Doctors in the House

by Carl Ellenberger, MD

The tragic onstage collapse and eventual death of oboist Bill Bennett after playing the long opening passage of the Strauss Concerto with the San Francisco Symphony came as a shock to everyone. A doctor from the audience jumped onto the stage. Any doctor would have done the same, though the anachronistic, "Is there a doctor in the house?" has become just a laugh line for comedians since the advent of 911. 

Once recalling John Delancie's fateful knock in 1945 on the door of a villa in Garmisch-Partenkirchen at the foot of the Zugspitze Mountain (see Memoir: Ted Kramers, Dec 11), the Concerto from now on will mostly remind us of the tragic event in Davies Hall. Oboists will have second thoughts about climbing that mountain, needlessly, because an underlying medical cause, like an aneurysm, not the concerto, undoubtedly brought down Bill Bennett. For me, remembering Bill will recall my experience as a "doctor in the house," in the Gretna Playhouse over the past 38 years.

Calmly settling in for a concert one summer evening I knew what to expect as soon as I noticed the usher walking deliberately into the audience during the opening Haydn String Quartet. He entered from the side, walked purposefully across the front of the hall, then headed up the aisle toward my seat. “Please come with me,” he whispered. I followed him as he retraced his steps, all heads in the audience turning, momentarily distracted from the music.

Although there were other physicians in the audience, many of my friends or acquaintances, I was the one the ushers always headed for. As “Founder” of the festival, everyone knew that usually “the doctor is in.” Over years of summer concerts, I had come to recognize, and dread, the deliberate somber approach the usher made tonight.

Three sides of our hall are open to the summer cottages arrayed along narrow tree-lined lanes that wind around the back of the theater. Some porches are so close they can serve as box seats — the exact intention of their 19th-century builders. But sounds travel both ways; motorbikes, barking dogs, and even baby strollers often disrupt the music. The emergency siren is by far the worst distraction; it wails three times whenever someone dials 911, each blast seeming interminable during a quiet slow movement. The siren sounded that night as I followed the usher across the adjacent park toward the steps of the 100-year-old wooden Chautauqua Hall of Philosophy, and the victim.

The audience for classical music is graying, some say, and, theoretically, at least, brings to concerts a greater risk of medical events. Some need assistance to transfer into wheelchairs or walkers from cars driven right to the entrance. Others arrive with even more elaborate medical equipment. Most walk slowly, arm in arm, up the slight incline to the entrance in the back. As I watch them pass by, I wonder who will be next. They like older classical music—from the 18th and 19th centuries—especially if played by young musicians. But these older generations prefer jazz by older artists, like the traditional jazz band that has aged 37 years since their first appearance in our concerts.

Fortunately, all of these performers, including dozens of septua- and octogenarians, have come and gone over the years without incident. I did have to repair Lionel Hampton’s vibraphone when a pedal fell off but never had to resuscitate Lionel Hampton. Stephane Grappelli (“Hot Club de France”) brilliantly made it through his concert at age 77 with the help of a bottle of Chivas Regal—stipulated in his contract—and left the stage unassisted to raucous cheers and standing applause. Skitch Henderson’s stories of working with most of the famous musicians of the past century proved as prodigious as his ability at the piano. Cleo Laine seemed just another grandmotherly "lady of a certain age" until bathed in stage light and transformed into a lovely alluring woman with an angelic voice.

I am always amazed by how music, hardwired into the brain during the first decades of life, stays there until the end. Onstage, in their universe, all great performers can seem ageless. The singer Joe Williams (“Every Day I Have the Blues”) died at age 80 while walking home from a hospital room that gave him the blues, but not until 3 years after a warm and lively performance on our stage.

I myself came close to disaster onstage on two occasions. Once, after imbibing at a pre-concert reception, my blood pressure dropped during a Prokofiev Sonata to the point where I lost vision for about 30 seconds. Fortunately, the rest of my brain continued to function, I remained standing and playing, and vision returned. Another time after an excessive dose of propranolol (used ill-advisedly by performers to allay "stage nerves" -- you can't play the flute with a dry "cotton mouth") the only casualty was the Ibert Flute Concerto. I remained standing and playing badly throughout.

