Failure to Rescue a Virtuoso: The Death of Emanuel Feuermann

The Patient

Annette Morreau, a musicologist, writer, and relative of Feuermann through marriage, interviewed many of their shared relatives and the cellist’s contemporaries for her biography on the great musician, the source for the quotations and facts in this article. ¹

Emanuel Feuerman was born on November 22, 1902, in an impoverished Jewish enclave in Kolomyia, a town in Galicia near the foothills of the Carpathian Mountains. His family was intensely musical. All five children played instruments from a young age, taught by the father, who eked out a living giving lessons from morning to late in the evening.

Two sons had extraordinary talent. The eldest son Sigmund, a prodigy on the violin, performed one of the Mendelssohn violin concertos with a full orchestra when he was just five-and-a-half. Younger brother Emanuel, tagging along on one of his older brother’s lessons, became entranced by a one-half sized cello off to the side of the studio. His father borrowed the instrument, gave his younger son a couple of lessons, and discovered his younger son’s genius. To develop the boys’ gifts the family moved to Vienna for formal instruction by the City of Music’s finest teachers, paid for by wealthy patrons.

It was Emanuel, not his brother, who made the transition from prodigy to mature artist. When the professor of cello at the Cologne Conservatory and principal cellist of the city orchestra unexpectedly died in 1919, Emanuel was named to the position. Some questioned whether it was appropriate for a 16-year-old to occupy the important chair. Conservatory officials responded, “[It] would be misleading even to suggest that there could be a second or third choice. ¹ ”

He was a triumph. In addition to concerts in Cologne in 1920, he pursued a relentless schedule of performances throughout Germany and in Europe in recitals and performances in the most famous venues. With an international reputation, in 1929 Feuermann was appointed professor of cello at the Berlin Akademische Hochschule für Musik, at 27 the youngest professor of music in the country. He was among a handful of international artists that continued to thrive after the Wall Street Crash of 1929 and the worldwide depression that followed.

Yet he could not escape the rise of the Nazis. Through electoral victories in the early 1930s, Hitler and the Nazis seized control of all government institutions, including the Hochschule. In March 1933 all Jews, including Feuermann, were summarily dismissed from the conservatory. Years later a document surfaced that gave the reason for his dismissal: “Feuermann – an ‘intolerable Jew’. ¹ ”

He lost his European bookings. Badly needing work and seeking refuge, Feuermann went on a concert tour that took him around the world. His performances in London, Japan, and Canada were huge successes. In December 1934, he made his American debut with the Chicago Symphony. After the New Year, he made his first appearance at Carnegie Hall with the New York Philharmonic.

The American audiences were enthralled. After one performance he played six encores, including his own arrangement of the Zigeunerweisen, Pablo de Saraste’s showpiece for violin. Critic Oliver Downes outdid the hackneyed comparisons with Casals. “The familiar piece of Sarasate,” he wrote, “provided in itself sufficient provocation for the remark that Mr. Feuermann can play the cello as Heifetz his fiddle. ¹ ”

In June he married Eva Reifenberg, the daughter of his patron in Cologne. Concert tours doubled as a search for a place for them to settle. Waiting out the Nazis in Cologne with Eva’s family, or in Vienna with his own, were out of the question. They briefly settled in Zürich but could not live under the restrictions Swiss authorities imposed on Jewish refugees.

With the income of an international star, he chose freedom in America. His frenetic schedule of concerts, broadcasts, and recordings elevated his profile to the top rank of soloists. For one of his performances of Strauss’s Don Quixote, he received a standing ovation before he performed the piece. In October he was the first soloist to perform in a broadcast of the NBC Symphony Orchestra under Arturo Toscanini, again playing the Don Quixote.

In February 1939, Eva returned to Vienna to be near family for the birth of Monica, their first child. Just one month later, Hitler invaded Austria and entrapped mother and child. It took months of fevered work and all of Feuermann’s international connections to get them out the country.

Now reunited, the young family settled in New Rochelle in a house overlooking Long Island Sound. He used earnings from his concerts and side endorsements to bring both sides of his family, in ones and twos, to safety in the States.

When the country entered the war, he performed in war bond rallies. On May 16, 1942, he took part in a rally in Camden, NJ, playing before an immense American flag as a backdrop.

“America is the last frontier for artists,” he was quoted in the New York Post. “Here, the idea that a musician or composer would be barred because of his racial background would be as ridiculous as it would be for me to destroy my Stradivarius cello because it was made by an Italian. ¹ ”

Camden was Feuermann’s last performance. He trusted his instrument to a friend for safekeeping as he went to the Park East Hospital on East 83rd Street, Manhattan, for surgery.

