Medical Mystery Behind Beethoven

by Holly Hosler

It’s not every day that Sinai Hospital Grand Rounds begins with the opening strains of a live rendition of “Romance No. 1 in G major.” But that’s exactly what happened yesterday morning in the Zamoiski Auditorium, where Phillip A. Mackowiak, M.D., gave a historical clinicopathologic presentation on Beethoven’s health problems. (Yes, that’s “Beethoven” as in Ludwig van.)

Before and after the presentation, Netanel Draiblate, Ph.D. candidate in violin performance at the University of Maryland College Park, wowed the audience of physicians with a couple of the extraordinary composer’s masterpieces.

University of Maryland School of Medicine’s Dr. Mackowiak, author of Post Mortem: Solving History’s Great Medical Mysteries, is an expert in using the historical record to shed light on the ailments suffered by luminaries such as Alexander the Great and Joan of Arc. He started the presentation by painting a picture of late 18th century Viennese life, a time of the Enlightenment and revolution, the Napoleonic Wars, high infant mortality and pre-Pasteurian medicine. Beethoven had been raised by an upright mother and an abusive, alcoholic father, who paraded him around courtly society to show off his talent.

Beethoven’s health problems began to show up in earnest when he was in his 20s. He suffered first from diarrhea and abdominal pain, which were to be a lifelong issue for him. (Beethoven himself revealed that the 4th movement of his 2nd symphony is a musical description of the rumblings of his bowels.)

However, Beethoven’s most famous malady is his loss of hearing. He began to notice the problem at the age of 26 and by age 32, he accepted that he would eventually become completely deaf. This plunged him into a deep depression; he was embarrassed that even though he was a composer, he would lose his auditory sense. Beethoven tried to compensate for his loss through the use of headphones, but he never again heard a sound after the age of 50. (Even so, he went on to write his 9th and final symphony, also known as "Ode to Joy", which is lauded by many as the greatest symphony ever composed.)

The great composer had a litany of other health problems: migraine headaches, rheumatism, bronchitis, jaundice, painful eye inflammation and nosebleeds, to name a few. His final illness was a combination of diarrhea, jaundice and pneumonia, among other things, and he died in a delirium at age 56. Among the abnormalities revealed by Beethoven’s autopsy were cerebral atrophy (brain), macronodular cirrhosis (liver) and renal papillary necrosis (kidneys).

Scholars are at odds as to whether Beethoven had one disease, such as syphilis, or several that accounted for his poor health. Diagnostic solutions to Beethoven’s medical mysteries have included typhus, Paget’s Disease and lead intoxication. A couple members of the Grand Rounds audience even suggested that tuberculosis may have contributed to Beethoven’s problems – certainly a possibility, as the disease was widespread at the time and had claimed the life of Beethoven’s mother.

However, syphilis remains the strongest candidate to explain the physical sufferings that Beethoven endured. Though the man came of age alongside actors and actresses (infamous in those days for their promiscuity) and was known to have had affairs with married women, Dr. Mackowiak believes that it was congenital syphilis – probably passed down from his father – that was the source of Beethoven’s ill health. Congenital syphilis does not usually affect its victims until they are in their 20s, which is consistent with when Beethoven started noticing his hearing problems.

In fact, with the exception of his kidney problems, syphilis could explain all of Beethoven’s various ailments. However, even his kidney problems have a plausible explanation: Beethoven’s brother, who was an apothecary, had provided him with analgesics for most of his life. These drugs could have very easily caused analgesic nephropathy leading to the renal papillary necrosis. (In other words, too many painkillers killed his kidneys.)

While a definitive diagnosis is impossible with the limited physical evidence we have left (the temporal bones of Beethoven’s skull were saved, but were lost in the decade or two after his death), today’s Grand Rounds reflects why it's so important to have teaching hospitals like Sinai. The lectures illustrate the fascinating art of diagnosing patients – even long after they are dead.