Hektoen International

A Journal of Medical Humanities

Ludwig van Beethoven: music and medicine

Michael Yafi
Chaden Yafi
Houston, Texas, United States

December 2020 marked the 250th anniversary of the birth of Ludwig van Beethoven. The causes of the composer’s deafness and his death at the age of fifty-six have remained unknown, even after an autopsy carried out soon after his death.

Beethoven was also known to have mood swings, which affected both his appearance and demeanor. They may also have been the reason for the distinguished emotional expression of sounds, rhythms, and tempos in his music. His music made him a pioneer of the Romantic period, which evolved from the previous, well-structured Classical and Baroque periods.

Frustrated with the inability of his physicians to make a diagnosis that could explain his physical symptoms, mood swings, and hearing loss, Beethoven asked his brother to request them to describe his malady after his death so that people would understand his behavior. In a letter written 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.”1

Beethoven home and surrounding area. Photos by Michael Yafi.

An autopsy was performed and published by Dr. Johann Wagner from the University of Vienna in 1827.2,3 Many modern physicians have revisited this publication trying to make a diagnosis. Wagner noticed that Beethoven’s skull was twice as thick as normal, with prominent cheekbones and forehead producing a lion-like appearance, which is known to occur in Paget’s disease of the bone (PDB).2 He also noted that the facial nerves were enlarged while the auditory nerves were atrophied, which would explain Beethoven’s deafness and facial appearance.2 The kidneys had regular calcareous deposits in all of the renal calices, representing calcified necrotic papillae, the first case of papillary necrosis recorded in the medical literature. This may have been caused by his uncontrolled ingestion of salicin, a commonly used analgesic of the era,3 and possible hyperparathyroidism causing the nephrocalcinosis.2

His liver was cirrhotic, probably from chronic alcohol consumption, and his pancreas had signs of inflammation, which could have contributed to his septic shock and death.2 A close historical look at Beethoven’s diet and alcohol consumption may also suggest a diagnosis of gout (he loved eating meat) and liver failure (he often drank wine in local bars). Beethoven was not rich, and he disliked aristocracy. He always preferred local bars where cheap wine was served. Since sugar was expensive, cheap wines in that era used lead acetate, also known as sugar of lead, which has a sweet flavor.4 This was a known cause of chronic lead intoxication, which may explain Beethoven’s erratic behavior. Chronic lead toxicity has complex neurotoxic effects including apoptosis and excitotoxicity, which affects neurotransmitter storage and release and alters neurotransmitter receptors.5

Symptoms of lead toxicity may commonly resemble Attention Deficit Hyperactivity Disorder (ADHD) in children, but other symptoms may be delayed such as loss of hearing, antisocial behavior, moodiness, delinquency, violence, and difficulties in executive functioning, attention, and affect.5,6 The Beethoven lead poisoning theory has been prevalent in the past few decades but also questioned based on new toxicology data.7 Other diagnoses such as lupus, Cogan syndrome, and syphilis have been considered for his neuropsychological symptoms and biopsy findings, but lead intoxication remains a plausible explanation. Chronic hypercalcemia from hyperparathyroidism could also explain his periods of depression.

Regardless of the cause of his mood swings, it was definitely translated into his compositions. One could indeed say that Beethoven was the father of modernism. He was the first composer to give all the elements of musical works equal rights. Thus, in his compositions he was able to profoundly and extensively develop musical ideas. Sometimes he would privilege the harmony (chord progressions), as in the introduction of the Pathétique Sonata (Photo 1), or the rhythm, as in the last movement of the Piano Sonata Op. 31 No. 3 (Photo 2).

His other celebrated firsts include the use of massive chords in piano works (anticipating the best of Stravinsky); the use of prolonged trills (not always for decorative purposes but also as meaningful pulsation); and the use of courageous dissonant intervals (as in his late string quartets). In every work one can find innovative compositional techniques and features that influenced the composers who came after him.

No doubt Beethoven invented a musical language proper to himself. We can immediately recognize his style by listening to only a few minutes of his music. The main feature in his music, perhaps reflecting his mood swings, is the powerful contrast of elements, as if opposing forces were tearing him from inside. These contrasts were not only applied to dynamics (loudness and softness), but also to other elements of music. For example, in rhythms, when he juxtaposes prolonged chords with snappy short notes (Photo 3); and the use of extreme piano registers (using very high notes along with very low ones), as in his late piano sonatas.

The sudden outbursts of anger that tear up the silence likewise mark his style, and were especially common in his late works. Thus, he opened the finale of the Ninth Symphony with a noisy, frenzied passage for the orchestra (Photo 4); and his last piano work, Bagatelle No. 6 Op. 126, with the same kind of tumultuous outburst (Photo 5).

