Hektoen International

A Journal of Medical Humanities

Mahler at 100: a medical history

Salvatore Mangione
Philadelphia, Pennsylvania, United States

Mahler conducting, 1901
Hans Schliessmann
Caricature satirizing Mahler’s conducting style
Published in Fliegende Blätter magazine

The year 2011 marks the 100th anniversary of the death of Gustav Mahler, the man who, more than anyone else, heralded the advent of a new musical century. Mahler died from subacute bacterial endocarditis, which, while relatively unknown in 1911, has claimed the lives of many famous people and renowned musicians, notably Robert Burns, Orville Gibson, Ottorino Respighi, and Benjamin Britten, and more recently, Bobby Darin and John Glascock.

Mahler had long been obsessed with the idea of death. He was the eldest survivor of 14 siblings, eight of whom died in childhood; the ninth was taken later by suicide. In his youth he spent much time writing dirges,1 and as an adult, he had added funeral marches to almost all of his symphonies. For Mahler, death was the ultimate separation, the culmination of a lifelong fear. “I am thrice homeless,” he once told his wife, “as a Bohemian in Austria; as an Austrian among Germans; and as a Jew throughout the world. Everywhere an intruder. Never welcome. Always a stranger in a strange land.”2 Notwithstanding his attempts to integrate into Viennese society (including a last minute conversion to Catholicism), he retained death, alienation, and disconnection as recurrent musical themes. As such, Leonard Bernstein, dubbing the 20th century “the century of death,” named Mahler its musical prophet.

Yet despite his lifelong romance with death, he had for the most part enjoyed good health. Despite the occasional setback—in 1901 he almost bled to death from hemorrhoids3—he kept an astonishingly busy schedule. An avid swimmer, hiker, and biker, he suffered only occasional migraines and various mild intestinal ailments—albeit narrowly escaping the cholera epidemic of 1892.4 Still, recurrent bouts of tonsillitis in childhood provided the telltale signs of his eventual demise—as they likely resulted in rheumatic heart disease and St. Vitus’ Dance, the jerky and peculiar gait that became Mahler’s trademark since his early twenties.5

In 1907, Mahler’s world dramatically changed when he witnessed the death of his young daughter just five days after his 47th birthday. His wife’s subsequent collapse from exhaustion prompted a visit by the local physician. Dr. Blumenthal reassured Frau Mahler that her health was fine. Then, as if on whim, he examined the maestro, only to discover a heart murmur, becoming the first to discover Mahler’s rheumatic valve disease. Eventually confirmed by the famed Viennese cardiologist Friedrich Kovacs, Mahler’s diagnosis, the sounds of which likely meant mitral stenosis and regurgitation, required a strict regimen of rest; Kovacs even forced Mahler to carry a pedometer to measure (and thus limit) his exertion. Although typical for that time, these restrictions made Mahler feel like an invalid, filling his brain with thoughts of imminent death. The result was the Ninth Symphony of 1909.

In his Harvard Lectures of 1973 Leonard Bernstein stated that the opening bars of the Ninth are indeed “an imitation of the arrhythmia of his failing heartbeat.”6 While insightful, Bernstein’s observation is medically incorrect: in fact, the opening bars reflect a rendition of Mahler’s murmur. He and his wife had long become painfully aware of the sound, as Frau Mahler noted, “for years I had been frightened by the whistling sound that could be heard very loudly on the second beat.”7

Mahler rendered this rumble of mitral stenosis in the opening of his Ninth Symphony: first, the short S1 and S2 (played respectively by cellos and horns) and then the fluttering sound of his damaged valve played by the strings.8,9 The heartbeat refrain returns throughout the rest of the first movement, which climaxes in the forceful tuba and trombone recreation of the heartbeat-murmur sequence before entering directly into a funeral passage.

Death, no longer merely an obsession, had become an inevitable fact. Following the tragic events of 1907, his music never revisited themes of triumph and redemption, instead exploring death, resignation, and acceptance.9 Yet while his music anticipated Mahler’s fatal heart attack, his cardiac condition remained stable until late 1910, when endocarditis finally set in.

