I was once general practitioner-cum-neurologist to members of a famous string quartet. They taught me many things. For example, ‘If you listen carefully to a live performance, why is the music sweeter in the second half of a concert?’ I ignorantly suggested that perhaps the musicians were now more relaxed or had adjusted their instruments according to the concert hall acoustics? No, I was firmly corrected. It was because they always insisted that their fees should be paid during the interval. I was told that when musicians are on the international circuit, in certain foreign parts it was not unknown for the local impresario to disappear with the box-office takings. ‘A Stradivarius fiddle always sounds sweeter when it rests on your wages!’

I was also taught an unusual and subtle test of incoordination. When professional musicians listen to the opening of a string performance, they listen for the sound produced by long slow bow movements. When the bow is furthest from the bridge, they are not surprised to hear unwritten vibrato. It indicates that the soloist is tense—not jaded or bored having just flown in from an overseas concert playing the same music. Professionals call this tremor ‘the pearlies’. It soon clears as the musician becomes absorbed in the music.

The second violinist developed the ‘pearlies’, which worsened the longer he played. The intimacy between quartet players is of course intense. I was informed that ‘a single soloist can get away with murder, a member of an orchestra can doze off unnoticed but there is no mercy for poor musicianship in a classical quartet’, particularly when the audience usually knows the music well. The ‘pearlies’, initially unnoticed by the critics, began to irritate all four musicians. Eventually, he had to drop out. Concerts were cancelled and his colleagues were obliged to play as a trio. He had no other symptoms. As he deteriorated, he consulted senior experienced consultant neurologists in many capital cities. At rest, examination was normal. The investigations available at that time—before scans both isotope and magnetic resonance—were normal. Reluctantly, the quartet accepted the ‘psychogenic’ diagnosis and the need for psychotherapy. He had been a refugee and his early life had been turbulent. He told me that, despite no objection to talking about himself for hours to another, he was not enthusiastic about paying for the service.

After many months of understandable depression, he developed early morning headaches. When he reported this to his therapist, including his discovery that he could often relieve the pain by dropping to his knees and placing his forehead on the ground, this bizarre posture was sadly misconstrued. He finally developed unequivocal papilloedema. Later, a benign colloid cyst was removed from the fourth ventricle—usually it occurs in the third—and he made a complete recovery. Indeed, he was judged to be playing better and with greater intensity and passion than ever.

‘Why not?’ said the patient. ‘My career was in shatters. I thought I was going to die. I came through the valley of death and now I am fully restored to life’.

For the clinician, the old aphorism still applies, ‘Listen to the patient carefully. He is telling you the diagnosis’, even if you cannot immediately understand his language.