Alcohol and the death of Ludwig van Beethoven: comparison of general biographies to the medical literature

Beethoven’s illnesses and mental states have been subjects of interest among musicians, historians, and physicians since his death on March 26, 1827. Several of the composer’s works have direct and indirect links to his illnesses. The famous “Holy Song of Praise to the Godhead from a Convalescent,” the slow movement of the String Quartet in A Minor, Opus 132, for example, was written after Beethoven suffered a serious “inflammation of the bowels” in April and May 1825. The composer himself connected his compositions to his health already in October 1802 in the famous Heiligenstadt Testament, when he stated that he had decided he could not commit suicide because of his developing deafness until he had brought forth all the works he felt compelled to express. Subsequently, scholars have made additional connections, such as in two recent studies [1, 2] that theorized that some of Beethoven’s rhythmic disturbances may have been tied to either cardiac arrhythmia or tinnitus. Curiosity about his physical and mental conditions is not limited to modern scholars. During his lifetime, friends, admirers, and detractors also sought to understand him and describe his music in the context of his illnesses. In 1802, Beethoven himself asked his physician, Dr. Johann Schmidt, to have his disease “described” (beschrieben) to the world after his death [3].

Dr. Schmidt’s death in 1809 and the loss of any notes he might have saved on the composer, as well as limitations in medical knowledge during the first half of the 19th century, meant that Beethoven’s wish could not be fulfilled. Nevertheless, investigations into the exact nature of the composer’s physical ailments continue. The existence of more than 2000 primary documents [4] (letters, conversation books, doctors’ notes, autopsy reports) have challenged modern scholars in reaching a general consensus regarding the cause of his deafness and his death [5].

More than 20 diagnoses have been offered over the past two centuries to make sense of Beethoven’s deafness as well as his ophthalmic, gastrointestinal, hepatic, renal, dermatological, and pulmonary conditions. It is well documented that in the final weeks of his life, he developed severe ascites as a result of liver disease, necessitating serial large-volume paracentesis [6]. The description of Beethoven’s autopsy findings, including cirrhosis and chronic pancreatitis, are often associated with chronic alcoholism [6]. Despite this plausible etiology, given the stigma of alcoholism and its possible incongruence with the heroic portrayal of Beethoven in the popular imagination, this condition may have been underemphasized. We therefore aimed to enumerate and compare the ways in which medical experts and biographers writing for a non-medical audience describe Beethoven’s final illness, and the extent to which the alcoholism is invoked.

We identified English-language monographs using a recently published survey of biographies of Beethoven [4], which were supplemented by the authors (n = 76). We then identified entries to the medical literature on the subject of Beethoven by searching for the term “Beethoven” in the MEDLINE database of PubMed®, a repository of peer-reviewed medical publications for the period 1936–2021. The search was conducted on August 15, 2021. The titles and abstracts of all results (n = 350) were reviewed, and relevant full-text publications were then reviewed for eligibility, defined as including at least one statement regarding the final illness and death of Beethoven. Journal articles as well as letters and comments on articles were included. Primary sources and transcripts were excluded. Sources were eligible if they were in English or translated into English. See Fig. 1 for the number of sources that were excluded.

For each source included, a manual review was conducted for statements on the direct cause of death; underlying causes of Beethoven’s chronic illnesses that were not invoked in the context of his final illness and death were not collected. All eligible publications were then reviewed for 1) statements regarding Beethoven’s alcohol consumption; 2) statements regarding whether Beethoven had health problems related to alcoholic consumption or alcoholism; 3) statements that invoke alcohol or alcoholism as a possible cause of his final illness; 4) statements that invoke alcohol or alcoholism as a contributory or exacerbating factor; 5) statements that invoke alcoholism as the most likely cause of final illness; and 6) statements that deny alcohol as a cause of final illness. We compared monographs to medical publications with regard to these outcomes with the chi-square test, using a two-sided p-value threshold of 0.05 for statistical significance. To assess for temporal trends, we used the Cochran–Armitage trend test to compare the relative proportions of these statements with the year of publication of the biographies and articles, using a two-sided p-value threshold of 0.05 for statistical significance.

