Zachary D Goldberger, Steven M Whiting, Joel D Howell. Perspectives in Biology and Medicine. Volume 57, Issue 2. Spring 2014.
The medical biography of Ludwig van Beethoven (1770-1827) remains enigmatic. Some of his health problems, such as his early and eventually profound deafness, are well documented and extensively discussed, although not necessarily well explained (Forbes 1970; Karmody and Bachor 2005; McCabe 1958; Stevens and Hemenway 1970). Other medical problems, and his ultimate cause of death, remain unclear. Perhaps unsurprisingly for such an important musical figure, there has been no dearth of speculation about the illnesses that may have befallen Beethoven. Medical historians and physicians have suggested (and often disagreed upon) a myriad of illnesses, including but hardly limited to (using 21st-century terminology) asthma, hepatic failure and cirrhosis in the context of alcohol abuse, Whipple’s disease, inflammatory bowel disease, Paget’s disease, syphilis, lead poisoning, diabetic nephropathy with subsequent renal papillary necrosis, hemochromatosis, and sarcoidosis (Davies 1993; Donnenberg et al. 2000; Drake 1994; Franzen 2008; Kubba and Young 1996; London 1964; Mai 2006; Naiken 1971; Palferman 1990).
Physicians, historians, and even musicologists have speculated that Beethoven suffered from heart disease, and our contemporary understanding of disease is that the various conditions medical historians have posited did place Beethoven at significant risk of experiencing cardiovascular disease. Upon his demise, Beethoven’s heart apparently was not found to reveal significant structural disease (Forbes 1970), but many of the tools we now use to examine the heart at autopsy were not available in the early 19th century. While not resulting in macroscopic changes to the heart, cardiovascular disease could have been manifest in cardiac arrhythmias: abnormal, irregular rhythms of the heartbeat. These speculations cannot be proved with certainty-indeed, the electrocardiogram was not part of routine clinical practice until well into the 20th century-but a possible diagnostic tool may be provided in Beethoven’s music.
Some have suggested that indirect evidence of abnormal heart rhythms is manifest in several of Beethoven’s compositions (Cheng 1997; Kappenberger 1986; Luderitz 1995; Vaisrub 1980). Although such claims must perforce remain speculative, a review of several compositions viewed in historical context supports the notion that Beethoven may have been reflecting his own physical sensations in his compositions-in other words, that he was, in a sense, setting an arrhythmia to music. We will examine this proposition, starting with an in-depth look at the work most often cited as evidence that Beethoven experienced an arrhythmia-the Piano Sonata in E-flat major, Opus 81a (Luderitz 1995). Additionally, we will highlight two later compositions-the String Quartet in B-flat major, Opus 130, and the Piano Sonata in A-flat major, Opus 110–that also may be “musical electrocardiograms.”
Piano Sonata in E-flat Major, Opus 81a
Beethoven’s Piano Sonata in E-flat Major, Opus 81a was composed in Vienna in 1809. The first movement, “Das Lebe Wohl,” was sketched in late April. Beethoven was both anticipating and dreading the departure from Vienna of Beethoven’s close friend and patron, the Archduke Rudolph of Austria (Cooper 2007). The other two movements, depicting, respectively, Rudolph’s absence and his anticipated return, were written later in the same year.
The sonata opens with an opening “horn-call” motif-three chords over which are written the three syllables “Le-be-wohl” (fare-thee-well). It continues with a distinctive rhythm comprising two shorter notes in dotted rhythm and a longer note. One could certainly explain the rhythm solely by referring to the convention of the French overture. The slow introduction, replete with dotted rhythms, was originally designed to accompany the stately entrance of the French king Louis XIV into his music room. On this account, by invoking the convention of the French overture, Beethoven paid tribute to his imperial (and most faithful) patron, the Archduke Rudolph. (Of note, Beethoven referenced the same convention-and in the same key-in the slow introductions of two other piano sonatas: Opus 13 [“Pathétique”] and Opus 111.) Dotted rhythms are also common in other contexts, of course-funeral marches, Irish jigs-that are not apposite here.
However, if we extend author and pianist Jürgen Uhde’s (1980) insight that the initial horn-call motive could represent departure, then the distinctive rhythmic pattern becomes something altogether different. Indeed, the subjective response to a sad leave-taking would already begin with the surprising turn taken in the horn-call’s third chord: instead of the E-flat major one might expect, Beethoven has chosen a wistful C minor. Harmonic surprise here intensifies the symbol of leave- taking into one of abandonment. In the following measures the bass descends by half-steps through the interval of a fourth (an age-old musical symbol of lament), while the melody rises in what seems a series of painful questioning gestures.
