Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education

                                         
Journal of Mind, Brain and Education Volume 8, Issue 1 March 2014, pp. 3-5.                                                             

Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education

Vincent P. de Luise MD, FACS  (1,2)
Corresponding author: 1. Harvard University 2. Yale University School of Medicine

ABSTRACT

The medical profession has for almost a century employed various types of “Rounds” as pedagogical tools to engage physicians, physicians-in-training, and their health care teams, in the clinical diagnosis and treatment of patients. This validated paradigm of medical rounds (MR) has recently been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain. There are four distinct types of MR which can be further analyzed to find commonalities and parallels with the domain of education. The four types of MR are (1) Morning Rounds, (2) Chart Rounds, (3) Grand Rounds, and (4) Ongoing Collaborations—each have unique pedagogical characteristics and serve different functions. They are, however, unified by common threads of dynamic and interpersonal interactions wherein teacher (physician) and learner (physician-in-training) share leathe now outmoded theory of the “empty vessel” and corroborate the concerning and fluidly exchange roles in the pedagogy. MR models supplant pt of the teaching brain. A formal analysis of MR underscores its ongoing utility in education both for its pedagogical innovations and for the Interactive and inherently human attributes that are required between teacher and learner for its efficacy.

Introduction

        Docendo discimus (“By teaching, we learn”)   Seneca (4 BCE-65 CE)

For almost a century, the medical profession has employed various types of “rounds” as pedagogical tools to engage physicians and physicians-in-training in the diagnosis and treatment of patients, and in the learning and teaching of medicine and surgery. The older, static notion of the physician “doctor” (Lat. doceo, docere = “to teach”) as teacher and the physician-in-training as the “empty-vessel” learner has been supplanted by Dynamic Systems Theory (DST) (complexity) models extended to education and brain development and the synchrony and synergy between teacher and learner and the teaching brain (Rodriguez, 2012). It has been discovered that, as a function of the interrelationship between teaching and learning, the development of the teaching brain occurs in spurts, with each cluster of spurts producing a new level of skill and understanding (Fischer et  al., 2007), a development that also occurs in medical rounds (MR). In recent years, the validated paradigm of MR has been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain (City, Elmore, Fiarman, & Teitel, 2009). Are there deeper insights that can be gleaned from an analysis of MR that can be extended to education? Are there parallels between the two disciplines that are foundational and that exemplify aspects of the teaching brain? Is it even possible to tease out those aspects of MR that are distinct from education, when MR is itself, in its essence, a consummate pedagogical exercise?
Answering these questions requires an analysis of the four types and functions of ME which can be translatable to education. Each of these types of MR represents a unique opportunity for teaching and learning, and provides insights into the teaching brain.

Morning Rounds (“Walking” Rounds)
Morning Rounds, the archetypal MR, are the daily episodes of teaching and learning that occur in virtually all hospital settings. An attending physician or hospitalist (hospitalists are physicians specialized in hospital-based medical care)—a more experienced physician or surgeon who has the ultimate medical responsibility for the team's patients—is accompanied by a group of physicians-in-training which includes interns (Post Graduate Year 1, PGY 1), residents (PGY 2–4), and medical students. Morning rounds is a community effort: it also includes nurses, social workers, pharmacists, and quality improvement specialists, all of whom play an ever-increasing role in patient care and resource utilization (Cooper & Elnicki, 2011).

The team “walks” the floor of the medical unit, surgical unit, or specific area of the patients for which they are responsible. The team goes to the bedside of each patient on that team's watch, where each patient represents a “classroom episode” of teaching and learning pedagogy. One of the physicians-in-training, usually the intern or resident, presents to the team that patient's history, laboratory testing and diagnostic imaging results, as well as a differential diagnosis of possible disease entities that could explain the patient's illness and reason for admission. At one time, these presentations had to be delivered from memory, to underscore to the physician-in-training that they had to have complete mastery of knowledge and understanding of the patient's condition before they could opine a treatment strategy. A discussion then ensues, often in the presence of the patient and in the form of a dialectic using the Socratic method, of the most likely diagnoses and best treatment options. If there are pertinent physical findings (e.g., a mass lesion, a heart murmur, a skin rash), the attending physician will identify and discuss them, ask permission of the patient to examine them, and then lead the physicians-in-training in the physical exam by palpation or auscultation of those physical findings as appropriate. This experiential, heuristic model of pedagogy inures not only to informing the physicians-in-training, but continually shapes and transforms the teacher's mind in response to the dialectic.

