Did the famous composer Gustav Mahler work his fatal heart murmur into his final ninth symphony? To try and answer this question, I’m joined by Dr. Kevin Nordstrom of the Great Composers Podcast. We’ll delve into Mahler’s diseases, a history of heart sounds, musical theory, his obsession with mortality, and the unfortunate circumstances of his own death. Classical music and medicine, in one podcast! What more could you want? And included (at no extra charge!) is a new #AdamAnswers about the origins of respiratory therapy.

You can listen to Dr. Nordstrom’s Great Composers Podcast on iTunes  or on his website.

Sources:

• Amenta C, “The Opening of Mahler’s Ninth Symphony and the Bernstein “Heart-beat” Hypothesis by Charles Amenta,” Naturlaut 4(1): 17-18, 2005.
• Cardoso F and Leese AJ. “Did Gustav Mahler have Syndenham’s chorea?” Mov Disord. 2006 Mar;21(3):289-92.
• Christy NP et al, “Gustav Mahler and his illnesses,” Trans Am Clin Climatol Assoc. 1971; 82: 200–217.
• Ferretti J et al, “History of Streptococcal Research.” Streptococcus pyogenes : Basic Biology to Clinical Manifestations.
• Hannah IR and Silverman ME, “A history of cardiac auscultation and some of its contributors,” Am J Cardiol. 2002 Aug 1;90(3):259-67.
• Levy D, “Gustav Mahler and Emanuel Libman: bacterial endocarditis in 1911,” Br Med J (Clin Res Ed). 1986 Dec 20-27;293(6562):1628-31.
• Mangione S, “Mahler at 100: a medical history,” Hektoen International. http://hekint.org/2017/01/30/mahler-at-100-a-medical-history/

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. This episode is called “The Curse of the Ninth,” and it’s the story of famed composer Gustav Mahler’s fatal heart murmur, and how he might have written it into his final ninth symphony.

And to tell this story, I’m joined by Dr. Kevin Nordstrom, host of the Great Composers Podcast, and a musician, musicologist, and teacher. He remembers the first time he saw Mahler’s 9th Symphony live:

I was on a date so I was a little distracted Sort of bewildering in a way; I was 21, spent a lot of time listening to Mahler but hadn’ty played a Mahler symphony at that point. It was an overwhelming symphjony, can’t really take it all in. Now I’ve played 1st 6 7 8, most people hadn’t played. Then coming back to ninth sympony and song of the earth, and now that I have 4 degrees under my belt, understanding how muysic works is much easier.

And what’s changed in the time since he’s listened to it as a teenager?

Took a look at the score again GARBLED pretty out there. Wouldn’t have noticed that as a teenager. In terms of the emotional content of it

Gustav Mahler was born in 1860 and died in 1911, and his life spans one of my favorite eras of medical history, but also history in general — the tail end of a period of great innovation and optimism that would be shattered by the Great War. He was born in Bohemia was a musical prodigy, and by his late 20s was conducting in major cities throughout Europe and even in New York. But he wasn’t primarily known as a composer. 

I think it’s important hwen we think about Mahler to realizze that he wasn’t really famous as a composer. He was world famous as a conductor though. And I think that after he deid, because his works were so long and difficult to play, there was no noe around to perpetuate his music, andanti Semitism, and  anti-German feelings 

And Mahler’s conducting was world famous. There’s a great postcard that I posted of Mahler from his time at the New York Philharmonic showcasing his flamboyant, jerky movements.

And just as  his life and music spanned Romantic period and modernity, his death was a tragic bridge between between two eras of medicine. When Mahler was a young man, he was afflicted with rheumatic fever. We rarely s ee the disease in high-income countries anymore, but it was a scourge in the pre-antibiotic era and still a common cause of heart disease in low and medium income countries — an estimated half a million people are stricken each year, mostly in the developing world. After a bout of strep throat, the body is confused by invading streptococci in a process called molecular mimicry, and attacks itself. Early on, patients get skin lesions and arthritis. The brain can be affected, causing jerky movements called Syndenham’s chorea, or St. Vitus’ dance. In fact, Mahler’s iconic jerky conducting style was likely a remnant of his earlier chorea. The most feared complication is carditis — as the body attacks its own heart, the valves and walls become scarred. While there might not be any symptoms initially, the damage is often permanent. The memory of rheumatic fever looms large in our collective consciousness, even though you may not have heard of it — your familiarity with “strep throat,” and the imperative of treating it rapidly with antibiotics are all memories of a time rheumatic fever was far more common.

