Orthopaedist reviews the theories and points to eighteenth century medical treatment

On Dec. 5, 1791, Wolfgang Amadeus Mozart—one of the world’s greatest and most prolific classical composers—died in Vienna at the age of 35, igniting a firestorm of rumor and speculation that continues to this day. Was Mozart poisoned by court composer and reputed rival Antonio Salieri, or was kidney failure, rheumatic fever, or even a parasitic infection to blame?

Retired orthopaedist and avid musician William J. Dawson, MD, recently sought to provide a clear historical perspective on the controversy. As bibliographer for the Performing Arts Medical Association (PAMA), Dr. Dawson analyzed scores of references in the PAMA database. His analysis was published in the June 2010 issue of the journal Medical Problems of Performing Artists.

Beginning the search
Dr. Dawson was able to obtain 81 of the 136 reference materials related to Mozart’s death that are listed in the PAMA database, including articles written by historians, musicologists, physicians, and journalists, as well as book excerpts and letters written by Mozart’s family members.

“Mozart began composing when he was 4 or 5 years old and toured with his father, Leopold, throughout Europe,” explained Dr. Dawson. “In letters to family friends, his father indicated that young Wolfgang had a lot of infectious diseases.”

Some theorists have suggested that one or more of these illnesses could be linked to Mozart’s death.

“Children nowadays still get many infectious diseases, but due to antibiotics and general health being better, they’re not as badly affected by them as children were in the late eighteenth century,” noted Dr. Dawson.

A brilliant, rising star
During his lifetime, Mozart composed more than 600 works in a wide range of genres, from opera to choral, piano, chamber, symphony, and concertante music. Although he achieved tremendous fame, the composer was plagued by financial problems and may have had various illnesses.

“A great deal of controversy surrounds Mozart’s last 6 months of life,” said Dr. Dawson, noting that a number of authors believe that Mozart experienced fatigue, abdominal pain, peripheral edema, weakness, headaches, and fainting.

Death of a genius
In late November 1791, Mozart fell severely ill. He struggled in vain to complete his Requiem Mass in D Minor while experiencing symptoms that may have included vomiting, painful swelling of the hands and feet, pallor, weight loss, and a rash. Two weeks later, Mozart was dead.

According to Dr. Dawson, one investigator counted 118 different theories regarding the composer’s death that have been posited over the centuries. Dr. Dawson grouped the theories into four main categories: infection, renal disease with associated complications, poisoning, and cardiac disease.

Some Mozart scholars believe a secondary flare up of an inflammatory disease—such as acute rheumatic fever with rheumatoid arthritis—killed the composer.

“Rheumatoid arthritis does follow streptococcal illnesses, which Mozart very likely had as a child,” he said. “But we don’t know that it was strep throat because bacteriology didn’t exist back then; this is all conjecture.”

Some theorists have focused on diseases such as bacterial endocarditis, streptococcal septicemia and infection, or tuberculosis, while others have implicated a parasitic infestation. One theory suggests that underdevelopment of the antihelical fold of Mozart’s left ear could have indicated a predisposition to kidney failure.

“The poisoning theories have also been talked about a lot,” said Dr. Dawson. “It has basically been disproved that Mozart was poisoned by taking a combination of mercury drugs for treatment of syphilis, by the composer Antonio Salieri, or by members of the Masonic order.”

A “deadly” treatment
Dr. Dawson believes that Mozart’s death was almost certainly hastened by the very treatment meant to restore his health: bloodletting.

“Mozart had a 2-week history of what sounds like a very febrile, painful illness that caused his joints to swell,” said Dr. Dawson. “But personally, I think acute hemorrhagic shock from being bled was the proximate cause of death.”

The composer may have lost as much as 2 liters of blood per week.

“Any orthopaedic surgeon who treats severe trauma is very aware of the difficulties that excessive blood loss can produce,” he said. “If a person is being bled in the midst of an acute infectious inflammatory disease with high fever and swollen joints—such as with acute rheumatic fever—it’s deadly.”

Of course, said Dr. Dawson, it is impossible to prove a cause of death because no autopsy was performed. The remains cannot be studied because the body was buried in an unmarked grave, in keeping with customs of the time. In addition, many of the writings about Mozart’s death are from people—including Mozart’s widow, Costanze—who were interviewed decades later, raising questions about the accuracy of their recollections.

“People ask me what killed Mozart,” said Dr. Dawson. “Well, he probably bled to death. Aside from that, it’s a big question mark.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org