Present Illness and Past Medical History

Several years previously, he had undergone surgery for a troublesome hernia during his first stay in New York in the winter of 1934-1935. The cellist considered the affliction and the operation to be minor inconveniences. He deferred surgery until he returned home to Germany in late April 1935. He wanted the operation to be done by someone he and his family knew.

The hernia repair was performed in Cologne by a Dr Rosenau. After surgery, Feuermann suffered a serious bout of postoperative ileus that was ascribed as an allergic reaction to anesthesia. Eva later recalled that the complication threatened his life until he was given a nicotine enema, on the basis that he was a heavy smoker. The intervention relieved the ileus and he recovered.

By 1942, he had developed painful hemorrhoids that were severe enough to require surgery. “I wonder how you are,” Eva wrote. “Does it hurt badly ¹ ?” As he had with his hernia, he shrugged off his malady as something not to be overly concerned about. “Oh, it’s nothing at all,” he wrote. “We will resume our work very soon again. ¹ ”

The Surgeon

Feuermann was financially well-off and did not have to worry about surgeons’ fees and expensive hospitals. His life, though, had radically changed. Instead living among the Cologne upper crust with ready access to the German surgical elite, in New York Feuermann and his family were refugees, isolated by their faith and culture from the American mainstream.

So, it probably became more important that his surgeon was someone he and his family knew. He chose his wife’s gynecologist, Siegfried Simon. A refugee living in New Rochelle like Feuermann, he was listed in the 1941-1942 edition of the Medical Directory of New York, New Jersey, and Connecticut as a general practitioner. ¹

Details of Simon’s education and training are lost to history. He received his medical degree in Bonn ¹ and was a product of the esteemed German medical education system of the late nineteenth and early twentieth century, a story chronicled by David Clark of the Maine Medical Center in Portland. ²

When William Halsted organized his residency training program at the Johns Hopkins Hospital in 1889, his model was the Germanic system of assigning young surgeons as assistants to a university clinic for several years until one eventually rose to the position of first assistant to the professor. ³ Abraham Flexner and reformers in medical education admired, in Clark’s words, “the principles of German medical education, including national standards for students and universities, academic freedom, [and] the expectation of postgraduate training. ² ”

There was one aspect of European medical practice that troubled the thousands of young U.S. physicians that flocked overseas for postgraduate medical training. “Visiting physicians and scholars praised German dedication to research, innovation, and teaching,” wrote Clark, “but disliked how European professors treated patients as social inferiors. ² ” Simon may have brought such an attitude of superiority to America, one that may have contributed to ignoring a patient in trouble.

Jewish doctors like Simon and Nissen were restricted from practicing at many of the most highly regarded hospitals in Manhattan. ¹ Simon admitted his patients to Park East Hospital, a secondary facility tucked away in the upper East Side. ⁴

Feuermann did not care. As when he had his hernia, Feuermann shrugged off his condition as trivial. The quality of surgeon and facility did not matter. In Morreau’s words, he “opted for a doctor he knew and disregarded that anything could go wrong. ¹ ”

Hospital Course

In her research for Feuermann’s biography, Morreau could not find the relevant medical records or operative report from Park East. She reconstructed the events of his hospital course from interviews with his wife, Eva, and others who visited the Feuermann home and the hospital. ¹

The operation was on May 16. Suzette Forgues, one of his students, arrived at the Feuermann home for her lesson not knowing that he was hospitalized. She found Eva in tears. Feuerman was on the phone, delirious after his procedure. Forgues could hear him “telling his wife Eva how lovely it was in Switzerland and how he enjoyed his little wild strawberries in the mountains.” “It was very sad,” she said, “because you realized that he was not fully conscious of what he was saying. ¹ ”

Joseph Berberich, an otolaryngologist who had been a professor in Frankfurt before he escaped to the U.S., visited Feuermann in the hospital. He immediately saw his condition was dire. He summoned Rudolf Nissen, former surgeon to the Charité in Berlin with an international reputation who was practicing in New York. Nissen diagnosed paralytic ileus and on May 23 performed a cecostomy as a desperate measure to salvage his patient.