Mahler was likely unaware of the effects rheumatic fever had on his body until 1907. His eldest daughter had died of scarlet fever — also caused by strep throat, again a reminder of the disastrous effects of these organisms prior to the invention of antibiotics. His wife Alma was stricken with grief, and their personal doctor came by for a home visit to make sure she was feeling okay. Almost on a whim, he listened to Mahler’s chest with his stethoscope, and noticed a harsh murmur and a whistle. [PLAY MITRAL STENOSIS SOUND NOW] Unnerved, Mahler immediately went for a second opinion with a prominent Viennese physician, who confirmed the murmur and diagnosed mitral regurgitation and stenosis from rheumatic heart disease — a thickening of his heart valves on the left side of his heart that both restricted blood flow, but also allowed the blood to slosh back the wrong direction. Unlike today, a diagnosis of rheumatic heart disease was almost a certain death sentence — though with an uncertain time frame. You could never be certain when death would happen.

But ruminating on death was old hat for Mahler:

His first piece when he was six old was a funeral march and polka. Fascinated his entire life. Fear came latter

From the very time of his birth, he was surrounded by death. Very similar to Beethoven for example. Had a younger brother who died at a very young age. First son passed away, and Mahler replacement. Hung over his head like a shadow. In 1890s bro Otto commited suicide. Musician at Vienna conservatory. Didn’t take it quite as hard — Otto was a drain on resources. Of 15  children 13 died.  Daughter then died two years before. 

Mahler was prescribed a strict regimen limiting his activities. He was even given a pedometer — a reminder that the Fitbit craze goes quite a bit further back — so he could appropriately limit steps. Mahler had always been active, and loved nothing more than hiking in the mountains surrounding his Austrian summer cottage. This enforced sedentary lifestyle darkened his mood, and his murmur constantly beating out of his chest set his thoughts to death. He heard it everywhere, even his his sleep; and it must have been quite loud (a VI/VI as we’d say today), as Alma later recalled, “For years I had been frightened by the whistling sound that could be heard very loudly on the second beat.” Adding to mental anguish, at the same time anti-Semitism forced him out of his conducting job at the Vienna Court Opera.

So all this is going on and he’s composing what was to be his ninth symphony. He was well aware of the Curse of the Ninth — the widespread superstition that since Beethoven, no composed had completed more than nine symphonies before dying. He thought he could cheat the system my calling the symphony a song cycle, which he called the Songs of the Earth.

In the Song of the Earth. He wouldn’t name it a ninth symph because he thought it would be his limit. Once you get to that point you have to die. He tried to sidestep by naming int eh Song of the Earth. He got his younger colleague Bruno Walter to conduct because he was afraid of it. 

After the Song of the Earth, Mahler was feeling confident enough to tackle his ninth symphony.

I think when he wrote the ninth in 1909 he had just, diagnosed with heart condition two years before. He was feeling a little bit better, so he wasn’t quite as afraid of it.  Come to terms that he was going to come to the end. 

Of course, a funeral dirge would be the major theme of the symphony. And for the motif that both opens and closes the symphony, there’s a theory that Mahler might have worked in his fatal heart murmur.

So before we get too much into that, let’s talk about heart sounds. Probably everyone has heard a recreation of heart sounds through a stethoscope: (regular heart sounds)

We call the two heart sounds S1 and S2, which you may also have heard as “lub” and “dub”. . Each sound is caused by different heart valves closing during systole, the period when the heart contracts and squeezes blood throughout the body.

But for most of history, we wouldn’t have had such a distinct understanding of what the heart sounded like. We know that the ancients would listen to their patients’ chests by placing their ear directly on the skin; we call this “immediate auscultation” today.  But the only references we have, such as in the Hippocratic corpus, are to listening to lung sounds, especially for fluid in the lung; and not to the heart. The first time we hear heart sounds specifically referenced is by William Harvey in the early 1600s who described them as a pulse in the chest,  “as two clacks of a water bellows to raise water.” In modern English, he’s describing the sound of water hitting against a valve in a hand pump, which would have been common London during this time period.. Which is pretty impressive — not only did Harvey describe the two heart sounds, his analogy described what causes them as well — turbulent flow against a closed valve. 

