The rising interest in the medical misfortunes of the variously famous or infamous is attested to by the recent addition of the Journal of Medical Biography to the roster of publications of the Royal Society of Medicine. In the past, this area of interest has all too often been the realm of amateur students of either biography or medicine, and sometimes of both. More recently, however, perhaps spurred by the development of serious scholars and students at such places as the Wellcome Institute in London, Johns Hopkins in Baltimore, Yale in New Haven, and the Institute for the History of Psychiatry at Cornell in New York, the quality of work published has improved dramatically. Nonetheless, it remains an art form, dependent on careful interpretation of partial and often misleading information. One must know medicine, and the "medicine" of the historical context under consideration.

Some years ago, Peter Davies published a medical biography of Mozart +(1). It was a model for us all: he assembled all of the then known material, from primary data such as letters, diaries, memoirs, and old newspapers to secondary sources such as biographies and recent articles on Mozart’s various complaints and ailments. Davies seemed to be conversant with a number of languages, including the then current language of medicine. He discussed all of the previously suggested and other reasonable explanations of Mozart’s complaints and symptoms and put forward his own conclusions, carefully distinguishing fact from supposition. His presentation of the available information permitted one to disagree (as I did about some of his assessments +[2]) on the basis of a review of the data. Since these data were necessarily incomplete, disagreements appear inevitable, underlining that these ventures are really a pleasant intellectual game. The enjoyment is comparable to reading a clinical pathology conference report in the New England Journal of Medicine.

Davies has now applied his own model scholarship to a two-volume study of Beethoven. The first volume, Beethoven in Person, is devoted primarily to the more clearly "medical" complaints; the second volume, The Character of a Genius, deals with psychological development, character structure, and the question of psychiatric illness. Beethoven, a composition student of Mozart, Haydn, and Salieri, is the exemplar in the popular imagination of the tortured, unworldly, semi-outcast and, at the least, somewhat mad genius. In this case, the stereotype may be accurate.

The first volume opens with a discussion of Beethoven’s physicians and their treatments, accounts of his deafness, his final illness, and the results of the autopsy. Reading Davies’s discussion of the diagnostic possibilities is like rereading French’s old textbook on differential diagnosis +(3). For example, after discussing the onset and course of Beethoven’s deafness, Davies considers meningo-neuro-labryrinthitis, typhus, meningitis, brucellosis, sarcoidosis, Whipple’s disease, intestinal autointoxication, autoimmune sensorineural deafness, head injury, Paget’s disease, and others before opting for a predominant sensorineural loss associated with a lesser conductive element and with the details of onset unknown. Davies opts for irritable bowel syndrome as a diagnosis for Beethoven’s recurrent gastrointestinal complaints and points to alcohol dependency and consequent cirrhosis and chronic pancreatitis as causes for his terminal liver failure.

The second volume reviews Beethoven’s childhood, adolescence, work, habits, and pastimes. It goes on to discuss his paranoia and other personality traits, including humor, and closes with a discussion of Beethoven’s depressive and manic tendencies. Goethe described him as "a wholly untamed personality" (The Character of a Genius, p. 185). I will not repeat Davies’s close examination of the data, his inferences, or his conclusions. I urge the reader to consult him directly. My major caveat is that Davies reasons from the emotional content of the music to Beethoven’s personal emotional state. Although there is likely to have been a closer correspondence for Beethoven than for a composer like Handel, this is, at best, uncertain ground.

Not all will agree with Davies’s conclusions about Beethoven’s illnesses. Milo Keynes +(4), for instance, also discussed Beethoven’s "personality, deafness, and bad health." He opted for Paget’s disease of the bone to account for his deafness (Davies would suggest that Keynes was misled by errors in the translation of the autopsy report), for systemic lupus erythematosus for many of his other symptoms, and for posthepatitic cirrhosis with hypertension in the portal venous system. He labels Beethoven’s behavioral problems with the old term "psychopathic," encompassing his charm, impulsivity, selfishness, and lack of insight, guilt, or remorse. Keynes does not feel that any of the several diagnostic criteria of current classification systems are adequately met. This view is echoed in a recent article by Engstrom et al. +(5) on Emil Kraepelin’s "Self-Assessment":

My own feeling is that neither Davies nor Keynes gives appropriate weight to the impact of debilitating illness and particularly to the early onset of deafness in precipitating behavioral difficulties in an individual so involved in the world of sound and so proud of the acuteness of his hearing. As Beethoven wrote to his friend, physician Franz Wegeler: "If I had any other profession I might be able to cope with my infirmity; but in my profession it is a terrible handicap" (Beethoven in Person, p. 43).

None of these diagnoses adds anything to our understanding or, more properly, to our lack of understanding of the origins and nature of Beethoven’s musical creativity. These remain a marvelous mystery. Nonetheless, we can admire both the entrancing, exciting, and emotionally moving product and Beethoven’s courageous ability to persevere in the face of his deafness and debilitating illness. Davies’s two volumes add immensely to our appreciation of a great artist’s ability to use and/or overcome his difficulties.