It was too late to save Feuermann’s life. He died on May 25, only nine days after the original operation, at age 39. ¹

Hiding Medical Error

Though he was involved in Feuermann’s care for only the final two days his life, Nissen signed the death certificate and ascribed the cause of death as pneumonia. Absent from Nissen’s death report was Simon’s involvement as surgeon. ¹

Feuermann’s death was confusing because complete recovery was expected after a minor operation for a commonplace condition. Surgical mistakes were often kept secret to preserve the reputations of the facility and those directly involved. Hiding medical misadventures were documented by Henry Ruth in his pioneering surveys of anesthetic deaths in Philadelphia in the latter half of the 1930s and first years of the 1940s. ⁵ Despite agreements of Philadelphia area hospitals to submit summaries of all deaths occurring on the day of surgery or the day after the procedure, Ruth wrote that “fatalities frequently were not reported to us.” There was an ingrained reluctance to divulge information on such cases. “It appeared that some hospitals believed that the group desired to unearth incriminating information, rather than function as an educational venture. ⁵ ”

In their essay on the necessity of full reporting of medical errors, Neil McIntyre, professor of medicine at the Royal Free Hospital School of Medicine in London, and Sir Karl Popper, the noted philosopher of science, wrote on the urge to hide medical mistakes. “An authority is not expected to err,” they wrote. “If he does, his errors tend to be covered up to uphold the idea of authority. ⁶ ” Medical error brings the fear of malpractice litigation. “It is hardly surprising that a doctor should try to conceal his error,” the authors wrote, “or the doctor should close ranks around a colleague when mistakes occur. ⁶ ”

Which is what Nissen did when he concealed Simon’s mismanagement. “Hiding mistakes must be regarded as a deadly sin,” McIntyre and Popper wrote. “Those that commit [medical errors] may not wish to have them brought to light, but equally obviously they should not be concealed since, after discussion and analysis, change in practice may prevent their repetition. ⁶ ”

M&M

Today an M&M conference provides the forum where medical errors are aired. M&M is a durable tool that identifies the causes of medical error and ways to correct them. It arose from Ernest Amory Codman’s (1869-1940) “end-result idea” (1914), where he tried to ascertain the errors that caused each death and complication. In reviewing his own caseload, he set the standard of personal accountability that is today an essential component of medical professionalism. ⁷

A functioning M&M evolved from maternity mortality conferences first convened in the early 1920s by obstetricians in New York and Philadelphia. They reviewed maternal deaths in their respective cities from 1930 to 1932 and found nearly two-thirds of deaths were preventable, most striking of which were the dozens of deaths from sepsis from nontherapeutic abortions. ⁸ Copying the approach to maternal deaths, in 1935 the Philadelphia Medical Society formed an anesthesia mortality commission to study anesthetic deaths from surgical operations. ⁵ Two-thirds of deaths were deemed preventable due to anesthetic mismanagement and lack of resuscitative intervention. ⁹

Jay Orlander, program director of the residency in medicine at Boston University, and his colleagues summarized surgical M&M as observed by Charles Bosk, a sociologist at the University of Pennsylvania, in his landmark sociological study of an academic surgical service, Forgive and Remember. ¹⁰ Bosk saw M&M as the setting where an attending surgeon faced the full department—chair, colleagues, trainees, and students—put on the “hair shirt” and took responsibility for a case that ended in death involved a major complication. In sociological terms, the attending modeled the social norms of “hierarchy of authority, open discourse, face-to-face interaction, and a public forum for the analysis of error and allocation of blame. ¹⁰ ”

Without a presentation at an M&M what happened to Feuermann and the cause of his death were never discovered. Hemorrhoid surgery was not generally thought to be life-threatening, so some speculated that he must have had a more serious condition, like cancer. The records his daughter Monica was able to review did not mention cancer. Feuermann had an active concert and recording schedule planned for after his surgery that belied such a diagnosis. ¹

Berberich speculated that Feuermann’s death was from peritonitis from rectal perforation, ¹ a known complication of hemorrhoid operations from when they were first documented by Jean Louis Petit in 1774. ¹¹ Simon may have dissected too deeply when dissecting the hemorrhoidal plexus beneath the mucosa and injured the muscularis, especially if he tore a varix and panicked trying to control bleeding.

Rectal perforation would cause perineal soft tissue infection if distal to the peritoneal reflection or generalized peritonitis if the free peritoneal cavity was entered. One would expect that Nissen, an experienced surgeon, would have drained infected tissue for the former and done an exploratory laparotomy for the latter.

Instead, he did a cecostomy, evidence that colonic dilatation was part of the overall clinical picture. The diagnosis that fits Feuermann’s complication best is acute colonic pseudo-obstruction (ACPO), ¹² often called Ogilvie’s syndrome after Sir William Heneage Ogilvie, the surgeon who in 1948 first described acute massive dilatation of the large intestine without organic obstruction. ¹³ A rare complication of critical illness and associated with the administration of narcotics, ACPO most often afflicts medically infirm elderly patients after major operations. It has a 15 percent mortality that can be as high as 36 to 44 percent if ischemia or perforation occurs. ¹²

Feuerman did not fit the clinical profile of one likely to develop ACPO. Not yet in middle age at the time of death, he led an active life. Aside from chain smoking he had no other medical conditions. Operations associated with ACPO are generally major orthopedic fixations and extensive burn procedures, not relatively limited operations like hemorrhoidectomies. ¹²

After surgery, he probably was given narcotics to relieve pain and delay return of bowel function to prevent straining and disrupting a ligature or suture line.^14,15 He had already showed a sensitivity to opioids years previously when he supposedly had postoperative ileus after his herniorrhaphy. Then a well-timed enema decompressed his colon, and he recovered.