Mahler was acutely aware of the risks of his stressful schedule. In a 1909 letter to Guido Adler, he complained about the hectic New York life. “Here real American turmoil prevails,” he wrote. “I have daily rehearsals and concerts. Must conserve my strength a great deal . . . If I survive these two years without injury—then, I hope, I can settle down to enjoying everything, and perhaps also creating con amore.”10 Two years later, he would be dead—perhaps helped in part by his wife’s extracurricular activities.

Alma Maria, née Schindler—but subsequently Mahler, Gropius, Werfel, and almost Kokoschka—was one of those rare persons who could move men and events through the sheer power of her personality. A flirt, a spendthrift, and a narcissist, she was also an articulate, well-connected, and power-hungry woman who enthralled all the rich and famous men she met. Falling under her spell in Vienna were director Max Burckhard, composer Alexander von Zemlinsky, and artist Gustav Klimt (who, quite appropriately, gave her the first “kiss”)—all before the age of 20. Then there was the 42-year-old Mahler, whom she married (pregnant) at age 22. Alma managed to stay faithful for seven years, until Walter Gropius came along.

Gropius was a charismatic German architect who, soon to cofound the Bauhaus school of design, would eventually enjoy an illustrious career in the United States. When he met Alma during the summer of 1910 he was merely a handsome and sexually inexperienced 27-year-old. Alma, at 31, was still grieving over her child’s death. The two met in Tobelbad, and Gropius was bewitched. On their first meeting they talked all night and soon thereafter consummated the liaison.

Mahler was in south Tyrol at the time, working on his Tenth (and soon-to-be incomplete) Symphony. Unaware of his wife’s undertakings, he worried about her depression. The flow of her letters had slowed down to a trickle, and she did not even send him a postcard for his 50th birthday. By then she and Gropius had other things on their minds—although deception was not among them. In a bizarre twist that would have intrigued even Freud, Walter wrote a passionate love letter to Alma but addressed it instead to Gustav—something that quickly sent Mahler’s libido into a nosedive and his brain into suicidal ideation.

He wired Sigmund Freud requesting an emergency consultation. Freud was on holiday in the Netherlands, but agreed to see him. The two met in Leiden and walked the cobblestone streets of the old town for over four hours. Sigmund later claimed he had ridden Gustav of all his neuroses.11

But Mahler’s health took a turn for the worst. By fall of 1910 he returned to New York with a serious illness; a cauterization of his tonsils in Vienna had not helped and possibly made him bacteremic.12 He looked mortally ill.13 His New York physician (a fellow-Austrian named Joseph Fraenkel) suspected endocarditis, a disease recently described by William Osler, Thomas Horder, and Emanuel Libman, a New Yorker famous for his dazzlingly fast diagnoses and his almost theatrical manner of announcing them. Fraenkel arranged a consultation.

The diviner came, saw, and detected fever, pallor, splenomegaly, a loud murmur, clubbing, and conjunctival petechiae.14 His assistant drew blood cultures; these eventually confirmed the diagnosis of Streptococcus viridans endocarditis—a death sentence in pre-antibiotic times.

Mahler wished to die in Vienna so that he could be buried in the same grave as his daughter. He travelled by ship to Cherbourg (assisted by the Italian musician Busoni, who comforted him with wine and puzzles in musical counterpoint) and then travelled by train to Paris for a consultation with the famous bacteriologist Chantemesse. He finally took the Orient Express to Vienna, where at the Loewe sanatorium, he was put under the care of Franz Chvostek, “the most celebrated doctor in town.”15 The sudden transient sense of wellness that often rekindled hopes in endocarditis patients—a phenomenon that Libman had dubbed the spes endocarditica—occasionally marked Mahler’s final days. But mostly there was a steady decline.