The review of Lockwood’s compendium of biographies [4] as well as those supplemented by the authors yielded 76 monographs spanning the years 1859–2021, of which 52 [3, 7‐57] (68.4%) were English-language, mentioned final illness, and focused on the biographical aspects of Beethoven’s life. The search of the medical literature using the search term “Beethoven” for the period 1936–2021 yielded 350 publications, of which 291 were excluded, leaving 59 publications [2, 6, 42, 58‐114] for review (see Fig. 1).

Among the 52 monographs and 59 medical articles that mention Beethoven’s final illness, the majority invoked hepatic causes ranging from liver failure, cirrhosis, dropsy or ascites, and hepatitis (Table 1). Other organ systems that were proposed as sites of his final illness include gastrointestinal diseases (5.8% of monographs and 1.7% of medical articles), pancreatic diseases (3.8% of monographs and 5.1% of medical articles), pulmonary conditions (25% of monographs and 6.8% of medical articles), and lead intoxication (1.9% of monographs and 6.8% of medical articles).

A comparison of biographies to medical articles with regard to Beethoven’s use of alcohol is shown in Table 2. Beethoven’s alcohol consumption was mentioned in 45 (87%) and 41 (69%) biographies and medical articles, respectively, a difference that was statistically significant (p < 0.001). Beethoven’s alcoholism was mentioned far less often in biographies compared to medical articles (1.9% versus 44%, respectively, p < 0.001). Alcohol use was invoked as a possible cause of the final illness in 3 (5.8%) and 12 (20%) biographies and medical articles, respectively (p = 0.025). Alcohol was invoked as a contributing or exacerbating factor of an underlying illness in 7 (13%) and 2 (3.4%) biographies and medical articles, respectively (p = 0.052). Alcoholism was invoked as the most likely cause of final illness in 4 (7.7%) and 9 (15%) biographies and medical articles, respectively (p = 0.216). Finally, alcoholism was explicitly denied as a factor in Beethoven’s personal and medical history in 9 (17%) and 11 (19%) biographies and medical articles, respectively (p = 0.855).

The number of identified articles and biographies that discuss Beethoven’s death and illness has increased over time, with the bulk of publications occurring within the past 30 years (Fig. 2). The Cochran–Armitage trend test was conducted to analyze outcomes regarding alcohol use and Beethoven’s final illness across three publication periods (prior to and including 1950, 1951–2000, and after 2000). The proportion of articles and biographies that mentioned Beethoven’s alcoholism increased over time, with alcoholism mentioned in 0%, 24%, and 43% of articles and biographies in the years preceding 1951, 1951–2000, and after 2000, respectively (p < 0.001).

When stratifying by source type, we found that the proportion of articles that invoked alcohol as the most likely cause of death increased significantly over time (p = 0.0287), and those that denied alcohol as the cause of illness decreased significantly over time (p = 0.02). The proportion of biographies that invoked alcohol as a possible cause of death increased significantly over time (p = 0.02, see Fig. 3a, b).

In December of 1826, Beethoven is said to have developed pneumonia while traveling back to Vienna from Gneixendorf in an open carriage [34]. He then decompensated further, showing symptoms such as abdominal pain, jaundice, and ascites [54]. Over the course of 4 months until his death in March of 1827, he received several large-volume paracenteses to treat severe ascites [29]. The postmortem examination conducted by Dr. Johann Wagner showed that the liver had shrunk to “half the size of a healthy one, was leathery and covered with nodules; the spleen was black and tough and twice its normal size; the pancreas too was unusually large and hard; and each of the pale kidneys contained numerous calcified stones” [79]. Thus, Beethoven’s final illness was a manifestation of decompensated cirrhosis, and the autopsy reports confirmed this as well as turbid ascites suggestive of peritonitis as a proximate cause of death. The presence of a thickened pancreatic duct together with cirrhosis is strongly suggestive of alcohol as an underlying cause of both abnormalities.

