Mozart’s deathbed letter to Leopold finally arrives in Salzburg

Doc Martin says:

In the second half of the eighteenth century the annual death rate in the large European cities was about four times that of today, with further increases during years of war or epidemics.

Thus, in Vienna, with a population of about 270 000, the mortality averaged 43 per thousand. This high figure was related not to the causes of death with which we are familiar today but to the main killers at that time which were the acute infections such as smallpox, typhoid, typhus, scarlet fever, and, in children, infantile diarrhoea. The chronic infections of tuberculosis and syphilis further added to premature death. Writing to his father in July 1783 on the birth of his first child, he writes:

“The child has been given to a foster nurse against my will or rather at my wish! For I was quite determined that whether she should be able to do so or not, my wife was never to feed her child. Yet I was equally determined that my child was never to take the milk of a stranger. I wanted the child to be brought up on water like my sister and myself. [He means pap, of course.] However, the midwife, my mother-in-law and most people here have begged and implored me not to allow it, if only for the reason that most children here who have been brought up on water do not survive, as the people here don’t know how to do it properly”.

In the event, the child died 4 weeks later when the Mozarts were out of town and only two of Constanze Mozart’s six children survived. In Salzburg, where pap was commonly used, the results were no better. Mozart and his sister were the only survivors of their mother’s seven children.

Life expectancy in the mid-eighteenth century, especially in the cities, was about 32 years. The main reason was the appalling infant mortality. In the years 1762-1776 the average death rate of children under 2 years was 49% and as many as 62% died before reaching the age of 5 years.

The chief cause was infantile diarrhoea arising from the low state of hygiene and the awful methods of infant feeding. Breast feeding by the mother was generally unpopular, so that for the middle and upper classes wet nursing was often practised to enable the mother to carry on with her normal life. However, the wet nurses often came from the worst background, were sometimes neglectful of their charges, or were themselves disease-ridden. The alternative to breast milk was the use of pap which was bread boiled with water or beer to which sugar was added. It is, therefore, interesting that Mozart himself had strong but misguided views on infant feeding.

Doc Martin says:

JS Jenkins MD, F.R.C.P in his monograph on the Medical history of Mozart, in the Journal of the Royal College of Physicians of London 25(4), 1991, reviews the medical evidence for a diagnosis.

https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC1295274&blobtype=pdf

At 55 minutes past midnight on December 5, 1791, the man whom many would regard as the greatest musical genius the world has ever known died at the age of 35. Such is Mozart’s fame, recently boosted in popular imagination by Peter Shaffer’s play and film of his life, that there seems to be an irresistible desire to fantasise about the manner of his life and death. In this bicentenary year of his death, it is the purpose of the present article to dispel as far as possible the myths which have arisen regarding Mozart’s health and death.

The lack of scientific methods of diagnosis in the 18th century often make contemporary descriptions of a disease difficult to interpret. A sensible approach is to use the day-to-day symptoms described in letters written by Mozart himself or, when he was a child, in those of his father Leopold. Fortunately, many of these letters are extant and provide a detailed account of the life and sickness of the Mozart family. Much of the speculation about Mozart’s life arises from the refusal to take note of the facts set out in the family letters.

The first illness of note that Mozart sustained was in 1762 when he was aged six. Its description by his father Leopold is typical of erythema nodosum. Two years later he was described as having the symptoms of acute tonsillitis and possibly peritonsillar abscess. In the autumn of 1765, first his sister, Maria Anna (Nannerl), and then Mozart himself were taken seriously ill with a fever, delirium and wasting, which lasting over a month may have been either typhoid or typhus, both of which were endemic in 18th century Europe.

At the ages of 7 and 10 Mozart had attacks of fever and severe pains in the joints, suggestive of rheumatic fever. In 1767 during an epidemic of smallpox Mozart contracted the disease, but fortunately the attack was of moderate degree and he recovered with a few pock marks on his face. Five years later there is some tenuous evidence, based upon his appearance in a portrait, that he may have had jaundice, possibly due to hepatitis. Mozart was then free from serious disease until 1784 when at the age of 28 he developed an acute illness consisting of drenching sweats, severe colic and vomiting, and many other persons were also ill at the time. This illness has been the subject of much speculation. Some have suggested this is renal colic and is a manifestation of supposed kidney disease but this discounts the epidemic nature of the illness.