Our audience has been less fortunate. As I headed for the Hall of Philosophy, memories of earlier urgent summons ran through my head. One August evening, heeding the call, I stepped out from the dimly lighted hall into total darkness. In my haste to reach a woman who had fallen outside, I forgot about the stone culvert that for over 100 years had directed water around the hall rather than into it as it flowed down the side of our modest mountain. My first step was not the 9 inches I expected, but four feet to the bottom of the ditch. As my extended right foot finally struck stone, a loud crack accompanied my astonishment. As I continued my fall, my right shoulder struck the side of the culvert. I diagnosed the comminuted fracture of my right humerus before painfully arising, but only after my first step detected the torn Achilles tendon. The fallen woman went home; I went to the hospital.

Another time an elderly woman fainted in the third row and the musicians stopped playing. I positioned her flat in the aisle. As she awakened, I learned from her husband that she had “fainted at concerts before.” The siren sounded as I helped her walk up the aisle to the back entrance of the hall. The first emergency vehicles arrived, sirens screaming and lights flashing. The rescuers brusquely elbowed me aside, announcing, “Stand back! EMT!” All five vehicles idled (why do they bring a fire engine?), motors running and lights flashing under the overhanging roof of the hall, as the embarrassed victim, fully recovered and sitting on the steps of the ambulance, completed the necessary insurance forms. Exhaust from the vehicles slowly filled the hall. My request to move them was “interference with a rescue,” a charge dismissed only after a thorough month-long investigation and a warning from the local constable.

I usually did not summon the wit of a friend, paged during a concert by the Philadelphia Orchestra. “What time is my appointment tomorrow, doc?” “You’ll have to find another neurologist,” he replied, “I just retired.” And then Jack retired.

A crowd was gathering in the twilight as I approached tonight’s victim. He was a robust middle-aged man dressed in shorts and a T-shirt. He appeared dusky and apneic, his mouth and sightless eyes open, a knee brace on his right leg. Again I was asked by an EMT to stand back, this time from a fruitless resuscitation effort. The chest pumping was far too gentle, but I knew he had been asystolic for more than 5 minutes. One after another screaming and flashing vehicles arrived, their occupants bursting out carrying cases of equipment in both hands. “Anyone know who he is?” they asked. No one responded. I felt helpless, sad, and even a little guilty because I was too late, not participating, or even wanted.

My guilt increased as I deserted the scene and walked back to the theater and the warm elegant sounds of the slow movement of the Haydn quartet, punctuated by still more sirens arriving. After the end of the allegro, I asked the musicians to pause until the sirens stopped. A violinist took the opportunity to talk to the audience, all still oblivious to the drama outside, about the F Major Quartet and why it had begun so loudly and abruptly: it was to command the attention of Haydn’s chattering aristocratic audience, he revealed.

Our audience, who had tittered as each siren joined the music, didn’t grasp the meaning of the ultimate eerie silence: rescue efforts had failed and none of the ambulances raced for the hospital. When the music began again, I couldn’t enjoy Haydn’s stylish, graceful humor, usually still vital after 200 years. The Charles Ives quartet was more unsettling to me than the composer, as always, deliberately intended it to be. The lyrical melodic strains of the final Dvorak quartet, although warm and soothing, didn’t fit at all as an impromptu requiem.

The next day’s newspaper identified the victim as a mathematics professor at a nearby college and father of three young children who had just finished his weekly pick-up basketball game. His wife and children had watched the game but were already on the road home when, after visiting the local ice cream parlor with his fellow players, their husband and father collapsed and died.

A 'Monster' of the Chickering

by Carl Ellenberger, MD

As our last "Monsters of the (Elizabethtown) Steinway" concert for this season approached (the legendary Emanuel Ax, Tuesday, March 19), my thoughts turned to pianists. Franz Liszt may not be the appropriate pianist to contemplate for this concert--perhaps an antithesis of Ax--but he was considered a musical 'monster' by some contemporaries. (Actually, our "monster" label applies to the repertoire, the Pathetique on this concert, not the player.)