Within the Morning Rounds model, there are not only distinct differences between teacher and learner, but also, as a result of the fluidity of the dialectic at any given moment, the teacher may become the learner and the learner a teacher. As the attending physician teaches an aspect of the patient's condition, or describes a particular clinical sign or finding, the physicians-in-training also participate in the pedagogy by asking deeper questions about those findings. This fluidity has parallels to the concept of synchrony in the DST model of the teaching brain (Rodriguez, 2012). A recent study has found that physicians-in-training (medical students in this particular study) actually learn differently, depending upon who is doing the teaching. At times, medical students acquire and understand a topic more fully if the intern or resident is doing the teaching than if the attending physician is doing so (Bodnar, Fowler, & Saint, 2013).

The syllogism that the physician-in-training represents the student, that the attending physician/hospitalist is the teacher, and that the patient is the object of the “teachable moment”—comparable in the educational setting to a classroom learning experience such as a book chapter reading or a science experiment—is far too simplistic. The pedagogical episodes in Morning Rounds are both top-down and bottom-up, as the data that are initially presented to the team by the physicians-in-training are then evaluated and modified not only by the attending physician, but by the whole team. Thus, the dialectic in MR is not just dyadic but rather remarkably fluid; observations and inquiries by the physicians-in-training, and the changes in laboratory test and imaging results over the course of the patient's hospital stay, modify the original diagnostic hypothesis and, as a direct consequence, alter suppositions about therapy.

Afternoon Rounds (“Chart” Rounds)

This episode of learning/teaching usually occurs at the nurses' station, or in a private room or a quiet area, away from patients. In these episodes of learning/teaching, the attending physician, hospitalist, or resident usually leads a discussion of each patient's lab test results and imaging results obtained during the day (i.e., since the end of the Morning Rounds). The “on-call” intern and/or resident are present to ensure that they understand each patient's diagnosis and current status for their responsibilities on the evening shift, as the other physicians go off-duty.

“Grand” Rounds

Grand Rounds are a form of top-down pedagogy which almost invariably take place in an auditorium venue, away from the patient bedside. The venue is physically located in the teaching hospital itself, or at the medical school with which the teaching hospital is affiliated. With the dramatic changes in health care delivery that have occurred, the auditorium maybe at a distance from the teaching hospital. Tele-videoconferencing allows members of the patient care team associated with that Grand Rounds case to be present in real-time, even if physically distant from the teaching hospital at the time of the presentation, as well as allowing physicians and physicians-in-training from satellite locations to participate.

In Grand Rounds, the pedagogy is usually delivered by a physician from a podium to a receptive audience of physicians and physicians-in-training, one of the latter of whom begins by presenting a patient case. Following the presentation, a physician expert in that patient's illness, discusses the case, bringing in relevant peer-reviewed data and literature. There is then an open forum of questions, answers, and alternative opinions exchanged between the physician expert and the physicians and physician-in-training in the audience, providing another example of the fluidity of MR pedagogy.

Technology now allows the archiving of Grand Rounds presentations, which then make these pedagogical episodes available as online videos. These can be viewed by physicians and physicians-in-training at a later date, enabling them to improve their knowledge and patient care, while accreting to one of the core ideals of the Hippocratic Oath: Medical education should be transparent and open, and physicians should actively share their knowledge without compensation in order to improve patient care (http://classics.mit.edu/Hippocrates/hippooath.html).

Ongoing Collaboration

Ongoing collaborations between physicians and basic science researchers are a separate yet crucial aspect of the teaching hospital–medical school model. These daily, ongoing teaching/learning episodes are harder to quantify, but which could be classified as a form of rounds. In these episodes of pedagogy, often taking place within the cafeteria or lounge of a teaching hospital, physicians and researchers tackle ongoing scientific challenges. These informal “chat” sessions have become essential as incubators for the cross-fertilization and transfer of ideas, so much so that a number of medical schools have purposely built common spaces easily accessible to both researchers and physicians to convene and discuss topics of mutual interest and inquiry. A result of these interactions and chats is often the birthing of a scientific breakthrough.

While these four identifiable types of MR are distinguishable based on either geographic or temporal grounds, the overarching aspect that unites them is that each is characterized by both dyadic as well as more complex and fluid interactions between teacher and learner. These are the synchronous, synergistic, and mutually beneficial relationships within the process of MR that inform the teacher as much as they impart knowledge to the learner.

Educators in general tend to have autonomous ideas about educating. In the domain of medicine, there are numerous disparate teaching styles in different pedagogical venues, the top-down lecture format of Grand Rounds being a prominent example. However, these individual styles of pedagogy are all subsumed in the context and structure of MR.

Teaching systems can be stratified into those capable responses: instinctual, higher-order student-centered teaching, or using more complex teaching brain teaching. At this most complex level, exemplified by the various types of MR, the teacher and student engage in a synchronistic teaching flow that achieves an optimal teaching and learning experience (Kent, 2013; Rodriguez, 2013). MR activities are inherently synchronistic and demonstrate teaching flow in the dynamic and complex interchange of teacher as teacher/student and student as student/teacher (Rodriguez, 2012, 2013).

