Hektoen International

A Journal of Medical Humanities

“Moonlight” and silence

Anne Jacobson
Oak Park, Illinois, United States


Woman at the Piano. Pierre-Auguste Renoir, 1875/76. Art Institute of Chicago.

At seventeen, I knew little about the limitations or losses that might cause a person to second-guess a vocation, deeply held belief, or identity. Perhaps those questions about the unknowable future inhabit the soul of a teenager under the guise of general angst and anxiety, or alternatively are tamped down by hubris and risk. I was probably swinging wildly between these states of being when my piano teacher decided I should learn all three movements of Beethoven’s Sonata No. 14 in C-sharp minor, better known as the “Moonlight” Sonata, for my senior piano recital.

I inhabited “Moonlight” for many months, my brain and fingertips forging connections that still express as muscle memory more than thirty years later. The beloved and well-known first movement of the sonata, the adagio, is in fact perfect for an angsty teenager to rehearse over and over again, annoying captive family members. The French composer Hector Berlioz described the movement as “one of those poems that human language does not know how to qualify.”1 Its haunting melody evokes melancholy and longing, which connected with listeners in Beethoven’s time much as it does in the present day. Beethoven himself questioned the popularity of the movement, even remarking to the composer Carl Czerny, “Surely I’ve written better things.”2 Although Beethoven may have been dismissive of the piece, he was also living through a time of questions, frustration, and loss in his own life. When he composed the piece in 1801, he had already lost an estimated 60% of his hearing, although he was purposely and painfully keeping this knowledge to himself.3

Beethoven had begun to experience the buzzing and ringing of tinnitus around 1796 when he was twenty-six years old. He also suffered the effects of recruitment—an increase in perceived loudness for certain frequencies—as well as decreased word recognition in conversation. By 1816 he is believed to have been completely deaf.4 In October 1802, just one year after “Moonlight” was composed, Beethoven was distraught and suicidal. In a letter composed to his brothers, known later as the Heiligenstadt Testament, he wrote:

Oh, you men who think or say that I am malevolent, stubborn, or misanthropic, how greatly do you wrong me. You do not know the secret cause which makes me seem that way to you. From childhood on, my heart and soul have been full of the tender feeling of goodwill, and I was even inclined to accomplish great things. But, think that for six years now I have been hopelessly afflicted, made worse by senseless physicians, from year to year deceived with hopes of improvement, finally compelled to face the prospect of a lasting malady (whose cure will take years or, perhaps, be impossible).5

Beethoven would go on to talk himself out of his suicidal intentions later in this rambling note, stating that he intended to go on living for the sake of his art. By describing himself as an artist, he identified differently than other contemporary or preceding composers.6 His music was not merely a commodity in demand or a product he happened to be skilled at creating. He saw his compositions as expressions of himself and fully intended to be immortalized through his art. As such, his progressive hearing loss and helplessness to prevent it was much more than a professional or economic hardship; it threatened the very core of who he believed himself to be.

Beethoven was a groundbreaking and highly original composer, of course, but first found fame as a pianist. As a young musician recently arrived in Vienna, his playing style was as intense and brash as the man himself, “hands high, smashing the piano, breaking strings, aiming for a hitherto unexploited kind of orchestral sonority on the keyboard.”7 Playing the piano became painful because of the paradoxical amplification of sound in the early and middle stages of hearing loss. Around 1811 Beethoven described one of his early strategies to cope with these symptoms, stating that stuffing “cotton in my ears at the pianoforte frees my hearing from the disagreeable noise.”8 As the hearing loss progressed, he employed a range of devices and remedies, including the use of hearing trumpets, bathing in tepid water from the Danube River, galvanism, and applying wet bark to his arms until blisters formed.9,10 His livelihood as a composer, performer, and conductor was in peril, but it was the existential threat to his soul as an artist that impelled him to continue to compose music from a place of profound physical and spiritual loss.

The cause of Beethoven’s deafness is unknown, although many diagnoses have been entertained. The composer himself seemed to draw a connection between his hearing loss and ongoing intestinal issues, which although unfounded was reinforced by his physicians.11 Typhus, syphilis, viral infection, and lead toxicity have all been proposed as possible causes, but evidence or a direct relationship with hearing loss are lacking. An intriguing theory based on a modern review of Beethoven’s autopsy report and constellation of symptoms is the diagnosis of Paget’s disease. Although the final cause of death was likely sepsis, pancreatitis, and alcoholic cirrhosis, Paget’s disease would account for the autopsy findings of an atrophied auditory nerve, likely caused by a hypertrophied internal auditory meatus; a thickened skull with prominent forehead and cheekbones; renal calyces riddled with calcium deposits; and a history of erratic behavior, which may be an effect of hypercalcemia.12

