Franz
Liszt and Alfred Graefe
Ophthalmic surgery in 1886
John
G. O'Shea MD
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
www.lesliehowardpianist.com
Email info@hyperion-records.co.uk
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 .
Cataracts:
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.
Coda
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
E-mail Address: LisztSoc@cs.com
References
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)
IV,102-110
13 O’Shea JG
Franz Liszt’s eye disease J R Soc. Med
1995 ; 88 : 562 -564