Gershwin’s Final Overture

George Gershwin (1898-1937)

George Gershwin (1898-1937)

The sound of jazz music is a far cry from the synthesized pop music known well to millennials. Despite this departure from one of the most significant movements in American music, Jazz continues to hold a special place in the hearts of every American. There is perhaps no tune more well known than “Rhapsody in Blue,” other than the National Anthem and other patriotic songs. This ragtime classic brings to conscious memories from a time in American history long since past. A time before stock markets crashed; between two World Wars, the roaring 1920’s. While the sale of alcohol was curbed to speakeasies, the fame of George Gershwin flourished throughout America.

George Gershwin (born Jacob Gershvin), a first generation American to Russian-Jewish immigrants, discovered music at the age of twelve when his mother procured a piano for the family household. By fifteen, the young Gershwin began playing marches, earning $15 per week preforming with a vocal group. During the late 1920’s, the 5 foot 10 inch, slim Gershwin moved to a New York City studio where he would generate a number of musicals which excelled on Broadway. By 1932, Gershwin won a Pulitzer Prize, and would soon relocate to Hollywood.

Plagued like many artists, Gershwin suffered with gastrointestinal symptoms for a large part of his career. Self-described as “composer’s stomach,” he frequently experienced recurrent bouts of nausea and constipation. “Nobody believes me when I say I’m sick.” In search of answers led Gershwin to the office of Dr. Gregory Zilboorg (a Russian trained physician who completed his US training at Columbia). Zilboorg specialized in psychoanalysis; his relationship with Gershwin was close having accompanied Gershwin on trip to Mexico. Despite seeking treatment and keeping accurate diet diaries, these symptoms would follow Gershwin to his grave.

A Case of Seizure – February 11, 1937

The Los Angeles philharmonic paid tribute to Gershwin by featuring his work, with the composer himself conducting the orchestra. During the Piano Concerto in F Major, Gershwin experienced an episode of syncope with loss of consciousness for 10-20 seconds. He did not have any spastic jerks, and he continued conducting after the event. His friend Oscar Levant questioned Gershwin about the event backstage, to which the composer stated a strange smell of burnt rubber prior to the blackout.

This distinct smell would return two months later, in April 1937, while at a barbershop in Beverly Hills. He discussed by telephone with Dr. Zilboorg this symptom. Zilboorg proposed in the past Gershwin’s symptoms to be psychosomatic, however upon hearing this new information knew there was a more organic cause to his condition.

Precarious Headaches – June 23, 1937

Having suffered two weeks of severe, pounding headaches, Gershwin was admitted to Cedars of Lebanon Hospital under the internist Dr. Gabriell Segall. During this admission, the headaches were localized to the frontal/temporal region, worse in the morning and associated with dizziness and nausea. The olfactory hallucinations also recurred, and his coordination was impaired.

Eugene Ziskind (1900-1993)

Eugene Ziskind (1900-1993)

Dr. Eugene Ziskind, a neurologist, examined Gershwin. His findings mentioned photophobia, normal reflexes, no papilledema, no visual field defects, no evidence of organic lesions. His EKG and cranial X-rays were also unremarkable. A lumbar puncture was recommended, but Gershwin refused to undergo the procedure due to pain. Dr. Ziskind attributed Gershwin’s presentation to hysteria, and he was later discharged.

For the next two weeks, Gershwin was trailed by a nurse, and utilized psychoanalytic services. However, his family and friends could see Gershwin’s condition worsening. He was unable to feed himself, and his piano playing was severely effected. Thinking Gershwin’s condition could be cured with rest, his family placed him in a private nursing facility in Beverly Hills. Ira Gershwin, George’s brother, visited the nursing center on July 9th to find his brother asleep. George would not awaken until 5 o’clock in the afternoon, and was in such debilitating state he collapsed on his way to the bathroom. Gershwin returned to the hospital.