Yet the rest of this piece continues with a calm, serene, and transparent writing, much like a spiritual utterance or prayer.

In his violin and piano sonata titled Kreutzer, the changes between calmness and violence are extreme, demanding focus and energy from the players throughout the large work and exhausting the possibilities of both instruments. These excesses of expression and exalted emotion mirror the tumultuous waves of psychological unrest and sudden fluctuations of feeling in the mind of the tormented composer.

Beethoven not only dramatically changed the hierarchy of musical elements, but he also changed their functions, meanings, and morphology. The melody, in his work, is no longer a clear horizontal line, but one that can be reduced to a short motive of three or four notes, as in Symphony No. 5. The elegant dominant seventh chord that leads to a tonic and gives a feeling of closure and rest is replaced by the anguished, unstable diminished seventh chord that leads to nowhere. The crescendo (getting gradually louder) intensifies, only to lead to softness (Photo 6).

As a master of harmonizing contrasting dualities, like his contemporary philosopher Hegel with his concept of antinomies, many pages of Beethoven’s music use a sort of dialog between two opposing forces, reflecting the duality in life: good/evil, willpower/submission, beauty/ugliness, and health/sickness.

One of the most fascinating pages in piano music is the slow movement of Beethoven’s fourth piano concerto. It is a musical dialogue between two entities; one side is delicate, imploring, soft, and bathed in pain (piano part) and the other side is strong, harsh, and authoritative (orchestral part) (Photo 7).

The piano, with its begging, delicacy, and gracefulness manages to convince the powerful orchestra to change and succumb to its world with empathy and peaceful harmony. The dialogue ends with the triumph of tenderness over harshness, vulnerability over strength.

This movement influenced many composers, such as Shostakovich in the introduction of his Concertino for Two Pianos (Photo 8).

Bartok also imitated it in the slow movement of his third piano concerto (but where the orchestra is in more accordance with the piano) (Photo 9).

When one listens to a piece of music written before Beethoven, it is easy to distinguish works from the Baroque period from those of the Classical period. But each composer who came after Beethoven expressed individual traits and a particular musical style. In a sense, it was Beethoven who allowed this to happen. His music covered every shade of emotion, from the most tender to the most violent, and shows his ability to rise above his suffering from his many medical ailments.

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  1. Beethoven, L. Heiligenstadt Testament, English Translation. www.beethoven.ws.
  2. Oisteth, S. Beethoven’s autopsy revisited: A pathologist sounds a final note. J.MedBiogr. 2017 ;25(3):139-147.
  3. Schwartz, A. Beethoven’s Renal Disease Based on His Autopsy: A Case of Papillary Necrosis. Am J of Kidney Diseases 21(6 )6, 1993, 643-652
  4. Rhodes, J. Sugar of Lead: A Deadly Sweetener. https://www.smithsonianmag.com/arts-culture/sugar-of-lead-a-deadly-sweetener-89984487/
  5. Sanders T, Liu Y, Buchner V, Tchounwou PB. Neurotoxic effects and biomarkers of lead exposure: a review. Rev Environ Health. 2009;24(1):15-45. doi:10.1515/reveh.2009.24.1.15
  6. Mason LH, Harp JP, Han DY. Pb neurotoxicity: neuropsychological effects of lead toxicity. Biomed Res Int. 2014;2014:840547. doi: 10.1155/2014/840547. Epub 2014 Jan 2. PMID: 24516855; PMCID: PMC3909981.
  7. Eisinger, J. The lead in Beethoven’s hair. 2007 Toxicological and Environmental Chemistry 90(1):1-5

MICHAEL YAFI, M.D., is a Professor and Director for The Division of Pediatric Endocrinology at UTHealth, (The University of Texas Health Science Center at Houston).

CHADEN YAFI, DMA, earned her Doctor of Musical Arts degree from Boston University, College of Fine Arts where she was a recipient of the prestigious Dean’s Award Scholarship. She also holds a Master’s in Piano Performance, and a Graduate Performance Diploma, both from the Longy School of Music of Bared College, a Bachelor in Piano performance from the Higher Institute of Music in Damascus, and a Bachelor in Pharmacy and Pharmaceutical Chemistry from Damascus University. Dr. Yafi works as pianist and piano pedagogue in Houston. She worked previously as piano faculty at Tufts University and Brookline School of Music in Boston. She has published three books Music in Their Hearts: Introduction to Contemporary Music Education (Arabic), Musical Ramifications: Essays on the Aesthetics of Music, (Arabic), and Aesthetic in Graduate Music Schools: Bringing Philosophy to the Learning of Music (English).

Winter 2021 



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