The patient was a 56-year-old man who presented with fever and
chills associated with ascites, abdominal pain and a hacking cough
with scant hemoptysis. The symptoms started two days prior to
presentation following an extended trip in an open-air cart during
the winter. Respirations were labored due to pleuritic and abdominal
pain. The patient had a long history of gastrointestinal problems
and childhood asthma. His initial gastrointestinal symptoms, which
began at the age of 22, were intermittent abdominal pain and diarrhea.
The symptoms progressed and by the age of 31 he complained of
abdominal pain associated with alternating bouts of diarrhea and
constipation, sometimes progressing to obstipation. Four years
prior to the onset of this illness, he had a bout of abdominal
pain, vomiting and diarrhea accompanied by jaundice which lasted
several months before resolving. Initially alcohol would relieve
the pain but later in the course of his disease, alcohol would
exacerbate the pain and diarrhea. Two years later, the onset of
lower extremity edema was noted accompanied by reports of occasional
epistaxis, hematemsis and hemoptysis.
Another dominant feature of the patient's medical history was
deafness which had its onset at the age of 28. Hearing difficulties
started in the left, followed by the right ear in association
with tinnitus. High pitch tones were lost initially, followed
by low tones with the development of total deafness by the age
of 44. The impact this problem on the patient's well-being was
magnified by the fact that he made his livelihood as a musician.
His loss of hearing was associated with progressive depression,
social isolation, self-neglect and frequent inappropriate behavior.
Other medical problems included asthma, occasional bouts of "rheumatism"
and gout as well as a history of 9 months of a painful eye which
required patching. The patient's younger brother was a pharmacist
and frequently supplied him with a broad array of unspecified
medications which the patient took in an erratic fashion.
The patient's father died of complications from alcoholism and
his mother and brother died of tuberculosis. The patient was unmarried,
and the details of sexual contacts are not clear. He did not smoke
but consumed moderate to large quantities of alcohol on a regular
basis with a penchant for sweet Hungarian wines and beer.
On examination the patient appeared ill and in moderate respiratory
distress. He was lying on a stretcher, groaning in pain. He showed
signs of wasting and was febrile with occasional rigors. Icterus
with jaundice were superimposed on darkly pigmented skin with
erythematous cheeks. Breathing was shallow and rapid. There was
dried blood in the nares as evidence of recent epistaxis. The
abdomen was markedly distended with obvious signs of massive ascites.
Hard nodules were palpated in the liver. The legs were markedly
edematous and there were scattered petichiae present.
Over the next two days, the ascites worsened, making breathing
difficult. In addition, the patient developed jaundice, rigors
and frank hemoptysis. Treatment with a salycilate-based, anti-inflammatory
regime provided significant relief, however five days later abdominal
pain returned in association with rigors, vomiting, diarrhea,
and worsening ascites and edema. A paracentesis was performed
which yielded 11 liters of cloudy fluid. This provided a degree
of relief but the procedure was complicated by continual seepage
from the puncture site and an erysipeloid wound infection. Ascitic
fluid eventually reaccumulated and a second large-volume paracentesis
which yielded clearer fluid was performed several weeks later.
Ascitic fluid continued to accumulate and two additional paracentesis
were performed over the next six weeks. A number of unspecified
medications, as well as alcohol, were administered in an effort
to treat the associated abdominal pain. The patient languished
for an additional four weeks becoming progressively more edematous
and wasted. Hemoptysis and epistaxis became more frequent and
he eventually developed anuria, became comatose and died.
A post mortem examination was performed.
Autopsy Findings
Ludwig van Beethoven died on March 27, 1827, and a post-mortem
examination was performed and recorded by Dr. Johann Wagner, who
was then an Assistant at the Vienna Pathologic Museum. His findings,
originally written in Latin, were lost and rediscovered in 1970.
Beethoven's body was exhumed twice, in 1863 and again in 1888.
Dr. Johann Wagner's findings:
The corpse was emaciated and covered with petechiae. The abdomen
was unusually dropsied and stretched. The auditory nerves were
shrivelled and destitute of neuronae. The convolutions of the
brain appear deeper, wider, and more numerous than ordinary. The
calvarium exhibited great density and thickness throughout, amounting
to one-half inch. The chest cavity and its contents were normal.
The abdominal cavity contained four liters of greyish-brown turbid
fluid. The liver was half the normal volume and greenish-blue
in color and beset with knots. The vessels were narrowed and bloodless.
The spleen was more than twice its normal size, dark colored and
firm. The pancreas was equally hard and firm. Both kidneys were
invested by a cellular membrane an inch thick. Every one of their
calyces were occupied by a calcaneous concretion of a wort-like
shape and as large as a split pea.