Davies, has put forward the view that at this time Mozart suffered his first attack of the Henoch-Schonlein syndrome, and then went on to develop nephritis. There is really no evidence for this supposition. The Henoch-Schonlein syndrome is rare in adults, there is no mention of a rash which is almost universal in this condition, there is no mention of joint symptoms, and it is clear that many other persons were also ill.

A diagnosis of acute gastrointestinal infection seems more likely. The year 1790 was a particularly bad one for Mozart. His finances were in grave disarray, he was worried about his wife’s health, and he complained of feeling ill with persistent severe toothache and headache. This suggests he had a dental abscess. Thereafter Mozart makes no mention of ill health of any kind in the many letters he wrote for over a year and which extend to within six weeks of his final illness.

Attitudes to illness in the 18th century Life expectancy for the inhabitants of 18th century Europe was about 35 years. Mozart wrote sadly of the death of a close friend, Count von Hatzfeld, a violinist: ‘He was just 31, my own age’. His physician and friend Sigismund Barasani died suddenly at the age of 29, and the physician who attended him in his final illness, Dr Mathias Sallaba, died six years later at the age of 31. The greatest killers were infections of various kinds, including smallpox, typhus, typhoid and epidemic scarlet fever. It is not surprising that, in an era when close friends and relatives were carried off with little warning, without effective treatment, the attitude of people to disease was different from that of today.

Personal health was a frequent topic of conversation, much as the state of the weather is now. Thus, the repeated reference in the letters of Mozart and his father to the health of the family is not a manifestation of hypochondriasis, but a realisation of the precarious nature of existence. It is, therefore, particularly significant that during the whole of his last year Mozart frequently expresses his concern about his wife’s health but makes no reference to any symptoms relating to himself. In fact, contrary to popular opinion, there is a great deal of positive evidence that he was indeed well.

The health of Mozart in his last year In July 1791, Mozart wrote: ‘as for my health, I feel pretty well’. The letters of October 7 and 8 are particularly revealing. Six weeks before his terminal illness he tells his wife, who was in Baden for her health, that his valet Primus had arrived with cutlets for his supper; ‘Che gusto!’ (How delicious!) he exclaims. The following evening he attended a performance of his opera The Magic Flute and was in a sufficiently boisterous mood to perpetrate a joke on Schikaneder, who was taking the role of Papageno, by playing the glockenspiel behind the scenes when there should have been silence.

Later that evening he says he ate a delicious slice of sturgeon, and ‘as I have a rather voracious appetite today I have sent him out to fetch some more’. The next day Mozart says he has slept very well and has just thoroughly enjoyed half a capon for breakfast .

On October 15 he demonstrated a very normal state of mind by the way he wrote animatedly about the good health of his elder son whom he had taken to see The Magic Flute, and about plans for his son’s future education. He then detailed the arrangements for supper that day
In addition to an undiminished appetite and good spirits, a further indicator of Mozart’s health is that he remained sexually potent during the last year of his life, since his last child was born less than five months before his death.
There is also little doubt concerning his libido, judged by the intimate letters he wrote to his wife. In his last few months of life, Mozart’s musical output was prodigious. According to Robbins Landon [6], Mozart really did compose virtually all his opera La Clemenza di Tito for the coronation of Emperor Leopold II in the astonishingly short time of 18 days. It is not surprising that he felt the strain of working all hours of the day and night to achieve this feat. One of the few independent contemporary references to Mozart’s health at this time, the Coronation Journal for Prague of September 1791, states that Mozart did not have much time to complete the composition and that he was the victim of an illness while he was finishing it.

Whatever this illness was, he obviously recovered from it very well, as shown by the extracts already quoted from letters he wrote following his return from Prague. Then in his final ten weeks he went on to complete The Magic Flute, and the clarinet concerto, composed a cantata for his Masonic Lodge and started the Requiem Mass. Far from being ground down by unrelenting chronic ill health, as many biographers would have it, he just did not have time to complete his last work before he was struck down suddenly by an epidemic illness which was then raging in Vienna.

The final illness Over the space of two centuries there have been many attempts to provide an explanation for Mozart’s death and none is completely satisfactory. One of the difficulties is that the first-hand account of the actual death, by his sister-in-law Sophie Haibel, was written 34 years after the event [8] for the biography of the composer by G. N. von Nissen [9], Constanze Mozart’s second husband. Its accuracy is therefore uncertain. On 18 November 1791 Mozart conducted his last completed work, the cantata to celebrate the opening of new premises for his Masonic Lodge. On November 20 he took to his bed very ill. The illness consisted of painful swelling of his extremities, inability to move in bed, drenching sweats and vomiting, and a burning head. It is stated that he retained his mental acuity until shortly before his death, the whole illness lasting 15 days [8, 9].