Regardless of etiology, it is well documented that Beethoven suffered from a variety of physical and emotional ailments and was known to self-medicate with alcohol. That he continued to compose innovative and enduring music while his health and hearing were deteriorating is remarkable. Music scholars have speculated on how he could have produced works of such originality and complexity when he was nearly or completely deaf. His musical performance training from a young age and well-developed habit of using notation as he composed likely played a role, as did his constant refinement of his relationship to his primary instrument, the piano.13 He likely began to rely more heavily on his vision as well, at least when conducting. In 1825 Joseph Böhm, the leader of a string quartet, described Beethoven as a conductor in his later years: “. . . for the unhappy man was so deaf he could no longer hear the heavenly sounds of his own compositions. And yet rehearsing in his presence was not easy. With close attention his eyes followed the bows and therefore he was able to judge the smallest imperfections in tempo or rhythm and correct them immediately.”14

As the public became aware of Beethoven’s hearing loss, his later works were interpreted and judged—both positively and negatively—in light of this knowledge. Beethoven himself is said to have told his assistant Anton Schindler that the now-iconic opening bars of the Fifth Symphony represented “fate knocking at the door,” and Hector Berlioz stated that the work reflected Beethoven’s “secret sorrows, his pent-up rage, his dreams so full of melancholy oppression . . .”15 Many of Beethoven’s middle and late works, in particular, may be considered as an illness narrative, which is the description not of a particular pathophysiological state, but of an individual’s reality within the lived experience of that state.16

At the time of its composition, Beethoven was acutely and desperately aware of the progression of his hearing loss, but had closed himself off from both possible criticism and support by keeping this knowledge to himself. Just as other unshared stories of loss and desperation become amplified in the echo chambers of isolation, the movements of the “Moonlight” progress from haunting melancholy, to light and incongruous hopefulness, to manic desperation. The wild swings in the emotional tone between these movements did not make much sense to me when I was a teenager, although as a parent of teens I now think that they probably should have. More importantly, having had personal and professional experience with navigating illness and loss, I understand Beethoven’s illness narrative on a deeper level. In his state of denial, irascibility, and isolation, he probably would not have described his composition in the same way. But that also highlights the beauty of multiple forms of communication and underscores the importance of awareness in human interaction, whether clinical or not: sometimes the most important parts of the story are told wordlessly.



  1. Rosen, C. and Ricci, G. Beethoven’s Piano Sonatas: A Short Companion. New Haven and London: Yale University Press, 2002, 156.
  2. Miller, N. Beethoven: Piano Sonata 14 “Moonlight” Movement I. Neil Miller Analyzed Editions, 2007, 1.
  3. Traynor, R. “Hearing Beethoven – Part II – The Medical Conclusion.” Hearing Health and Technology Matters, May 12, 2011. www.hearinghealthmatters.org.
  4. Ibid.
  5. Beethoven, L. Heiligenstadt Testament, English Translation. www.beethoven.ws.
  6. Schonberg, H. The Lives of the Great Composers. New York: W.W. Norton & Company, 3rd edition, 1997, 111.
  7. Ibid, 113
  8. Wallace, R. Hearing Beethoven: A Story of Musical Loss and Discovery. Chicago: University of Chicago Press, 2018, 20.
  9. Classic FM, “So if Beethoven was completely deaf, how did he compose?” https://www.classicfm.com/composers/beethoven/guides/deaf-hearing-loss-composing/
  10. Schonberg, The Lives of the Great Composers, 115.
  11. Wallace, Hearing Beethoven: A Story of Musical Loss and Discovery, 12.
  12. Oiseth, SJ. “Beethoven’s autopsy revisited: a pathologist sounds a final note.” Journal of Medical Biography, Oct 27, 2015.
  13. Wallace, Hearing Beethoven: A Story of Musical Loss and Discovery, 64-69.
  14. Schonberg, The Lives of the Great Composers, 116.
  15. Gibbs, C. “Notes on Beethoven’s Fifth Symphony.” NPR Music, June 9, 2006. https://www.npr.org/templates/story/story.php?storyId=5473894
  16. Kalitzkus, V. and Matthiessen, P. “Narrative-Based Medicine: Potential, Pitfalls, and Practice.” The Permanente Journal, Winter 2009, Vol 13(1), 80 – 86.



ANNE JACOBSON, MD, MPH, is a family physician, writer, consultant, and editor. Her published works may be found in Hektoen International, The Examined Life Journal, The Journal of the American Medical Association, in the anthology At The End of Life: True Stories About How We Die, and others. A collection of her writing may be found at www.thewritetowander.com. She is the Associate Editor of Hektoen International Journal of Medical Humanities.


Highlighted in Frontispiece Volume 12, Issue 1 – Winter 2020

Fall 2019  |  Sections  |  Music Box

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