The Death of a Male Musician With a Mysterious Malady

Albert B. Lowenfels, MD

Disclosures

October 03, 2007

What Are the Diagnostic Possibilities?

The diagnosis given at the time of Mozart's death was acute miliary fever, which was described by William Osler in 1892 "as an infectious disease of dubious nature... characterized by fever, profuse sweats and an eruption of miliary vesicles. The severe cases present the symptoms of intense infection: delirium, high fever, profound prostration and haemorrage." All these symptoms correspond closely with those described for Mozart's illness, but miliary fever was a somewhat catch-all name at the time for any syndrome marked by a seedlike rash.[1,2]

Despite a large number of published hypotheses, the actual cause of Mozart's death remains enigmatic. An autopsy was never performed. The following are some suggested causes for Mozart's final illness (Table).

Mozart was a sickly child and had many bouts of upper respiratory infection, accompanied by fever, joint pain, and one documented case of skin nodules. His history is compatible with streptococcal infection. Rheumatic fever, perhaps starting with scarlet fever, could have led to nephritis and then to kidney failure. Fitzgerald and coauthors[3] favor the diagnosis of rheumatic fever. Rheumatic fever, however, does not explain the chronic ailments of Mozart's last year.

A compelling hypothesis was put forth by Dr. Peter J. Davies,[4] who believed that the end cause was Schönlein-Henoch syndrome (SHS), which developed as a result of streptococcal infection, leading to erythema nodosum, rheumatic fever, and finally, SHS. According to Davies, the incidence of renal involvement in adult cases of SHS is as high as 61% and nearly 30% of adults with SHS nephritis die as a result, usually from renal failure. Furthermore, chronic nephritis that can progress to chronic renal failure develops in 10% of patients with SHS who have renal involvement. A major objection to this diagnosis is the lack of any mention of purpura, which is common in SHS, but Davies argues that a skin rash was noted by Drs. Closset and Sallaba, who attended Mozart.[5]

Prior to his death Mozart believed he was being poisoned. After his death, Mozart's wife, Constance, also reported that he had been poisoned. Who would have wanted to poison Mozart?

Salieri, a popular contemporary composer, was one suspect. He clearly lacked Mozart's talent, and there was a potentially lethal competition that was imaginatively explored in the play and movie Amadeus. Supporting the claim, at the end of his life, Salieri did confess to poisoning his competitor, but at that time Salieri was said to be mentally incompetent.

Another suspect put forth was an unknown member of Mozart's Masonic lodge because it was thought that Mozart revealed lodge secrets in the famous opera The Magic Flute.

Another question: If he was poisoned, what agent could have caused his symptoms? Mercury was commonly used to treat venereal disease during the 18th century and can lead to renal failure and edema -- prominent findings at the time of Mozart's death.[6] It is unlikely, however, that Mozart received this agent, either as poison or as treatment for syphilis. There is no evidence that Mozart had a venereal disease, and this agent causes severe tremors, which Mozart did not experience.

Acute epidemic Disease. According to the Austrian Medical Superintendent, Dr. Edward Guldener von Lobes, at the time of Mozart's death in Vienna, many other inhabitants were dying as a result of a virulent epidemic that gripped the city. Although the exact nature of this malady remains uncertain, it is possible that, given his weak constitution, Mozart died of a recent acute epidemic infection disorder.

Trichinosis. Hirschmann[7] believes that trichinosis was the cause of Mozart's death because it is associated with his symptoms -- fever, edema, and limb pain -- and can be fatal. Furthermore, Mozart, in a letter to his wife, remarked upon eating pork cutlets 6 weeks prior to his death. The time interval fits with the known incubation period for trichinosis, and this parasitic disease was present in Europe at the end of the 18th century. Myalgia, a common finding in trichinosis,[8] was not a prominent feature of Mozart's illness, as pointed out by Dupouy-Camet.[9]

Subdural Hematoma From Skull Fracture. One of the most tantalizing hypotheses is that Mozart died from a fractured skull that had led to a chronic subdural hematoma.[10] What is the evidence for this suggestion? After his death in 1791, Mozart was interred in a common grave. Legend has it that the grave digger, Joseph Rothmayer, who knew of Mozart's fame, identified the body by placing a wire around his neck. A decade later he exhumed the skull, which then disappeared until it turned up in 1842. In 1868, it became the possession of the Viennese anatomist Joseph Hyrtl, and in 1902, it became the property of the Salzburg Mozarteum, where it was displayed.[11,12]

Interest in the skull was revived in 1991, when Pierre-François Puech, a French anthropologist, examined the skull and detected a partially healed skull fracture, which might have been the cause of a subdural hematoma. There is no recorded evidence of a serious fall, but Mozart frequently rode horses and conceivably could have fallen with sufficient force to fracture his skull. But did this skull belong to Mozart? Scientists from the US Armed Forces Institute of Pathology successfully extracted 3 DNA samples from the putative Mozart skull and from the bones of 2 women thought to be Mozart's niece and grandmother.[12] Although the DNA test proved that the Mozart skull was a male, all 3 samples turned out to be from unrelated persons, so the test could not determine whether the skull was really Mozart's. It is still possible that the fractured skull belongs to Mozart, but proving the true identity will require additional DNA testing of remains known to belong to Mozart's relatives.

Other Suspects. Other suspected diseases to explain Mozart's death at an early age include syphilis, cerebral hemorrhage or stroke, and typhus fever. After more than 250 years, however, it is difficult to assess whether one of these diseases was the cause of Mozart's death.

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