This time he was not as lucky. The cecostomy was too late to reverse his progressive deterioration. He was likely in multiple organ failure: delirium, manifested as confused speech during his phone call to his wife; and acute respiratory distress syndrome, as pneumonia, the professed cause of death.

Failure to Rescue

Feuermann’s death was a textbook example of failure to rescue, defined as mortality after a major complication after surgery. Failure to rescue is a concept adopted as a quality indicator by the Agency for Healthcare Research and Quality. ¹⁶

In one recent review, nearly two-thirds (63%) of cases of failure to rescue from anesthetic complications were preventable. The most common cause was failure of recognition (eg, delayed recognition of hypotension), followed by failure to monitor (absence of blood pressure monitoring), delay in escalation (failure to call for help), and delay in making a definitive diagnosis (not diagnosing postoperative hemorrhage and returning to the operating room). ¹⁷

In Feuermann’s case, the fundamental failure was not recognizing a grave complication after surgery. His past trouble with his hernia operation predicted he was at risk for a similar complication, paralytic ileus, after his hemorrhoidectomy. Simon ignored his patient’s problematic surgical history and thereby was not alert to what became a repeat episode of a life-threatening reaction to anesthesia and surgery.

Simon did not see that his patient was not recovering as expected. The one who saw that Feuermann was in trouble was a visitor who happened to be a doctor. It was the visitor, not the surgeon, who called for help and escalated care. Nissen, a surgeon not involved in Feuermann’s case, saw that if the patient was to have a chance at recovery the colon had to be decompressed. An earlier intervention, either cecostomy or a simple enema, might have been lifesaving.

In surgery, delays in diagnosis and treatment too often lead to complications and death. For Feuermann, the delay occurred because Simon was not alert to his patient’s vulnerability to postoperative ileus. He had disengaged from his patient’s care after surgery. It was left to other doctors to recognize the gravity of Feuermann’s condition and salvage the situation.

Meaning of Music

Feuermann’s death shattered the musical world. To pianist Artur Rubenstein Feuermann had already supplanted Casals as the world’s greatest cellist. “[Feuermann] became for me the greatest cellist of all time because I did hear Casals at his best,” Rubenstein said, “but [Casals] never reached the musicianship of Emanuel Feuermann. ¹ ”

Violinist Jascha Heifetz was crushed. He had performed with Feuermann on major recordings, notably Brahms’s Double Concerto for Violin and Cello in A minor in 1939 and with Rubenstein, the original “Million Dollar Trio” recordings of 1941. ¹⁸ Feuermann’s passing left him bereft of enthusiasm to play with any other cellist. Morreau quoted Heifetz: “A talent like Feuermann’s comes around once in a hundred years. ¹ ” It would be 7 years before the violinist would perform with another cellist, Gregor Piatigorsky, at Ravenna in 1949.

A who’s who of virtuosos were among the 300 who attended the funeral. Listed among the pallbearers were conductors Eugene Ormandy, George Szell, and Toscanini, pianists Artur Schnabel and Rudolf Serkin, and violinists Mischa Elman and Efrem Zimbalist. At the memorial, Szell spoke on “Feuermann, the World’s Friend.” “The great artist in him, combined with the qualities of a fine human being,” Szell said, “will always make him stand out as one of the unforgettable figures of our lives. ¹ ”

Szell’s comments were inadequate in conveying the void many felt after Feuermann’s passing. Ormandy expressed why the cellist’s colleagues and audiences felt the pain of his loss so deeply. “The solo cello of Feuermann,” said Ormandy, “was something which led me on to what music really means, what it has to say. ¹⁸ ”

Feuermann Recordings

Sasha Margolis’s article has links to two recordings of Feuermann under the “essential historical recordings” feature of Strings magazine ¹⁸ : the Haydn Cello Concerto in D Op. 101 with the London Philharmonic under Sir Malcolm Sargent and the Bloch Schelomo with the Philadelphia Orchestra under Ormandy. YouTube has a video of Feuermann playing Dvorak and Popper (https://www.youtube.com/watch?app=desktop&v=D1NMBh47mGw). Many Feuermann recordings are on Apple Music and Amazon, including the songs listed in present article. Two personal favorites are Schumann’s Kinderszenen Op. 15, No. 7: Traumerei, and Sarasate’s Zigeunerweisen, Op. 20, No. 1.