Maurice Ravel's dementia: the silence of a genius

ABSTRACT Maurice Ravel is one of the most important French musicians. In the last years of his life, Ravel was victim of a dementia of uncertain etiology that caused aphasia, apraxia, agraphia and amusia. The artistic brain of the author of eternal musical compositions was progressively silenced due to his neurodegenerative disease. On the 90 th anniversary of Boléro, this historical note revisits Ravel's case and discusses the relationship of his dementia to his artistic production. It illustrates the intimacy that can exist between art, music, creativity, and neurology.

Palavras-chave: Demência; arte; música: neurologia. In 1932, Ravel was victim of a car accident in Paris and, shortly after, his health clearly deteriorated. Difficulties in writing increased and he was no longer capable of writing his own music. In 1933, he confided to one of his friends: "I will never write my Jeanne d' Arc; this opera is here, in my head, I hear it, but I will never write it. It's over, I can no longer write my music" 2,3 . While on holiday at Saint Jean de Luz, Ravel wanted to show Marie Gaudin how to skim a pebble on the sea but instead he struck her on the face. Due to apraxia, Ravel lost the ability to swim, having to be brought in from the sea by his friends. In the words of the French writer Colette, "he did not try anymore to speak, and yet, sitting between us, he gave the impression of someone who is at risk of disintegrating" 2,3,4 . In November 1933, he made his last public appearance, performing the Boléro.

RAVEL'S DIAGNOSIS
What was the nature of the brain disease that cause Ravel's decline? The exact cause remains speculative as an autopsy was not performed. However, there is consensus on the diagnosis of dementia 3,4,5 . The Brazilian neuropathologist, Walter Edgar Maffei, was an eyewitness to Ravel's deterioration and, during his whole life in Brazil, Maffei confirmed that Ravel had become a demented person. The slow evolution of the condition also suggests a progressive degenerative disease. Interestingly, Ravel's father also presented with a cognitive deterioration in his last years of life, which may raise the question whether Ravel's neurological disease had a hereditary component 1,2 . Among the diagnostic possibilities, Alzheimer's disease is the most common cause of progressive cerebral degeneration and, therefore, it is the most frequent diagnosis of Ravel's disease as well 5 . Nevertheless, the age of onset was earlier than usually seen in Alzheimer's disease, and Ravel did not experience memory or visuospatial troubles. Primary progressive aphasia could be a diagnostic hypothesis although Alajouanine had not characterized Ravel's aphasia as severe. Corticobasal degeneration has already been considered as well, due to Ravel's dysexecutive syndrome, apraxia and aphasia 6 . Nevertheless, asymmetric extrapyramidal symptoms have never been reported to sustain this diagnosis. Recently described, primary age-related tauopathy is another possibility for Ravel's dementia that cannot be ruled out 7 .

RAVEL'S NEUROSURGERY
In 1937, his condition drastically deteriorated so that, in hope of finding a cause for Ravel's problem, doctors recommended neurosurgery. Professor Clovis Vincent, one of the most eminent neurosurgeons in Europe, reluctantly agreed to perform a right-sided craniotomy 8,9 . However, during the procedure Prof. Vincent did not find any evidence of atrophy, tumor or hematoma that could explain Ravel's condition 8,9 . After the surgery, Ravel lapsed into coma and died nine days later, in December, 1937.

THE IMPACT OF DEMENTIA ON MUSIC
Some musicologists believe that Ravel's last works, especially the Boléro, are a symptom of his amusia and reflect the underlying neurological disease. The relentless repetitions of the theme in Boléro have been pointed out as signs of the disease. According to Ravel's own words, Boléro was "sixteen minutes of music without music". Specialists consider Boléro to be a pure form of musical obsession: the monotonal and repetitive pattern of the composition could represent a form of frontal perseveration 1,3,10,11 . Some authors have developed the theory that Ravel's illness would have affected primarily the right hemisphere. Amaducci et al. 10 state that Ravel's last musical compositions demonstrate right hemisphere functional characteristics and suggest a shift of the two sides of the brain in favor of the right as result of the disease. In the Piano Concerto for the Left Hand, the orchestration uses a great amount of timbre and has a particular irregular pulsating style. A plausible explanation for this observation is that, to avoid the difficulty of elaborating on a complex structured theme, Ravel adopted the alternative use of different timbres, which suggests the music originated predominantly in the right hemisphere, as rhythm is associated mainly with the left hemisphere 10,11,12 . Furthermore, Ravel's artistic productions were deeply linked to his childhood memories as one can observe in Ma Mère, l'Enfant et les Sortilèges and in Ballade de la Reine morte d'aimer 2 . It is reasonable to imagine that a dementia could have interfered with his creative process somehow. In July 1937, Ravel admitted the impact of the disease on his creativity: "I still have so much music in my head, I've said nothing, I still have so much to say". Maurice's genius surrendered to his neurological disease and his musical artistic brain was silenced 10,12 .
Ravel's premature disablement represented an immeasurable loss to art and music. However, Maurice Ravel's case is of great interest for the exploration of the Neurology of a demented brain. It illustrates the intimacy that can exist between art, music, creativity, and Neurology.