The next breakthrough was Rene Laennec. His life was the entire inspiration for Episode 9, so just stop now and listen to that if you hadn’t heard it. But for the short version, Laennec was a young physician on the TB wards at Necker Hospital in Paris. He was called to examine a young woman with clear signs of a diseased heart. The gentlemanly Laennec immediately demurred, and I quote:

“Direct auscultation was as uncomfortable for the doctor as it was for the patient, disgust in itself making it impracticable in hospitals, It was hardly suitable where most women were concerned and, with some the very size of their breasts was a physical obstacle to the employment of this method”

So feeling bashful, he remembered a game from his childhood, where children would transmit sounds through a stick by scratching on one end, and rolled up a quire of paper and placed it on the chest. Laennec took this observations and developed what he called his “cylinder,” alternatively known as a stethoscope. Originally just a long tube, over time it developed into the doctor necklace that we know today. As I talked about in episode 9, he revolutionized listening to lung sounds, but he wouldn’t do as good a job with the heart. Like Harvey, he described the two heart sounds, but his guesses about what caused each were completely off. He thought the first and second heart sounds were caused by the contraction of the chambers of the heart, rather than the valves, and his description would take decades to be debunked — by a veterinarian, in fact, who put a catheter in the heart of a horse to figure out what was going on, an experiment that later influenced Werner Forssman decades later to thread a urinary catheter in his own heart and win a Nobel Prize — so listen to Episode 21 if you want to hear that story.

The second half of the nineteenth century was full of innovation and description in listening to the heart — doctors identified two extra heart sounds, extra sounds poetically called murmurs, and a squeaky sound called a rub. Working with lots of vivisected animals and human autopsies, doctors were able to correlate all these sounds with human heart disease. Which is to say, when Mahler’s doctor listened to his heart that day in 1907, he had a pretty good idea of what was going on inside his chest. 

So let’s get back to the ninth symphony. The most famous advocate of the heart murmur motif is Leonard Bernstein. Let’s listen for a second to the symphony directed by Bernstein himself: [https://www.youtube.com/watch?v=wWxX-kf-2MI}

What Bernstein noted was a heartbeat motif established in those opening measures — the first and second heart sounds being played by the cellos and horn, with the musical murmur coming in between. This motif quickly turns dark and pessimistic  and returns again and again throughout the symphony, and is the “most dramatic and disruptive moment in the movement leading directly into a funeral cortege passage.” Each time, the music “murmur” motif appears between the musical S1 and S2 — neither appears separately in the piece.

So let’s listen to the mitral stenosis murmur again:

And then the motif again:

Again, I am no musicologist. But fortunately I have one on the show, and he is not convinced.

William Riveter (1955, younger than Bernstein). Doesn’t seem to be something a musicologist would latch on to. Looking for facts in the way a composer constructs the music. Bc Mahler never said, yes this is my erratic heart beat, composer would be skeptical. But coming from somebody like Bernstein, as a descendent of Mahler at the NY Phil, he had a ltitle bit of a connection. I took it more of the hyperbole of a conductor trying to inspire. If i were muysician, would be very inspired. But as a musicologist, would snub my nose and say Mahler never said that.

Actually when first brought to my attention. I’m the wrong kind of doctor to really know what a heart murmur is. Initially thought it was the fluttering sextuplet tremolo. I think more important than the opening statemnet in the tremolo. If whole symphony is a farewell to life — mirror. First movement is in D major. Last is in D flat. Clearly a subterranean movement. 

Youre not gonna find this explanation anywhere else. Original to me and my observations of the score…. Motive (violin plays) and then later on turns into the viola. … four notes F# A B A. End of the piece .. last movement, retrograde inversion, backwards and upside down, in a subterranean key (violas) Bflat aflat g aflat Literally created a sort of mirror of life and death.

Motive and … last two measures reverts back to the original form (*violin again), albeit in a different key.   

Motive + orchestration — I think that’s pretyt telling what he’s trying to say. First is like life, second finishes with death. 

Again, from a musician’s point of view, that’s a reach… you can see it in the music, I haven’t found the explanation there. But I think it’s evident in the score. Especially considering how german compositional practice organized, variation the most important thing, the same motive throughout the entire pieace. Definitely in the realm of what he would have done.

 Mahler, I found different opinions on how much of his personal autobiography was written into his music; seems that Mahler was never realaly explicit about life evenbts that he wrote in. So writing in his heart murmur would be a very overtr expression of his life… and a little bit out of cahracter. 

So take from that what you will. 

So I mentioned earlier that Mahler lived and died in a tragic transition era for medicine. His doctors were able to diagnose his heart condition with great accuracy — but they weren’t able to do anything about it. And again, when he fell ill in New York City, he was attended to by the famous physician Emanuel Libman, who cultured his blood. We actually have the original lab report, which states a definitive diagnosis of subacute bacterial endocarditis with a blood culture heavy with streptococcus. The organism had only been discovered a few decades before, and it would be another few decades until an effective treatment — penicillin — became available. Medical science had unequivocally advanced; but our treatments were mostly still stuck in the past millennium. As Mahler declined, Libman apparently discussed phlebotomy, that is, bloodletting, with his patient. 

