CardioExchange Archive

The CardioExchange editors interview Dr. Zachary Goldberger about his collaborative study of the relationship between cardiac health and musical composition inspired by the work of Ludwig van Beethoven. The paper is published in Perspective in Biology and Medicine.

CardioExchange Editors: You just published a very interesting and unusual article, could you describe what you wrote about?

Goldberger: This paper was a collaboration between a cardiologist, a Beethoven scholar, and a medical historian, and explores the hypothesis that Beethoven suffered from cardiac arrhythmias. Musicologists, medical historians, and cardiologists have speculated that he had an arrhythmia, and that distinct rhythmic motifs in the opening of Piano Sonata in E-flat major (Opus 81a) were “transpositions” of premature ventricular beats. Our paper segues off this previous notion and attempts to amplify it by identifying other Beethoven works which include “arrhythmic” tempi. Was the composer mapping his own electrophysiologic dynamics onto musical scores? We reexamined Opus 81a to see why others felt that it was a direct arrhythmic transposition. Then we studied other works where “arrhythmia” may be manifest: we examined the 5^th movement (Cavatina) of the String Quartet in B-flat major (Opus 130) composed in 1825, and Piano Sonata in A-flat major (Opus 110) composed in 1821.

CardioExchange Editors: How did you happen to think about this project? What was the spark of creativity that led to it?

Goldberger: Music was the “overture” to my career path into medicine. I grew up studying classical piano, and I had two albums of solo piano compositions published by the time I entered college at Brown. The second of these was entitled “Heartsongs: Musical Mappings of the Heartbeat.” This work was part of a collaboration between the Boston Museum of Science, investigators at Harvard Medical School, and Boston University. We were able to translate the cardiac interbeat interval fluctuations—derived from Holter monitoring in both healthy subjects and those with heart disease—into music. The intervals were translated into numerical sequences which were then mapped onto the musical scale. The rise and fall of the melody (of which I had no control) — not the rhythm—reflects these interbeat intervals.The variation in healthy hearts produced a very complex, variable melody line. Patients with severe cardiac disease (i.e., heart failure with reduced ejection fraction) yielded a melody line that was more monotonous in range and dynamics. A “heartsong” from a healthy subject (Heartsong 1), will therefore sound slightly different than one from a patient with heart failure (Heartsong 15).

This early connection between music and the heartbeat sparked my interest in medicine and influenced my decision to become a cardiologist. During my cardiology fellowship at the University of Michigan, I read the remarkable book History of the Disorders of Cardiac Rhythms by German electrophysiologist Berndt Lüderitz. In the preface, he mentions that Beethoven was thought to have an arrhythmia, as described above. I looked further and found that a few others had mentioned this hypothesis as well. But it wasn’t entirely clear where the notion originally came from, even after corresponding with these individuals. I looked briefly at Beethoven’s letters written around the time of the sonata as well as the report of his autopsy, but neither provided any definite evidence. Of critical importance was the fact that the ECG was not introduced into practice until more than century after Beethoven’s death.

After my cardiology fellowship, I entered the Robert Wood Johnson Clinical Scholars Program at Michigan where I met Dr. Joel Howell, an internist, medical historian, and a classical music enthusiast. I asked his opinion about the hypothesis that Beethoven may have had a cardiac arrhythmia. He introduced me to Dr. Steven Whiting, a professor and Beethoven scholar at the UM School of Music. The three of us met in his office, listened to music for a few hours, and we were off.

CardioExchange Editors: You mentioned that Mahler also may have been influenced by arrhythmias, can you explain more about that?

Goldberger: This merits some clarification. Mahler likely suffered from rheumatic heart disease with mitral valve pathology. This diagnosis was discovered incidentally by the physician who was tending to his wife in 1907 after the death of their daughter. He examined the composer and heard a murmur, later confirmed by the famed Viennese cardiologist Friedrich Kovacs. Indeed, while mitral stenosis (and possible concomitant regurgitation) may lead to atrial fibrillation, its relevance to Mahler’s compositions requires more investigation. As other have asked, does the opening of his 9^th symphony actually have features reminiscent of rumbles and snaps? At the very least, perhaps posing this question and related ones will enhance the “auscultatory awareness” of our trainees.

CardioExchange Editors: Do you think that adequate treatment of Beethoven would have robbed the world of some masterpieces?

Goldberger: Absolutely not. Part of Beethoven’s genius, his sublimity, was to overcome adversity and transcend limitations with his art. We want to emphasize that this paper presents a speculation and may offer a new dimension by which one can attend to Beethoven, as well as other works of music. We are listening to his music with a stethoscope. We invite the reader-listener to approach these works with open minds and open ears, and formulate their own opinions. Most important is simply to listen to the music, which speaks for itself and for all of us in ways that need no translation (nor an ECG).