The teaching brain is not subordinate to the learning brain; rather, the two are in a dynamic cycle of synergy and synchrony with each other (Rodriguez, 2012). The ultimate measure of effective teaching is not to assess whether an individual has learned a specific piece of knowledge, but rather to evaluate whether the learner and teacher come closer together in thought and skill, that they should flow together successfully within each other's context (Rodriguez, 2013). MR are pedagogical episodes that exemplify this point. MR maintain physicians, physicians-in-training, and researchers in a constantly engaged and challenged environment, continually pushing them to refine their understanding of their patients' condition by being informed by the most recent medical knowledge that supports their diagnosis and care. In an increasingly technological world, with laptops and PDAs at once essential to education (as learning tools, not as teachers) but also serving as further barriers to direct human contact, MR remain the most human and enduring of pedagogical activities. At the core of all of these dynamic pedagogical episodes is the observation that MR hinge upon, indeed require, face-to-face interactions between physicians, physicians-in-training, researchers, and their teams, and conversely, without these critical human interactions, that would be little if any pedagogy (Yano, 2013) and suboptimal patient care.

MR are not just about learning; they are also very much about teaching and about the synergies and effective outcomes that result. Educators need to employ many of the strategies found in MR to enhance their own ability to diagnose the problems that occur in their areas of responsibility and expertise, and in a collaborative fashion find the most effective solutions. These teachable moments and learnable moments need to become as essential in education as they have been in medicine.

REFERENCES

• Bodnar, T. W., Fowler, K. E., & Saint, S. (2013). Does the structure of inpatient rounds affect medical student education? International Journal of Medical Education, 4, 96–100.
• City, E., Elmore, R. F., Fiarman, S. E., & Teitel, L. (2009). Instructional rounds in education. Cambridge, MA: Harvard Education Press.
• Cooper, D. M., & Elnicki, D. M. (2011). Resource utilization patterns of third-year medical students. The Clinical Teacher, 8, 43–47.
• Fischer, K. W., Daniel, D. B., Immordino-Yang, M. H., Stern, E., Battro, A., & Koizumi, H. (2007). Why Mind, Brain, and Education? Why now? Mind, Brain, and Education, 1, 1–2.
• Kent, A. (2013). Synchronization as a classroom dynamic. Mind, Brain and Education, 7, 13–18.
• Rodriguez, V. (2012). The teaching brain and the end of the empty vessel. Mind, Brain, and Education, 6, 177–185.
• Rodriguez, V. (2013). The human nervous system as a framework for teaching and the teaching brain. Mind, Brain, and Education, 7, 2–12.
• The Hippocratic Oath. (2009) Retrieved from http://classics.mit.edu/Hippocrates/hippooath.html
• Yano, K. (2013). The science and human interaction of teaching. Mind, Brain, and Education, 7, 19–29.

A Mozartean and Proustian Madeleine: Vienna Nocturne

A Mozartean and Proustian Madeleine

Vienna Nocturne by Vivien Shotwell
A Story of Wolfgang Mozart and Nancy (Anna Selina) Storace
The Mark Twain House, Hartford, CT  May 8, 2014
A Review - Vincent de Luise MD

“Anna had seen many virtuosi play. Wolfgang Mozart surpassed them all. He exhaled, and so many breathing notes unfurled from his unhesitating hands. He played as she had always wished to sing—how she imagined she might sing if she were not so excitable and striving, but selfless and assured, bound to music alone.“-                                                
an excerpt from the novel, Vienna Nocturne, by Vivien Shotwell

I had the privilege and pleasure this evening of attending author and mezzo-soprano Vivien Shotwell's beguiling lecture and mini-recital at the historic Mark Twain House and Museum in Hartford. The evening featured Ms. Shotwell and her first novel, Vienna Nocturne, an elegant portrayal of life in Vienna in a time gone by, and of the relationship between Wolfgang Mozart and Anna Selina (Nancy Storace).
Ms. Shotwell's writing of Vienna Nocturne was catalyzed by her hearing Mozart's gorgeous concert aria, Ch'io mi scordi di te...non temer amato ben (KV 505), a love song which Mozart wrote for Ms. Storace, upon her departure from Vienna in 1787.

