclopedia of the great composers and their music. New York: Doubleday, 1953: 82. 9. Schoenfeld, MR. Nicolo Paganini. Musical magician and Marfan mutant? JAMA 1978; 239: 40. 10. The Columbia Encyclopedia, Ed W. Bridgwater and S. Kurtz, New York: Columbia Univ Press 1963: 931. 11. Berrett, J. Theodor Billroth, N Eng J Med 1961; 264: 38. 12. Cross, M. Encyclopedia of the Great Composers and Their Music. New York: Doubleday, 1953: 109. 13. A History of Music in Pictures. Ed. J. Kinsky. London, JM Dent. 1963: 290. 14. Heymont, G. Much Ado About Mozart. Sky (April) 1991: 10. 15. Biancolli, L. The Mozart Handbook. New York: World Publishing Co. 629: 569. 16. Yu ASL, Brenner BM. Diagnosing Mozart's Mortal Illness: An exercise in cranionephrology. J Am Soc Nephrol 1992; 2: 1666. 17. Guillery EN. Did Mozart Die of Kidney Disease? A review from the bicentennial of his death. J Am Soc Nephrol 1992; 2: 1671. 18. The Beethoven Companion. Ed. TK Scherman, L Biancolli. New York: Doubleday, 1972; 1230:813. -19. London SJ. Beethoven. Case report of a titan's last crisis. Arch Intern Med 1964; 113:442.

Art in medicine: musicians, physicians and physician-musician.

ART IN MEDICINE: MUSICIANS, PHYSICIANS AND PHYSICIAN-MUSICIAN JAMES J. CERDA GAINESVILLE, FL INTRODUCTION According to Strohl (1) the profession of...
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