The findings of the present analysis confirm our hypothesis that alcoholism and alcohol as a cause of Beethoven’s death are more commonly invoked in medical articles than by biographers writing for a non-medical audience. The majority of texts (86.5% of biographies and 59.3% of articles) included in this study identify Beethoven’s final illness as liver disease or liver failure, though the specific diagnosis was variable and included cirrhosis, ascites or dropsy, portal hypertension, and hepatitis (see Table 1). For both source types, popular alternative explanations included pneumonia, renal papillary necrosis, inflammatory bowel disease, and pancreatitis—all of which are supported by the anatomical changes observed during the autopsy examination or by reports of the composer’s illnesses throughout his life in the form of letters and secondhand accounts. These alternative explanations were often diagnosed in conjunction with another condition (i.e., a diagnosis of renal papillary necrosis as well as cirrhosis).

The discrepancy between biographies and articles in attributing the final illness to a hepatic origin may be due to medical scholars’ tendency to seek a unifying diagnosis that encompasses not just the liver failure but all of Beethoven’s physical ailments, including hearing loss. The diagnoses that have been offered by these articles include irritable bowel syndrome, Whipple disease, sarcoidosis, and systemic lupus erythematosus [77, 79]. Lead toxicity has also been offered as a unifying cause of Beethoven’s symptoms, but there is insufficient evidence for this claim. For example, the bone sample that scientists used to test for lead toxicity most likely did not come from the composer [115, 116].

Our primary aim was to compare the portrayal of Beethoven’s final illness in the context of his alcohol consumption by musicological and medical scholars. Though biographies were significantly more likely to mention Beethoven’s alcohol consumption, medical articles were more likely to state that Beethoven had alcohol use disorder, previously commonly referred to as alcoholism. Furthermore, medical articles were significantly more likely to invoke alcohol use as a possible cause of his final illness (Table 2). Though biographies were more likely to state that alcohol was a contributing or exacerbating factor of an underlying illness, the difference was not significant. There was also no significant difference in the proportion of texts that invoked alcohol as the most likely cause.

A minority of writers, regardless of background (17% of medical and 19% of musicological scholars), denied alcoholism as a factor in Beethoven’s medical history. This statistic may be a result of the tendency within the medical community to propose a wider range of conclusions; medical scholars invoked alcohol use as a cause of death nearly as often as they denied the composer’s alcoholism. As mentioned above, medical articles often sought to find unifying diagnoses that encompass Beethoven’s early hearing loss. Though alcohol use can lead to derangements in multiple organ systems, it is not classically associated with early hearing loss. In addition to offering unifying diagnoses, medical writers also shared many of the opinions shared by biographies, which pointed to the autopsy findings that showed macro-nodules as opposed to the micro-nodules commonly associated with alcoholic cirrhosis [37, 79, 89]. Some authors also pointed out that Beethoven did not abuse alcohol because its sedative effects would have hindered the composer’s creativity and productivity [86, 92], despite the widely acknowledged clinical phenotype of a “high-functioning” individual with alcohol use disorder.

We found that the proportion of all scholarly texts including statements regarding Beethoven’s alcoholism and statements invoking alcohol as a possible or the most likely cause of his final illness have increased significantly over time. However, this is in part driven by the fact that medical articles were disproportionately represented in the later years of the analysis. Nevertheless, when stratifying by text source type, we found that even among biographies intended for non-medical audiences, the proportion of articles invoking alcohol as the most likely cause of Beethoven’s death have increased significantly over time, and the proportion of articles denying alcohol as a causal factor have decreased over time. However, this finding should be treated with caution, given that only one non-medical biography predating 1951 was included in this analysis.

To our knowledge, this is the first systematic assessment of the medical and non-medical literature regarding Beethoven’s final illness and death. A significant limitation of this study is that only English-language sources were included. Future studies should expand this analysis to non-English biographies and should further investigate the plausibility of alcohol as the etiology of Beethoven’s cirrhosis by quantifying alcohol consumption using primary sources, including conversation books and contemporary accounts.