“Music embodies feeling without forcing it to contend and combine with thought, as it is forced in most arts and especially in the art of words.”

So said the Hungarian, Liszt, the 19th Century’s greatest piano virtuoso and arguably the greatest who ever walked the planet. Even his contemporaries mispronounced his name (list, not the Victor-Borgean “Schlitz”). Bathed in controversy ever since his birth in 1811, Liszt earned the contempt of Robert and Clara Schumann, Chopin, and Brahms, who accused him (and his son-in-law, Richard Wagner) of vulgar showmanship (“a smasher of pianos”) contrary to their view that music should be played only for its own sake. (They never heard Liberace.) But they were awestruck by, perhaps jealous of, his ability and would probably agree that Liszt could make his Chickering (a gift) do just as much as anyone (except maybe Marc-André Hamelin) will ever be able to do on any piano, even a modern Steinway. And most might agree with Charles Rosen:

“The harmonics can be banal, the melodies almost nonexistent…” In some of the Hungarian Rhapsodies, there is “zero degree of musical invention if we insist that invention must consist of melody, rhythm, harmony, and counterpoint. Nevertheless, played with a certain elegance, these are both dazzling and enchanting. The real invention concerns texture, density, tone color, and intensity—the various noises that can be made with a piano—and it is startlingly original. The piano was taught to make new sounds. These sounds often did not conform to an ideal of beauty, either Classical or Romantic, but they enlarged the meaning of music, made possible new modes of expression. On a much larger scale, Liszt did for the piano what Paganini had done for the violin. Listeners were impressed not only with the beauty of Paganini’s tone quality but also with its occasional ugliness and brutality, with the way he literally attacked his instrument for such dramatic effect. Liszt made a new range of dramatic piano sound possible, and in so doing thoroughly overhauled the technique of keyboard playing.”

Liszt exploited not only virtuosity but also a satanic public image and a Gothic taste for the macabre with all its paraphernalia--dances of death, etc. He was also a virtuoso conductor, doing more than anyone else of his time (except maybe Berlioz) to create the modern image of the orchestra conductor as an international star. He invented the symphonic “tone poem” (like Les Préludes) and was the first composer to write atonal (at least “harmonically audacious”) music foreshadowing Debussy and Schoenberg.

Liszt also acquired an international rock star-like reputation for erotic conquest, cultivating the image of a Don Juan. He used dazzling “transcendental” (his word) virtuosity as a representation of sexual domination, and women fought over his snuff-box and pieces of his handkerchief. His piano fantasy, Reminiscences of Don Giovanni, could be considered a self-portrait, just as everyone had assumed that Byron’s Don Juan was autobiographical. 

Although he had fathered three children by age 25, Liszt finally wanted to marry after retiring from the concert stage at age 35 at the peak of his performing career. To his chagrin, the Vatican revoked its sanction of the divorce of his intended, Princess Carolyne Sayn-Wittgenstein. Liszt became an abbé, albeit an urbane and composing abbé who could marry anyone else if he wished--but never did during the remainder of his 75 years.

In the first great age of pianistic virtuosity, Liszt was a scrupulous editor of works of other composers—and also borrower of their themes. In a nod to the Baroque era, he said, “A person of any mental quality has ideas of his own,” an initiative indispensable for first-rate performing as well as composing. Thus, no two performances, based on 'a few useful instructions'” in the score were ever expected to be the same, no two interpretations of a score’s written directives were ever meant to sound the same—not if performers employed ideas of their own to allow “the emotions to radiate and shine in their own character."

Most of Liszt’s piano works that have remained in repertoire and gave Liszt his stature -- more than a few indescribably beautiful --come from before 1850, even though, according to Rosen, “…the musical material is either invented by someone else or, with some very significant exceptions, it is shoddy and tired, likely to grate on the nerves of any musician of delicate sensibility.” 