Dr. Segall admitted Gershwin around midnight, together with Dr. Carl Rand, a neurosurgeon. Gershwin was in a coma. Segall ordered IV fluids (50% sucrose) throughout the night. Dr. Ziskind examined Gershwin again. The physical findings, corroborated by Dr. Rand, were as followed:

Eyes closed; unresponsive to verbal stimulus; responsive to pain; spontaneously moving limbs

Pupils small, irregular with limited reaction to light; tracks, unable to gaze upward

Optic discs with bilateral papilledema; blurring of disc margins; fresh hemorrhages

Visual fields not tested

Right lower facial weakness; corner of mouth sagging; nasal folds obliterated

Hearing not assessed

Pharyngeal reflex present; no tongue deviation

No nuchal rigidity; Kernig’s negative

Hand grasps equal bilaterally

No tremor

Gershwin’s coma is characterized as severe [Glasgow coma score roughly < 9]. The inability to look up [upward gaze palsy] is likely a sign of Parinaud’s syndrome, and indicates an upper brainstem lesion. The optic discs indicate increased pressure in the cranial vault. Facial weakness indicates cranial nerve involvement [CN VII]. This collation of physical findings indicates a space occupying lesion in the infratentorial space.

Cedars of Lebanon Hospital 1956

Cedars of Lebanon Hospital 1956

At 9:30AM on July 10, Gershwin’s family was notified about his poor prognosis. A lumbar puncture was performed at 3:30PM on July 10. The opening pressure was 400mm; examination of the cerebrospinal fluid was unremarkable. Later examination showed hyperactive reflexes, positive Babinski bilateral, intermittent positive Hoffman sign on the left. Gershwin’s condition was worsening.

Giants Cross Paths

When an American treasure is in dire need of medical help, the foremost experts in the required field are called to the bedside. Dr. Rand suggested further consultation for Gershwin. Leonore Gershwin, the wife of Ira, called George’s friend Emil Mosbacher. Mosbacher worked on the stock exchange in New York. Leonore urged Mosbacher to fly out an outstanding neurosurgeon to aid George. Mosbacher calls no less than Dr. Harvey Cushing in Boston. Cushing refused operating since he had retired; however, Cushing recommended Dr. Walter Dandy at Johns Hopkins.

Mosbacher tracks Dandy on a yacht, vacationing on the Chesapeake Bay with Maryland Governor Harry Nice. A telegram was sent to the White House, which authorized two Navy Destroyers to go procure the surgeon-at-sea. Dr. Dandy was located, brought to shore, and escorted to Cumberland, Maryland. Dandy was flown to Newark, NJ.

Howard Naffziger (1884-1964)

Howard Naffziger (1884-1964)

Dr. Naffziger, professor of neurosurgery at UC medical school, arrived at the hospital at 9:30PM July 10th. He too was vacationing on a boat in Lake Tahoe. Dr. Rand had begun trephining Gershwin’s skull for a ventriculogram to localize the brain lesion. A right temporal lobe lesion compressing the right ventricle with deviation passed the midline.  A conference call between Mosbacher, Dr. Dandy and Dr. Naffziger indicated emergent surgery was needed. Dr. Dandy, who had arrived in Newark, called off his flight. Gershwin was taken to the operating room for removal of the tumor. The procedure was complete just after midnight.

Postoperatively, Gershwin’s temperature rose to 106.5 Fahrenheit, pulse 180 and respiration rate to 45. He died in a coma at 10:45AM July 11 with his brother Ira at his bedside; he was 38 years old.

Aftermath

The pathology report indicated the 4cm X 3cm X 2cm mass to be consistent microscopically with what now is known as glioblastoma multiforme. Dr. Dandy reached out to Dr. Segall to explain that the fulminant nature of the tumor, especially at the outset, would have likely guaranteed recurrence. Gershwin, had he survived, would have had a very poor prognosis.

Word spread throughout the world with the death of Gershwin. His death added to a list of legendary composers with short, brilliant careers including: Mozart at 36, Schubert at 31 and Bellini at 34. He was laid to rest in a mausoleum built by his mother in 1941 in Mt. Hope Cemetery, with a glass window exposing blue silk hangings in honor of “Rhapsody in Blue.”

For a brief moment in history, the greatest minds in medicine attempted to heal the greatest mind in music. The outcome was not the stuff of romantic films, but of tragedy. Our patients are debilitated and immobilized by injury, and we enable them to return to the hobbies and jobs they love. Their passion to return to their way of living, inspires us to get them there. Gershwin’s death is not all tragedy, from his case we can derive the motivation and passion to become better physicians.

References

“George Gershwin—Illustrious American Composer.” The American Journal of Surgical Pathology 3.5 (1979): 473-78. Print.

Ljunggren, Bengt. “The Case of George Gershwin.” Neurosurgery 10.6 (1982): 733-36. Print.

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