The diagnosis made by Mozart’s physicians, Dr Closset and Dr Sallaba, was ‘heated miliary fever’, which simply refers to a fever with a rash. A valuable contemporary medical opinion is provided by Dr Guldener von Lobes, senior City Medical Health Officer in Vienna. He did not personally attend Mozart but was in almost daily consultation with Dr Closset over the case and, writing in 1824, said that Mozart ‘fell sick in the late autumn of a rheumatic and inflammatory fever’, and ‘this malady attacked at this time a great many of the inhabitants of Vienna, and for not a few of them it had the same fatal conclusion and the same symptoms as in the case of Mozart.

It seems, therefore, that an acute infectious epidemic disease was responsible for Mozart’s death. The fact that his mental faculties were said to be intact during the illness would exclude typhoid and typhus fevers, one of which he had probably contracted anyway in his early life.

A possible diagnosis is acute streptococcal septicaemia. Epidemics of septic scarlet fever were common and were almost certainly related to the particular virulence of the (3 haemolytic streptococcus in former times. The story which has been current since the early biographies were published, which still continues to be disseminated, is that Mozart suffered a series of illnesses during his life which resulted in grave deterioration in his health, and during his last year he fought a losing battle against chronic disease. It is stated that following his return from Prague in the middle of September, 1791, he suffered from recurrent headaches, frequently fainted during the completion of The Magic Flute, and became steadily more depressed.

In a famous episode recounted by his wife, Mozart was supposed to have told her that he was convinced that his death was imminent, that he was being poisoned, and that he was writing the Requiem for himself. It is difficult to see why these stories have been, and continue to be since accepted, completely contrary accounts are provided by Mozart himself. Most writers rely on the biographies of F. X. Niemetschek, G. N. Nissen and the diaries of Vincent and Mary Novello, ignoring the fact that all the information for these biographies stemmed from one person, Mozart’s widow Constanze, and that they were written many years after the composer’s death.
The early 19th century biographers had a tendency to dramatise the lives of the composers and there is also no doubt that Constanze had a vested financial interest in fostering the image of her late husband as a martyr to his music, thereby rendering his achievements even more impressive; over the space of years there was ample opportunity for her to embellish and romanticise incidents of their life together. She was not noted for her strict adherence to the truth, as witnessed by her initial attempts to pass off the Requiem as entirely the work of her husband.

Stories were current soon after Mozart’s death that he died from the administration of poison. They persisted in many forms until recent years. There is no evidence whatever on medical grounds that he was poisoned by his rival Salieri, by the Freemasons or anyone else, and this theory is now entirely discredited.

There have been many other opinions about the nature of Mozart’s mortal illness, including subacute bacterial endocarditis acute rheumatic fever and excessive venesections and even extradural haematoma. However, the view that continues to be most widely held is that during the latter part of his life Mozart suffered from chronic renal disease culminating in renal failure

It is often believed that the composer suffered from post-streptococcal glomerulonephritis proceeding to chronic nephritis, and this theory has recently been reiterated by Wheater .

There is absolutely no evidence for this diagnosis. There are certainly descriptions in his early life of repeated attacks which resemble post-streptococcal rheumatic fever, albeit of a moderate degree, but the development of the further complication of nephritis in such a patient is known to be exceedingly uncommon. In a determined attempt to provide another cause for chronic renal failure, Davies has advocated Henoch-Schonlein syndrome but, as already indicated, this diagnosis cannot be substantiated by the medical evidence.

Examination of Mozart’s letters towards the end of his life reveals that he had enormous mental energy, an undiminished appetite, and unimpaired fertility. These features are clinically incompatible with renal failure or, for that matter, with any other serious chronic disease. In conclusion, during his life Mozart suffered from diseases which were common in 18th century Europe and he died of an epidemic fever which killed many others. In this respect his medical history was similar to that of many of his contemporaries. The tragedy is that by his early death the world was deprived of yet more fruits of his tremendous genius. So, let us now cease from concerning ourselves about his death, and listen instead to what his music tells us.