After 1850 Liszt’s compositions became more refined and, in later years, more austere. These last years were devoted above all too short piano pieces and to religious music. The well-known Hungarian Rhapsody No. 2, (the one of 19 most used in old Disney animated cartoons), comes from the earlier period. 

My apologies to the artist. I have had copies of these drawings for over 40 years and long ago forgot their origin. Anyone know?

Listen to the last of Liszt's Transcendental Etudes by Valentina Lisitsa.

Listen to La Campanella by Valentina Lisitsa and watch them build a Bösendorer piano. 

What (if anything) Ails Classical Music? A Neurologic Diagnosis

by Carl Ellenberger, MD

I went to a concert by the Gryphon Trio at "International Classical Concerts of the Desert." They played three chestnuts beautifully--Haydn, Dvorak, Beethoven--no doubt for the umpteenth time, on a raised platform in a ballroom attached to the Rancho Mirage Public Library slightly smaller than a basketball court. It was a 'classical' classical concert: two classical works -- intermission -- final classical work, lacking only the contemporary piece often sandwiched between the chestnuts. 

An attentive and enthusiastic audience filled all 300 chairs. At intermission I strolled around and identified only five people who appeared younger than age 60. Three may have been shepherded by a grandparent. Men wore coats and ties; women evening dresses, at 4 PM, here in a mecca for well-to-do retirees and golfing winter vacationers. 

Looking over grey heads in audiences, anxious observers for centuries have predicted the demise of classical music along with its listeners. Data from the NEA confirms that the classical music audience is indeed older and has been diminishing in size over the past few decades. Although death hasn't occurred, such predictions have intensified along with speculations about the pathogenesis of the terminal illness which may never have seemed more likely than it does now. Orchestras, dance, and opera companies have gone bankrupt; corporate, foundation, governmental, and individual patronage and concert attendance has plummeted; classical radio has almost disappeared (hooray for KUSC!); large record companies have turned to other music as the lifespan of the CD nears its end; schools have dropped music education; and so on. It was frightening to hear someone say the other day: "We don't know whether anyone will be listening to Beethoven 50 years from now." (For the record, I think it's more likely humanity will destroy itself first.)

Adam Gopnik wrote about music and his kids (Music To Your Ears, New Yorker, Jan 28): 

"It isn't a question of classical tastes against pop; it's a question of small forms heard in motion against large forms heard with solemn intent.... They snatch at music as we snatched at movies, filling our heads with plural images." 

Young generations rarely hear music sitting down and they rarely, as Linus in Peanuts confided decades ago to an incredulous Lucy, "just listen to it" (Brahms). They dance to it, sing to it, drive to it, jog to it. Sitting quietly for hours looking at 70 musicians bowing, blowing, plucking and pounding just isn't a pleasure they seek, especially those with little listening experience and attention spans shortened by TV and digital devices. A classical concert may be like incuriously staring for hours at a Cezanne canvas in a museum knowing little about art, history, or impressionism. (Gustavo Dudamel said last Friday that's how Monet showed him how to conduct Debussy's La Mer.)

Classical music, of course, is available in amazing abundance in the 'cloud.' You can mix movements of symphonies and sonatas with Sugababes and Boyzone into a random shuffle on your iPod for playing on your commute, your morning run, or in your bathroom, providing wall-to-wall 24/7 background on which to play out daily life. No solemn intent involved. An anonymous violinist can serve an identical Chaconne to millions of casual listeners, cost-effective and free while they rack up miles on a treadmill.

Speculation abounds as to the reason(s) for this change: the fast pace of modern life, the growth and evolution of alternative electronic entertainment, expensive tickets; inconvenience of traveling to concerts; an idea that classical music requires education and refined taste that, like for fine food and wine, requires years of experience; or that classical concerts intimidate the uninitiated, keeping them from concerts because they don't know the rules and regulations. We are accused of snobbery, of believing that only classical music is real music,  that we worship the "permanent collection," and ignore music of the present. We hear that younger generations reject the snooty formal affairs with old arrogant musicians in full evening dress.  