Ms. Shotwell spoke this evening with The Mark Twain House's director of communication Craig Hotchkiss about her childhood loving vocal music and opera, that Die Zauberflote was the first opera she saw , that she was drawn to a career as a vocalist while at Williams College under the mentorship there of bass-baritone Keith Kibler where she first sang Ch'io mi scordi di te, about her studies  at the famed Iowa Writer's Workshop where she received  her MFA, and about her time at Yale School of Music where she received her Masters in Vocal Performance under the legendary Doris Yarick-Cross.  Ms. Shotwell is also a 2009 Regional Finalist of the Metropolitan Opera National Council Auditions.
Ms. Shotwell has woven a lovely and elegiac story about life in the Vienna of the 1780s, about Nancy Storace and her initial struggles in London, Napoli and Venezia building a career as an operatic vocalist, and then of her being called to Vienna to sing, where at the age 21,she first meets the then 30-year old Mozart in 1786.
Both Storace and Mozart were prodigies as children, were both married to others at the time of their meeting in Vienna, and who then developed a very special friendship. 
The basic facts of the novel are true (but there is no evidence that Mozart and Nancy ever had an affair during their time together).  Nonetheless, a special kinetic energy existed between them.  Composers often conjure and create their genius Art when inspired by another artist, a Muse, if you will. I am thinking of Anton Stadler inspiring Mozart's foundational clarinet works, and Richard Muhlfeld doing the same for Brahms at the end of his life with his trinity of clarinet pieces.
Vienna Nocturne is an engaging and lyrical story, which Ms. Shotwell spins in "prose as spirited, timeless and touching as Mozart's greatest compositions" (per the book's liner notes).
A fascinating aspect of Ms. Shotwell's talk this evening was how her book, which has now been translated into ten languages, has been re-titled in each country's market !
Here in the US, it is entitled Vienna Nocturne. In Italy, it has been retitled L'amante di Mozart ("Mozart's lover"), in Germany the book is called Die Schule der Liebenden -("The School for Lovers" (taken evidently from the subtitle of Cosi - La scuola degli amanti), in Hungary, it is entitled Mozart's Muse, and in Turkey, one finds the book as  Vienna Waltz, (which is odd because the waltz hadn't really been invented yet).
 Actually, Ms. Shotwell wanted to entitle her book, Amato ben  ( My Beloved  - a title which I personally love, as it derives from two words from the second part of Ch'io mi scordi di te... non temer amato ben.) Her title was rejected in favor of Vienna Nocturne.
Ms. Shotwell, a tall and willowy mezzo, began the evening before her interview by warming up with the Habanera from Carmen, and then sang the ineffable lied Abendempfindung an Laura, KV 523 in a setting for mezzo soprano, sensitively accompanied by Kyle Swann of the Yale School of Music piano faculty.
Before Ms. Shotwell sang Abendempfindung, she told us of the tripartite nature of this sublime lied of Mozart, which talks about special friendships and the evanescence and impermanence of life, and what happens to friendships after one passes on. 
She mentioned Arleen Auger during the talk, and so here is the wondrous Ms. Auger in an indelible performance of Abendempfindung:
http://www.youtube.com/watch?v=sY3QktRielY
It was a delightful evening of Mozart, whose story and music is, for me, always a Proustian madeleine, opening up memories of the lives that I have led before, and the lives that I have yet to lead.
Ars longa,
Vincent de Luise M.D.
@ Vincent P. de Luise MD 2014
 
(The images below are of the Mark Twain House, the wonderful setting for the interview; Ms. Shotwell engagingly explaining her artistic arc and trajectory; Ms. Shotwell and myself right before the book signing; and two of the book covers of the novel. She signed my copy of her book - "Dear Vincent. So great to meet a Mozart expert -Thank you so much for your warmth and joy ! "   To which I would add, "Thank you, Ms. Shotwell, for giving us such a lovingly written reverie and timeless story about Mozart and his Muse."
An die Musik!
Vincent de Luise
@ Vincent P. de Luise MD 2014

The Eyes of Bach and Handel

This essay was originally written for the  internet website, Only Opera  (www.onlyopera.com)

George Frideric Handel and Johann Sebastian Bach were two towering figures of the Baroque. Coincidently, they shared the same birth year, 1685, were both born in Germany, and only a month apart. Handel’s Messiah is an operatic oratorio, like his operas Giulio Cesare, Rodelinda and Alcina. Johann Sebastian Bach’s b minor Mass is a grand and operatic work of depth, breadth, texture and complexity. But something else united these two Baroque masters. That other bond between these two musical giants was that they both suffered visual loss at the end of their lives, possibly cataracts, and both may have had eye surgery by the same charlatan surgeon who went by the name, The Chevalier John Taylor.

It is the following excerpt from the autobiography of the Chevalier John Taylor that has catalyzed this essay on Bach and Handel and their failing eyesight:

“I have, at Leipsick (Leipzig), seen a celebrated master of music, who had already arrived to his 88^th year, and who received his sight by my hands; it is with this very man that the famous Handel was first educated, and with whom I once thought to have had the same success, having all circumstances in his favour, motions of the pupil, and light, &c, but upon drawing the curtain, we found the bottom defective, from a paralytic disorder.” (ref.1)

The “celebrated master of music” was, of course, Johann Sebastian Bach, who was likely 65 and not "in his 88th" year when Taylor met the composer. Handel was not educated by Bach. The two likely never met, although Bach tried several times, was very fond of Handel’s music, and copied some of it out. Taylor did treat Bach, but it is not as clear whether Taylor operated on Handel, although the last clause in the excerpt above makes this writer think that Taylor may have treated Handel, as we shall see.                                                 

                                                 *****

The Chevalier John Taylor was born in 1703, the son of a surgeon of the same name. He studied at St Thomas’ Hospital under Professor William Cheselden.  Taylor decided to specialize in eye diseases, and soon thereafter proclaimed himself an “ophthalmiater” (a neologism that Taylor  himself coined, to mean  an “eye physician”). He became the self-proclaimed oculist (ophthalmologist) to King George II and the pope. His motto was "in optics, expertissimus!"