The rhythmic pattern is irregular-a dotted rhythm that follows a longer note with a shorter one. To associate the distinctive rhythm of the melody with an arrhythmia is to give a visceral immediacy to the play of musical symbols. The same rhythmic pattern persists in the principal theme of the Allegro. At both tempos, the rhythmic pattern seems to register a physical symptom of psychological distress, namely slow irregular heartbeats (in the Adagio), then racing irregular heartbeats (in the Allegro). This rhythmic profile has been ascribed to premature ventricular complexes (PVCs) (Kappenberger 1986; Luderitz 1995). Such extrasystoles can be felt as early beats, or as skipped beats. In addition, a premature beat (or an ectopic beat) is often followed by a compensatory pause. We hear several such prominent pauses in the introduction to Opus 81a, as well as in the opening movement, often apparent after “syncopal” phrasing. The sudden pause in the last measure immediately precedes the entrance of the “Lebewohl” motive. Through much of the ensuing development section, the symbol of departure alternates with the racing-heartbeat figure.
This sonata was composed at a time when Beethoven was under considerable emotional stress, a known trigger for arrhythmias. One reason for stress was Austria’s declaration of war against Napoleonic France on April 9, 1809. Moreover Beethoven’s patron Rudolph (along with the rest of the imperial family) was compelled to leave Vienna in early May. Just four months before, Beethoven himself had been ready to leave Vienna to become court composer for the King of Westphalia in Kassel. He had been convinced to stay by an annuity contract, in which Archduke Rudolph and the Bohemian princes Kinsky and Lobkowitz guaranteed Beethoven an income for life, if only he maintained his residence in Vienna (or some other city within the Hapsburg realm). By the time the French first bombarded and then occupied Vienna, all three patrons had leftthe city, and the annuity for which Beethoven had remained in Vienna was very much in doubt.
In addition to the music and its historical context, Beethoven’s own words strengthen the suspicion that, more than other works, this sonata might explicitly reflect the outside world. Opus 81a is the only explicitly programmatic piano sonata, one for which Beethoven intended a separate title for each movement: “Lebewohl” (farewell), “Abwesenheit” (absence), and “Wiedersehen” (return). However, the publisher Breitkopf & Härtel disregarded these titles, and labeled the sonata Les Adieux. Beethoven was not happy with this change. He replied on October 9, 1811: “Lebewohl is something quite different from Les Adieux, the first one says to one alone, from the heart, the other to an entire assembly, to entire cities” (Anderson 1986, no. 325; Briefwechsel Gesamtausgabe no. 523). Notably, a similar dedication to Rudolph is made in Missa Solemnis, completed four years before Beethoven’s own death: “Von Herzen-möge es zum Herzen gehen!” (From the heart-may it go to the heart!). Given that Beethoven explicitly stated that each part of this sonata was intended to represent his emotions, it is certainly possible that the rhythms came from some of his own inner feelings.
String Quartet in B-flat Major, Opus 130
Beethoven’s String Quartet in B-flat Major, Opus 130, was completed in December 1825. The fifth movement, titled Cavatina and to be played adagio molto espressivo (slowly, very expressively), is a work of great emotional force; Beethoven said that the music always made him weep (Hatten 2004). In the middle of the Cavatina, the key suddenly modulates to C-flat major. The syncopated melody combines with triplets in the accompaniments. This section is marked beklemmt, a German word that can be translated as “heavy of heart.” But the German word also carries other connotations: in addition to a sensation of heaviness, it also evokes the sensation of being “pinched” or “squeezed.” Pianist Jonathan Biss (2011), in a recent publication, says that this section evokes for him a sensation of shortness of breath, which he associates with intense emotion, but which could also be associated with cardiac arrhythmias. This section of the quartet lasts only seven measures and ends with a pause, before the original theme returns. The sensation of the chest being “squeezed,” possibly associated with shortness of breath, quickly brings to mind the possibility of ischemic heart disease. Such ischemia could be either the cause or the result of an arrhythmia.
The arrhythmic quality of this section is unquestionable-an unbalanced rhythmicmetrical quality is bound up with a change of character, a darkening of emotion involving a sense of uncertainty, disorientation, or even fear. This brief unsettled section of the quartet suggests a short paroxysm of an atrial tachyarrhythmia, perhaps with associated cardiac ischemia. The pause at the end may well represent a compensatory pause.