Undoubtedly, there is some truth and validity to all of the above, in varying proportions depending where, geographically and demographically you are talking about. People on the West Coast, for example, may be puzzled by all the fuss. Just try to get a ticket to hear the LA Phil in Walt Disney Hall! Meanwhile the Minnesota Orchestra is on the verge of collapse, other orchestras no longer exist. Emanuel Ax (Gretna Music, March 19) will play to about 400 people in Elizabethtown PA just weeks after playing to thousands in Berlin. Cultural life in the US may be condensing around islands of vibrancy separated by a vast wasteland inhabited mostly by the '99 percent' where all the 'fine arts' are low in priority and struggle to survive. The NEA data shows relatively small average declines but in many places the declines have reached extreme levels. 

Most of these thoughts are packaged into the word "classical" so we try to minimize its use. Most are in the minds of those who do attend classical music concerts; others probably don't have them. "Classical," of course, also connotes a sense of history, another concept often lost in the surge of 'progress' or daily scramble to pay the mortgage. 

Reassurance (speculative as is some of the above) came from the late pianist and scholar Charles Rosen. He felt that the future of classical music is assured so long as enough young musicians want to play it. Judging by the amazing rise in the level of performance over the years since my education, increasing competition among students for positions at conservatories, not just in the US but in Asia, South America, Europe, and even the Middle East, indicates to me that there is no shortage of young players entering the pipeline leading to artistry. Probably more good pianists play today than played throughout allof history.

The problems lie in the declining interest in (or in biz-speak, "market demand" for) the work of classical performing artists.

Nevertheless, we may be making a mistake to view this simply as a marketing challenge. Instead it may be a cultural change driven by multiple determinants. President Obama's State of the Union speech hinted at one. Based on accumulating evidence he drew a clear connection between what children do in their first decade of life--the earlier, the better--and what they can do and who they are as adults. Inherent in this connection is the concept of brain "plasticity" and "critical" and "sensitive" periods in child development.

Brain plasticity refers to gain and loss of brain abilities. Practice that improves performance on a musical instrument is a perfect illustration of plasticity, as is any kind of learning. Recently we have learned that acquisition of brain abilities is accompanied by actual anatomic, physiologic, and chemical changes that we can observe and measure in several ways, microscopic and macroscopic. Of course abilities must be maintained by regular use; otherwise they may be lost; plasticity in that opposite (losing abilities) direction is generally called "atrophy." 

A good example of detectable changes in the brain is the growth in size of the corpus callosum--the large cable connecting (see it crossing in the right image) the right and left hemispheres--in pianists who practice. If they start practicing before the age of 7 years, their corpus callosums become larger. "Bulking up" the corpus callosum by using it for the enormous degree of coordination -- "sensorimotor synchronization" --  between the two brain hemispheres required to play a Schubert Sonata, causes it to enlarge like muscles of a weight lifter; the enlargement is greatest if the practice starts before the age of seven years.

sliced front to back                    sliced side to side

That plasticity varies during the course of every individual's lifetime has been known for some time. In general it is greater when we are younger and declines with aging. But during our first decades of life we pass through critical and sensitive periods of plasticity for the acquisition of various abilities. For example, if a child does not use both eyes together because she was born with strabismus ('crossed' eyes) that are not straightened by about the age of 6, then she can never develop brain capacity for binocular stereoscopic (3D) vision, the most acute kind of depth perception. The critical period for acquiring that ability begins at birth and ends completely in the middle of the first decade of life. 

For acquisition of other abilities the first decade also has sensitive periods, as illustrated by the corpus callosum observation. These abilities, like language, can be gained to some degree at any age, but are more readily developed if they are acquired during the sensitive period. That reality has always been obvious to musicians, educators and scientists. You can't hope to become a concert pianist or olympic tennis star if you first sit down at the keyboard or walk onto a court at the age of 12, for example. That is too late. Now there is evidence (so far only in mice) that a switch gradually suppresses plasticity after adolescence, a protein called the "NoGo Receptor," (NgR1) in order to stabilize or "hardwire" the brain for life.