The Chevalier John Taylor (1703-1772)

Taylor was an itinerant surgeon, and for the most part, despite his medical training, a charlatan.  He coined the expression, “Qui visum visam dat” or “He who gives sight, gives life.” He jumbled this correctly written Latin motto into a grammatically garbled, “qui dat videre dat vivere,” and put the quote on the canvas side of his horse-drawn wagon, which was everywhere adorned  with painted eyes, and from which he would bring out the nostrums and elixirs of his charlatan trade and feign to cure the visually impaired.  

Taylor would go from town to town, treating the blind, and if he diagnosed that they had cataracts (a clouding of the crystalline lens with age), he would “couch” the cataracts from patients so afflicted. Then, he would skip town before the almost inevitable consequences of eye surgery at the time (bleeding and infection) came to pass. According to scholarship by Professor Richard Zegers of the University of Amsterdam, the Chevalier Taylor once confessed that when he started practicing in Switzerland after medical school, he “blinded hundreds of patients.” (ref.2) 
Cataract surgery in the 18^th century was not the remarkable, world-wide success story that it is today. With incisions smaller than an eighth of an inch, modern-day cataract surgery is a triumph. Cataracts are removed by ultrasonically emulsifying them.  Through the same minute incision, a foldable plastic lens implant is unfolded in the eye to restore and improve eyesight. Cataract surgery is the most commonly performed of all surgeries and, using benefit-risk and outcome metrics, the most successful.

In Taylor’s era, however, there did not exist the finely detailed technology we have now. Back then, oculists waited for cataracts to become mature, or “ripe,” then went inside the eye (without anesthesia!), and, using a small, sharp hook or lance, pushed or depressed (“couched” ) the cataract into the the fluid in the back of the eye called the vitreous humour, and ideally, though not always, out of the pupillary axis, thus allowing light to re-enter. This was now unfocused light which got into the back of the eye and the retina. Thus, the patient still needed glasses (those strong, thick, “coke bottle” glasses) to restore some form of clear vision.

Johann Sebastian Bach (1685-1750)

Johann Sebastian Bach was born in Leipzig in 1685. He became a renowned composer of church and organ music, cantatas and concertos, composing over 1100 works. Apparently, Bach's only infirmity was his vision. 
Bach was said to have had “naturally bad vision… weakened by a lot of study.” (ref.2)
If Bach were nearsighted (myopic), which is likely, it was not very severe, as he was able to sit at the organ for extended periods of time over the course of years and read music without glasses. He also had very narrow eyelids, which has been noted in much of the vetted portraiture (see above).

Because of his failing eyesight, likely due to cataracts, Bach was introduced to the Chevalier John Taylor, who, in 1750, performed two operations on the composer. Bach may have experienced some improvement after the first operation, but it is evident from the newspaper articles of the day, which still exist, that after the second operation (and it is not clear if one or both eyes were operated upon in the second intervention), he became “completely” and bilaterally blind. The adverb “completely” is subject to interpretation, and “complete blindness" to a layperson is not the same thing as “complete” or "total" blindness is to an ophthalmologist. To an ophthalmologist, that would be no light perception.

A few days after the surgery, Bach was not only unable to see, but he became quite ill. He developed what was described as a hitziges Fieber ( a non-specififc term which translates as a “burning fever”). He lingered on for a few months and died on July 28, 1750 at 6:15 PM, at age 66. (ref. 2)

It has been postulated that Bach developed either an eye infection from the surgery, or an increase in intraocular (eye) pressure, and  a subsequent stroke. 
It is not clear that the eye surgery was directly causal to Bach’s demise. As Professor Zegers posits, Bach lived about four months after the eye operation, and an endophthalmitis (an infection of the inner tissues of the eye), if it had gone into the central nervous system to cause a septic meningitis, would not have taken four months to cause a fatal infection, but would have occurred much sooner. (ref.2)

                                               

Georg Frideric Handel (1685-1759)

Georg Frideric Handel was born in Halle, Germany in 1685. After a wondrous tour of Italy between 1705 and 1709, where he became informed by Italian operatic style, he thereafter settled in England, where he continued his employ under George I, who had preceded him to the island kingdom a few years earlier.