Mahler lived his life in a profound transitional period is Western culture — the halcyon period the Great War, so it’s poetic that the man fascinated with death from his earliest years would die in a medical transition. 

I don’t think he would have been a very happy guy had he survived much longer. I think he was ready to go. All the musical things that happened after he died, he wouldn’t have liekd that much. Blessing in disguise. 

Well, that’s it for the show! I want to thank Dr. Kevin Nordstrom of the Great Composers podcast! I had a ton of fun discussing Mahler and murmurs with him; and there’s a bonus segment from our conversation at the end of the show. So thanks again, and I can’t wait to collaborate again soon.

But wait. It’s time for #AdamAnswers, where I answer any and all questions you have about medicine, no matter how silly or profound they are. And today we have a question from Kentner Scarborough. He asks, “This question is admittedly a bit self serving as I am a Respiratory Therapist; but I can’t help but wonder how the field got started? Also, how come no one outside the hospital (and tbh, plenty of people inside the hospital) knows who the hell we are? I’ve been in a plethora of ripe for TV dramatic medical situations, intubating, performing CPR, helping with treatment and decisions in, by definition, life threatening situations; and I have yet to see an RT represented in any of these as the public sees them. Is this simply another of the many oversights by medical drama producers? Or is it, as many of my RT brethren seem to believe, a deliberate and concerted effort to keep us sputum suckers in the shadows? 

These are two great questions, and they sort of tie into each other. So Kentner suggests that lots of people outside of the hospital — or in it, for that matter — might not know what an RT does. They are licensed medical professionals here in the US, and an increasing number of other countries, who treat patients with respiratory issues in a number of settings — this might include asthma counseling in a clinic, ventilator and airway management in an ICU, and chest clearance for patients with cystic fibrosis. The field is shockingly new — even by the most liberal estimates, it’s less than 80  years old. In comparison, modern professional nursing dates back to at least the 1850s. Two medical inventions spurred its development: the first was the development and widespread use of oxygen in medical care in the first half of the 20th century. Technicians called “oxygen orderlies” were trained on the job to help set up and maintain the complicated and expensive equipment. The second was the invention of the iron lung, which provided a novel way to provide negative pressure ventilation starting in the 1930s, especially for victims of polio. In the early 1940s in Chicago, an on-the-job training program was started at the now defunct Michael Reese hospital for “inhalation therapists”, who would not only serve as oxygen orderlies, but also help provide respiratory care for patients coming out of surgery. The Inhalation Therapy Association, now the American Academy of Respiratory Care, was formed soon after in 1947 in Chicago. The polio epidemic of the 50s saw the widespread use of iron lungs, and the need for more inhalation therapists to help treat patients in them By the 1960s respiratory therapy as we know it today was beginning to take hold. 

So the address your second question — why isn’t there more public awareness of the roles of respiratory therapists? I don’t really have an answer for this, but I’m happy to speculate. First of all, it’s a new field, and its role has changed considerably over the past half-century. That might not be enough time to enter the cultural zeitgeist. The other is that most people do not come into contact with RTs unless they have respiratory diseases. A similar “recognition gap” has plagued physical, occupational, and speech and language pathologists, though this seems to be slowly changing, and I can actually think of some prominent use of PT and OT in television shows (Breaking Bad in particular). As far as medical dramas are concerned, they have a long history of “doctor chauvinism” and minimizing the role of anyone without an MD, while at the same time absurdly inflating the actual scope of what a doctor actually does. I’m one of those annoying doctors who takes pride in not watching medical dramas — though I’m happy to quote articles about how they warp patient expectations — but after perusing some blog posts by angry RTs, I gotta say I’m with your colleagues; producers are trying to keep the “sputum suckers” in the shadows — but I wouldn’t take it personally. They do it to basically every other medical profession other than doctors too.

So thanks for the great question Kentner! And to everyone else listening who works in a hospital, say thanks to your local respiratory therapist. We all appreciate what you do. And respiratory care awareness week is in October of each year.

So that’s actually it for the show. This episode is five years in the making. I first heard about Mahler’s murmur from physical exam great Sal Mangione of Temple University when I attended a lecture by him my intern year. Since then I’ve been obsessed with a creative way to tell the story to my listeners. I originally planned this as a second episode (since the first was also based on Sal Mangione). My biggest problem, of course, what that I know very little — really nothing — about classical music. So I am so indebted to Dr. Kevin Nordstrom of the Great Composers Podcast for joining me for this episode. I had a ton of fun doing it, and can’t wait to do it again. Let me know what you guys thought!

All of my sources are in the shownotes. 

And finally, while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.