After the sensitive period ends you can certainly learn to play the piano or to play tennis, but you cannot become a pro. Language has a sensitive period that begins at birth, or very shortly after, and lasts for years, indefinitely tapering off in the second or third decade; some believe that humans take longer to fully develop (take longer to reach adulthood) than other species because of that long sensitive period for language. I would argue that that the same applies to music. Language and music are two abilities unique to the human species. Educators say "read to your kids." Perhaps they should say, "Read to and sing with your kids."

To a degree that remains to be clarified plasticity may be transferrable from one skill to another. For example, disciplined and guided practice on the piano may improve ability to acquire other skills, say ability in mathematics or language, or just improve general intelligence. (See "Learning Music Makes Kids Smarter" Oct 11, 2012, and this) Not all players in the student orchestras of Venezuela's El Sistema become musicians, but they are more likely to succeed in other fields than their non-musical peers. 

Both music and language education can start early, say at age 2-3 (compare that with education in philosophy or statistics that can't). Language is learned through conversations and reading with parents. Similarly musical training can begin with rhythm and simple songs and dances. There are few better illustrations of success-rewarding-effort than practicing a musical instrument. Think of a Suzuki class. An added benefit is that musical training can put very young children into cooperative and productive social contact. (We can suspect that most members of the current House of Representatives never played in the school band.)

Another advantage of very early education is suggested by other recent observations: the earlier and higher the quality of that early education, the longer the individual is likely to continue education--through college or graduate and professional schools and beyond. That observation may explain data from the NEA: the chance of an adult being in an audience for a classical music concert increases with the duration of that person's education. With a graduate-school education you are nine times more likely to be found at a concert (or in a museum) than with only a high school diploma. The naive explanation for that observation, that you must be highly educated to appreciate classical music, has little support. But another explanation may apply: if you associate with educated peers, they are more likely to go to, or take you to, a classical music concert than to a Justin Bieber Tour.

Knowing the brain's development schedule can help a student plan his life. If you start on the piano or tennis court when you are 6 years old, you might--if you have all the other requisite abilities, and sacrifice your teenage years to as many as 10,000 hours of guided practice--become a pro by the age of 20. That leaves the rest of your life for study of other things, to become a scientist, doctor, teacher, or judge, an Albert Schweitzer, for example. Learning to master the clarinet can equip you later to more easily acquire other knowledge and skills. 

You can't follow that schedule in reverse. Late-starting tennis players and pianists are forever amateurs, playing for their own enjoyment, rarely for ticket buyers. There is a difference between one child who starts to play the piano at age 5-6 and practices, and another who decides to imitate what s/he hears on an iPod at age 13.

Musical ability on one hand and understanding and appreciating complex music on the other, two closely-related brain abilities, are learned, and best learned when you are very young and your brain is most "sensitive" to that task. I am never surprised to learn from a member of our audience that s/he played in the school band or sang in a choir.

The reality that music education has been jettisoned by uninformed and cash-poor school boards gives me little hope that current and future generations will acquire what is necessary to understand classical music written in any era, including yesterday. If children continue to be denied opportunities during critical and sensitive periods of their lives to learn basic musical skills, gaining a life-long love of music will be increasingly unlikely as they get older. Indeed, learning anything might be more difficult.

Nevertheless, an amazing number of the very young somehow seem to discover a passion for music in time. Perhaps that number will even increase in the YouTube era as chance discoveries by web-surfing three-year-olds lead to, "Mommy I want a violin!" But considering the trends in our culture, they may have to play for each other when they become adults.

Addendum: David Hahn, songwriter and former Broadway conductor looks  at one part of the elephant: The 4,000 musicians in 51 major orchestras, 2% of all musicians in the US, are paid far too much for what the market will bear, largely because of the efforts of their union, the American Federation of Musicians. See Solving the Symphony Crisis for his suggested solutions.

Addendum 2: Listen to the brilliant and eloquent commencement address by flutist Claire Chase. Is this a map to the future?