In 1751, at the age of 66, and after four decades of extraordinary success in opera and oratorio, Handel began noticing changes in his eyesight. There is no direct documentation that Handel was seen or cared for by the Chevalier John Taylor, apart from Taylor’s own writings (see above). 

It is difficult to know exactly what specific disorder may have caused Handel’s visual loss. Some scholars insist that Handel had cataracts, because there is evidence that he had these putative cataracts “couched” lanced, pushing them out of the central pupillary axis). 
According to the Chevalier Taylor, he performed these procedures on Handel on several occasions. If this is the case, then Handel’s medical history mimicked J.S. Bach’s. Fortunately for Handel, despite unsuccessful surgery to both eyes, he lived a few more years after the operations.

A closer reading of Handel’s personal correspondence makes it clear, however, that the visual loss he sustained was not only initially monocular, but binocular, and his loss of sight in each eye consecutively, was abrupt.

The rapid loss of sight implied in the correspondence implies that Handel may not have suffered from cataracts, since cataracts do not cause sudden visual loss. Therefore, despite the bombastic pronouncements and rodomontade by the Chevalier Taylor that Handel had "cataracts," it is more likely that he sustained a sudden loss of blood, or “stroke”, to the ophthalmic artery of each eye, from an entity called anterior ischemic optic neuropathy (AION).
In closely reading the excerpt from the Chevalier Taylor's diaries, that last clause gives a clue, ".....but upon drawing the curtain, we found the bottom defective, from a paralytic disorder."
"Upon drawing the curtain" is a metaphor to imply that, "upon removing the cataract" (if it existed), Taylor evidently did find that the "bottom" (or "fundus" the back of the eye, where the retina and optic nerve are) was defective,  "from a paralytic disorder." This could have meant the consequences of sudden blood loss or "stroke."
In those days, the concept of  a stroke to a target tissue or organ was not as clearly understood, although the brilliant English physician William Harvey had made great discoveries in that regard a century earlier, in his monumental Du Motu Cordis (On the Motion of the Heart) of 1628.

A sudden loss of blood ("stroke") of the ophthalmic artery, the major blood vessel serving the front or anterior part or head of the optic nerve, causes the tissue in that crucial location  to die (infarct) from lack of blood flow. AION can be associated with other systemic illnesses such as rheumatoid arthritis, and present with headaches, myalgias, arthralgias and anorexia.  Handel's age of 66 years at that time is consistent with case studies of AION, whereas it would be a bit young for someone to have significant visual loss from cataracts. 

It is also of note that AION is more common in those with Scandinavian or German heritage. Handel, born in Germany, fit this demographic risk factor as well. On August 5, 1752, The General Advertiser of London reported: “We hear that George-Frederick Handel, Esq., the celebrated Composer of Musick, was seized a few Days ago with a Paralytick Disorder of the Head, which has deprived him of Sight."

 Statue and Memorial of G.F. Handel  with

"I know my Redeemer Liveth" from Messiah

           by Louis Francois Roubilia         

   Westminister Abbey  unveiled in 1762)

After he lost his vision, Handel's general health inexorably declined through the last eight years of his life. He became more religious, more introspective, and retreated into a cocoon of solitude and silence. Although he still played the organ and acceded to conduct the occasional Messiah, Handel's overall compositional style changed. He went on to complete the oratorio Jephtha in 1752, but that was to be his last work in the genre.  Handel's days as a composer of opera were long past as well; his last opera, Deidamia, premiered in 1741. He died on April 14, 1759, at the age of 74, a justly famous and widely admired cultural icon, having never married. He was buried in Westminster Abbey. He left his estate to his niece, Johanna, and also, as per four separate codicils, to his friends, his servants and several charities.

Posterity has been a most grateful beneficiary of the works of both J.S. Bach and "Mr. Handel." Their rich musical creations are a trove extraordinary in quantity and quality. Despite their visual impairment, Bach and Handel retained a wondrous auditory capacity, through which they conjured and created a sublime musical legacy.

©2014 Vincent P. de Luise MD FACS

1. D.M. Jackson. Bach, Handel and the Chevalier John Taylor, Medical History, 12: 385-393, 1968.

2. R. Zegers, The Eyes of Johann Sebastian Bach, Archives of Ophthalmology, 123: 1427-1430, 2005.

         

A Promise Broken? Weaving the threads of Mozart's C Minor Mass

Wolfgang Mozart  Portrait by his brother-in-law, Joseph Lange

By the end of the 1770s, Wolfgang Mozart (1756 – 1791) had become increasingly restless at being in the cultural purgatory that was Salzburg at the time. He had weathered several contretemps about his employment there under the imperious Archbishop Heironymus Colloredo, and after a celebrated argument and a figurative and literal “kick in the pants,” moved permanently to Vienna in June, 1781. 

As one of the first freelance musicians, Mozart frequently sought a reason to compose, whether it was for a commission, a public performance, or an “Akademie” (a subscription concert). 