Piano Sonata in A-flat Major, Opus 110
Composed in 1821, the Piano Sonata in A-flat Major, Opus 110, is the central piano sonata in the group of three (opp. 109-111) that make up Beethoven’s final contributions to the genre. Beethoven was prevented from completing the sonatas on schedule by several factors, including medical problems that included an attack of jaundice. The finale of Opus 110 has a quite unusual structure: it contains two fugues, each preceded by an “arioso dolente” (lamenting song). The second arioso has an asymmetrical melody in concert with repeated chords in the bass. The ostinato, repetitive quality of the lefthand bears some resemblance to rapid tachyarrhythmia, often associated with chest heaviness and palpitations. The melody played in the right hand sounds like a vocal line being sung, but as though the singer is feeling dyspneic, gasping for air and able to get out only a syllable or two with each breath. This would not be an unusual sensation for someone experiencing a tachyarrhythmia.
Under continual medical care from his mid-twenties, Beethoven encountered more than his share of doctors and characteristically minced no words in his estimation of them. In a June 29, 1801 letter revealing his increasing deafness to his dear friend Franz Gerhard Wegeler (himself a physician), Beethoven complained of a “medical ass” (medizinischer asinus) who had prescribed cold baths for his diarrhea (Anderson 1986, no. 51; Briefwechsel Gesamtausgabe no. 65). In his next letter to Wegeler (November 16, 1801), he complains with equal bitterness of his next doctor, who has prescribed vesicatories applied to both arms (“an extremely unpleasant treatment”). At the same time, Beethoven is eager to know what Wegeler thinks of galvanism, which (so he has been told) has restored hearing to two deaf patients (Anderson 1986, no. 54; Briefwechsel Gesamtausgabe no. 70).
Beethoven is said to have suffered from a host of other ailments, related and unrelated. However, we must read any list of Beethoven’s medical diagnoses with extreme caution, for retrospective diagnosis is fraught with difficulties. To begin, it is hard to know how to interpret the medical descriptions of the time. Even a name as seemingly clear as “asthma” has a fundamentally different meaning in the early 21st century than it did in the 18th and 19th centuries. Additionally, almost all of today’s diagnostic medical tests did not exist in the past. Moreover, the very concepts on which contemporary medical diagnosis exists (as well as the very concept of most of the diseases from which Beethoven is thought to have suffered) were still decades, if not centuries, away when Beethoven died in 1827. All of this makes any attempt at specific disease diagnosis problematic. Nonetheless, the constellation of symptoms and the common association of an irregular heartbeat with so many diseases make it a reasonable assumption that Beethoven likely experienced irregular heartbeats. While these have been purported to be extrasystolic beats, they arguably may have been due to other rhythms that cause irregularity (for example, atrial fibrillation, atrial flutter with variable conduction, or even multifocal atrial tachycardia).
We can neither prove nor disprove that Beethoven suffered from cardiac arrhythmias. Certainly he was predisposed to extrasystoles or even paroxysms of atrial fibrillation. Some have suggested that certain rhythmic motifs were direct transpositions of an arrhythmia, a hypothesis based solely on Opus 81a. Intrigued by this hypothesis, we have attempted to strengthen it by placing other works of Beethoven music in their historical context, and by identifying several compositions in which an arrhythmia may be manifest.
We make two other assumptions in this essay. First, we assume that Beethoven was aware of his heart’s rhythm. One can usually become aware of one’s heartbeat simply by resting quietly, and surely there is no quieter existence than being completely deaf (Luderitz 1995). The gradual diminution of one sense, hearing, probably left Beethoven’s other senses more acute, and his deafness may very well have left him even more aware of the beating of his heart. Furthermore, Beethoven is not the only composer whose work may have been influenced by his heartbeat: Mahler suffered from a serious cardiac disorder that may be manifest in his compositions as well (Amenta 2005).
Second, we assume that Beethoven’s compositions reflected his understanding of the outside world. He is explicit about this association in only a few places- notably in works involving poetic or liturgical texts (the Cantata on the Death of Emperor Joseph, Fidelio, the Missa solemnis, and the Ninth Symphony), but also in purely instrumental works (such as the Pathétique Sonata, the Eroica and Pastoral Symphonies, and the finale of the String Quartet, Opus 135). But he may have drawn musical inspiration from what he felt within his own body in his other works as well, not only in an emotional sense, but also in a very literal sense, as he felt the pulsations of his heart.
Finally, we recognize that the musical “arrhythmia” may simply manifest Beethoven’s genius as a composer, and that similar rhythmic intricacies may be identified in other works by many composers. However, in highly charged passages of certain pieces, the possibility of cardiac arrhythmia can lend a quite physical aspect to one’s interpretation of the music in question. These passages can seem, in an unexpectedly literal sense, to be heartfelt.