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Bum notes — ‘cello scrotum’ and other such afflictions

The hedonistic lifestyles of certain musicians will be familiar to many readers, but the unexpected dangers of playing a musical instrument may not.

Aware that I have an interest in musicians’ health, last week a medical colleague alerted my attention on Twitter to an interesting article in the October 2013 edition of Der Hautarzt (German dermatology journal), describing a condition I hadn’t heard before of called ‘fiddler’s neck’.

Fiddler’s neck is a condition where the afflicted violin (or viola) player develops an unsightly mark on the neck — just beneath the angle of the jaw. Although not that well recognised among dermatologists, it is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition (of quite different aetiology) seen in teenagers. The abnormality is due to an area hyperpigmentation and lichenification of the skin due to the rubbing of the instrument on the neck (erythema, scaling, cyst formation, scarring and inflammatory papules or pustules also occur). The article describes the development of a ‘violin hickey’ in (an undoubtedly embarrassed) 72-year-old lady.

Reading about this curious affliction prompted a ‘knight’s move’ wander through the literature on instrument-specific afflictions — and there’s lots to choose from.

Violinists who succumb to violinist’s hickey are also, presumably, susceptible to a condition known as ‘fiddler’s jaw’ (a condition akin to temporomandibular joint disorder, which comes about because of the way the violin is ‘clamped’ between the angle of the jaw and the shoulder), ‘fiddler’s finger’ (Garrod’s pads of the dorsal interphalangeal joints of the left index and middle fingers) and ‘pizzicato paronychia’ (infection in the nail-fold in string players secondary to pizzicato playing). A similar condition can also develop in pianists.

‘Fiddler’s neck’ is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition seen in teenagers

Jazz aficionados will immediately recognise the ballooned-cheeked appearance of ‘Satchmo’s syndrome’ in trumpet player ‘Dizzy’ Gillespie. The condition, originally named after Louis ’satchel mouth’ Armstrong, occurs in trumpet players, trombonists and French horn players comes about as a result of rupture of the orbicularis oris muscle (due to high pressures generated while playing high notes). Pressing the hard metal mouthpiece hard against the soft tissues of the lips without warming up can also cause injury; Freddie Hubbard, the well known jazz trumpeter, allegedly tore his lip during an “ill-advised high-note cutting contest” with another trumpeter, according to the Jazz Times in 2009.

Other hidden dangers of playing wind instruments include ‘flautist’s chin’ — a dermatological condition brought about by irritation from saliva and possibly nickel allergy, and ‘clarinetist’s cheilitis’ (perhaps explaining the ubiquity of the ‘jazz goatee’ in certain musicians). The spread of herpes, HPV and hepatitis have also been described due to the use of instruments that have not been cleaned properly (again, much like ‘violin hickey’, other aetiologies may need to be considered).

Both ‘guitarist groin’ (lower-limb DVT due to the pressure of a guitar held in the classical posture for long periods on the flexed thigh) and ‘guitar nipple’ have also been described. The latter is a form of ‘traumatic mastitis’ and was originally described in a letter to the BMJ in 1973. The case series describes a series of younger female guitarists, who all developed a cystic swelling about the base of the nipple. The cause, it seems, was the playing of full-sized guitars (by younger musicians) and direct trauma to the nipple area by the instrument.

Shortly after the ‘guitar nipple’ report was published, the BMJ published a letter describing an intriguing condition known as ‘cello scrotum’. The eight-line letter, published in 1974, describes the case of a professional cellist who developed an inflamed scrotum which, the author suggested, came about as a result of playing the cello for several hours a day.

Whereas the accuracy of the report was later questioned by other commentators (one suggesting that scrotal friction against the supporting chair was more likely to be responsible than direct cello trauma, per se), it was frequently cited in the literature over the years until the original author finally wrote to the BMJ in 2008, admitting that the case had been fabricated. The original letter had actually been signed and submitted by the Chairman of a brewery in Suffolk (the husband of a doctor) as a practical joke — never expecting that it might be published.

Hopefully there’s no practical jokers among the authors of the reports of the other conditions described.

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