While in Salzburg, Mozart had written numerous compositions for the Catholic Church at the request of the Archbishop, but these were mostly formulaic pieces, static in nature. This was as a result of a decree by Emperor Joseph II to "simplify" (read, shorten) the Mass.  Mozart’s efforts in the genre of church music were thus to that point largely simple, brief, muted motets, and missae breves, written for shorter services that were curated to be more “approachable” for parishioners.  

Once out of the employ of the Archbishop, Mozart was freed from any further obligations to write masses.  Yet, in the summer of 1782, for no apparent reason, Mozart started to compose a large setting for a full Mass. A devout Catholic, Mozart had not yet been introduced to masonry, so he was likely still thinking about religious topics as compositions, although never with the same zeal and passion that he felt about opera or concertos. 

On August 4 of that year, and before having even received his own father Leopold’s blessing, Mozart married Constanze Weber, one of the four musically talented daughters of a Mannheim family then living in Vienna. Leopold did not think the Weber family was aristocratic enough, and felt that a spouse would be a ‘distraction” from his son’s composing.

 

On January 4, 1783, Mozart wrote to his father, promising to compose for him a Mass if he would be allowed to bring his new bride to Salzburg. Mozart wrote that he had begun work on a new Mass which he would perform there, and stated that “as proof that I really made the promise…. the score of half a Mass for which I still have high hopes…. lays half-finished on my desk.”

While this composition may have been yet one more filial obligation by Mozart (as well as a peace offering) to his demanding father, it may also have been a gift of praise for the convalescence of Constanze, who by September, 1782, was pregnant with their first child, and herself quite ill. 

Yet, despite Mozart’s promise to his father of a complete work, that never occurred. The “promise kept” to his father resulted in the wondrous fragment which we will hear this afternoon: the “Great” Mass in C minor (The Mass K.V. 427).
 
Mozart worked episodically on the Mass for over a year, yet it was far from completed when it was first performed on October 26, 1783, in Salzburg’s St. Peter’s Abbey, a monastery found in 683 C.E., which was celebrating its 1100th anniversary. 

What has come down to us of this work in Mozart’s hand is a Kyrie and a Gloria, and a Credo which breaks off after the et Incarnatus est.  Mozart only sketched parts of the Sanctus and Benedictus, but he did not put pen to paper for the Agnus Dei.

Mozart's autograph of the Kyrie of the C Minor Mass

      Mozart's autograph of the Kyrie of the C Minor Mass

The form of composition of this Mass is a cantata mass of Baroque tradition, in which the Latin text of the liturgy of the Mass is laid out in pieces as a series of separate movements, rather than “through-composed” (music with the liturgical text sung without interruption). It is surmised that Mozart may have interpolated movements from some of his previously composed masses to provide a full setting for this Mass, or that those missing movements were sung as Gregorian plainchant. 

Musicologists have been quick to criticize the Mass as lacking in stylistic cohesion and unity. There are several reasons to support this observation, the most compelling of which was an event of momentous importance that occurred soon after Mozart moved to Vienna: his introduction to the Baron Gottfried van Swieten. 

A wealthy diplomat and government official, van Swieten was also a talented amateur musician, a close friend of C.P.E. Bach and Joseph Haydn, and a passionate admirer of the works of J.S. Bach and Handel. Indeed, van Swieten owned copies of Bach’s b minor Mass and Handel’s Messiah. Mozart quickly became fascinated, and then obsessed,  with the music of these Baroque masters, and began transcribing their works, adding his own ideas in fugue and counterpoint style from their templates. It was as if Mozart had entered a time-warp and began composing in the Baroque vernacular of the early eighteenth century.

Yet, Mozart had for a long time also been drawn to the theater and opera, and it appears that after a few months of wrestling with this “crisis of fugue and counterpoint” he turned back to his true passion, which was to push the boundaries and constraints of Classical Style to their ultimate reaches in the service of his operatic and concerto compositions.

As a result of this conflict, a number of different musical genres figure in the Mass. The two outer movements contain contrapuntal choral fugues in the style of J.S. Bach, there is a Handelian double chorus in the Credo and another reminiscent of Bach in the Domine. Mozart returned to echo Handel in the double dotted figures which abound in the Qui Tollis. The Quoniam, a trio for the two sopranos and tenor, channels Pergolesi. The monumentality of the Mass is also evident in its length, which had he completed it, would have been comparable to Bach’s b minor Mass, and as complex, with choruses in four, five and even at times, in eight parts.

However, Mozart also composed and embedded three full-blown operatic arias in the Mass: the Christe Eleison, where the soprano line dramatically bisects the Kyrie, and two other arias which are in the “Italian style”: the sublime Laudamus te and the otherworldly et incarnatus est. These two arias are so exquisite, refined, and internally complete that they are sometimes performed as stand-alone concert pieces. Both are written for soprano voice, but for sopranos with different Fachs (vocal ranges). 

The Laudamus te has an extraordinarily wide compass, and is usually sung today by either lyric sopranos or mezzos. In contrast, et incarnatus est has a higher tessitura, contains several C6 notes (“high Cs”), and is sung by coloratura sopranos. Mozart always did not distinguish between soprano voice types, and often challenged his singers; indeed there are several tricky octaval leaps and vocal landmines in these splendid solos. 

 Constanze Weber Mozart
Portrait by her brother-in law Joseph Lange

Mozart and Constanze left Salzburg for Vienna the day after the October 26th performance.

Mozart would never again see his birthplace,  and the Mass would not be heard again for over one hundred years.
 
The central mystery of the C Minor Mass remains: why did Mozart never feel the obligation to complete the work? 

In 1785, he took what he had composed of the C Minor Mass, added an aria for soprano and another for tenor, set the music to a different text, and produced the oratorio/cantata, Davidde Penitente (K.V. 469). Apart from the added two arias, the work contains no new material.  

Could Mozart have left the Mass unfinished because, by 1782, he finally made the psychological and physical break from his father, and no longer felt he owed him a completed work? Could Mozart have composed the Mass in joyful celebration of Constanze’s recovery from illness and the birth of their first child, Raimund Leopold in July 1782; and then, with the child’s death two months later, could he have been so disconsolate that he abandoned it? 

Could the Mass have simply been an exercise in Baroque counterpoint and fugue composition, and once Mozart had figured out that genre (as he figured out everything else, though this genre evidently took even Mozart some time), that it started to bore him, his creative juices flowing back to more contemporary and operatic directions ? Given that the Mass was not written as a commission, and was composed at least in part as “payback to dad,” could Mozart not have felt any need at all to finish the work, as there was no money to be earned from this endeavor? We will never know. 

Given its incomplete state, a number of composers have offered reconstructions. These include efforts by Robert Levin, H.C. Robbins-Landon, Richard Maunder, Franz Beyer, and Georg Alois Schmitt, whose 1901 completion resurrected the work from its unwarranted oblivion and is the setting heard this afternoon.

The Schmitt completion provides most of the missing movements, adds a mezzo soprano to the vocal soloists, and provides a duet and a trio. The orchestration is for strings, oboes, bassoons, trumpets, horns and timpani.

With the C Minor Mass, we are left with a fragment and a conundrum, one which will be eternally insoluble. 

Yet, what Mozart has left to us remains an extraordinary composition. Even though it is incomplete, much like Mozart’s opus ultimum, the Requiem in D Minor, the C Minor Mass is a masterpiece. Not only is it on its own merit one of the greatest of mass settings, it is the bridge that connects J.S. Bach’s magisterial B Minor Mass with Beethoven’s indomitable Missa Solemnis, and it is also a bridge between the human, the mystical and the divine.  

Befittingly, the C Minor Mass has been bestowed the surname, “Great,” which honors it in perpetuity as a transcendent summation of the entirety of eighteenth century sacred music, from the hand of music’s greatest genius as he approached the pinnacle of his creative powers. 

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Mozart composed the motet, Ave Verum Corpus (K.V. 618), in June, 1791, for the Feast of Corpus Christi and as a gift to his close friend Anton Stoll, organist and choirmaster of the church in Baden bei Wien. It was only the second piece of sacred music written by Mozart since the C Minor Mass eight years earlier. Its forty-six measures have justifiably been called the "most beautiful piece of music ever written." A work of astonishing simplicity and at once, wondrous profundity, Ave Verum Corpus bestows upon the listener a sublime and enduring message of sacred devotion.



The 1819 posthumour portrait of
Mozart by Barbara Kraft
Gesellschaft der Musikfreunde

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Mozart’s last three and greatest symphonies, the 39th in Eb major, the 40^th in G minor and the 41^st in C major, were all written in the space of a few months, in the summer of 1788, in an astonishing burst of creative genius. The symphony in g minor (K.V. 550) is often called the “Great”, to distinguish  it from the so-called “little” g minor symphony (the 25th); they are the only two of Mozart's forty-one full symphonies in a minor key. The first movement of the 40th symphony begins darkly, and curiously not with an introductory theme. Rather, it starts with the exposition, introduced here by the strings, a strategy Mozart would similarly employ in his last piano concerto, the 27th in Bb, K.V. 595 (and that Mendelssohn later used in his second and greatest violin concerto). Another interesting aspect of thi symphony is that Mozart originally composed it without clarinets, and then revised the score to include two clarinets, undoubtedly as homage to his Masonic friends, Johann and Anton and Johann Stadler, who were the finest clarinetists in Vienna at that time.

                                 Sic Transit Gloria Mundi

©  Vincent P. de Luise M.D.  2014