Mahler spent his last days at the Loewe receiving experimental (and useless) serum treatments, oxygen, caffeine, digitalis, and radium compresses for his acutely swollen joints.16 He died at midnight on May 18, 1911. His last words were, “Mozart . . . Mozart.” He was not even 51 years old. The New York Times later reported that his heart was pierced with a needle to confirm his death, as Mahler had specifically requested.17 Four days later a huge crowd stood silently in a torrential rain for his funeral in Vienna. As the maestro was finally laid to rest in his daughter’s grave, a beautiful rainbow broke through the clouds.18

With Mahler’s death, a whole world seemed to come to an end. Within a year, the Titanic sank in the Atlantic. Three years later Europe descended into the abyss of World War I, and in less than three decades a genocidal war consumed Mahler’s niece, who, deported to Auschwitz, conducted the Women’s Orchestra before perishing there. The century of death prophesied by Mahler’s music had come to pass.19

Mahler’s music had also ended. The curse of the Ninth (the superstition that any symphonic composer from Beethoven onward would die soon after writing his own Ninth Symphony) was fulfilled; Mahler never completed his Tenth. He never even attended the premiere of his Ninth Symphony, which was conducted in Vienna a year after his death by his protégé Bruno Walter.

Of interest, Walter Gropius, then soon to marry Mahler’s widow, also celebrated his 28th birthday on the day of Mahler’s death—a coincidence that might have entertained Sigmund Freud. Gropius’ marriage would not last long. Furious about her out-of-wedlock child with Franz Werfel, he bitterly divorced her in 1920. But even more intriguingly, Gropius eventually succumbed to Mahler’s disease. Having time on its side, endocarditis waited patiently for 58 years before catching up with Gropius in Boston, where the old German architect was Emeritus at Harvard. Physicians at Tufts tried in vain to save him (including a heroic aortic valve replacement), but to no avail. Walter Gropius died on July 5, 1969 in Boston’s Pratt Diagnostic Hospital, his window overlooking Tufts Medical Center, which he had helped design. It was just two days short of Mahler’s 109th birthday.


  1. Feder S. Gustav Mahler: A life in crisis. New Haven and London: Yale University Press; 2004:p.18–19.
  2. Rosenzweig A, Barham J. Gustav Mahler: New insights into his life, times and work. London: Ashgate Publishing; 2007: p.30.
  3. Lebrecht N. Why Mahler?: How one man and ten symphonies changed our world. New York: Pantheon Books; 2010:p.103–104.
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  5. Barham J. Perspectives on Gustav Mahler. London: Ashgate Pub Ltd; 2005: p.440.
  6. Bernstein L. The unanswered question: Six talks at Harvard. Kultur International Films, Ltd; 1973; and Cambridge, MA: Harvard University Press; 1976: p.317.
  7. de La Grange HL. Gustav Mahler. Oxford and New York: Oxford University Press; 2000:p.694–695. (Vienna: Triumph and disillusion: 1904–1907, vol 3)
  8. Amenta C. The opening of Mahler’s Ninth Symphony and the Bernstein “heart-beat” hypothesis. Naturlaut. 2005; 4: p.17–18.
  9. Greenberg R. Mahler: His life and music. Chantilly, VA: The Great Courses; 2001.
  10. Feder S. Gustav Mahler: A life in Crisis. New Haven and London: Yale University Press; 2004: p.174
  11. Kuehm JL. Encounter at Leyden: Gustav Mahler consults Sigmund Freud. Psychoanal Rev. 1965; 52:5–25.
  12. Mahler A. Gustav Mahler: Memories and letters (transl. Creighton B). Seattle and London: University of Washington Press; 1968: p.166.
  13. Zoltan R. Gustav Mahler’s American years: 1907-1911: A documentary history. New York: Pendragon Press; 1989: p.377, 397.
  14. Baehr G. Personal communication to the authors: Letter dated November 17, 1970. In: Christy NP, Christy BM, and Wood BG. Gustav Mahler and his illnesses. Trans Am Clin Climatol Assoc. 1971; 82:200–217.
  15. Mahler A. Gustav Mahler: Memories and letters (transl. Creighton B). Seattle and London: University of Washington Press; 1968: p.183.
  16. Levy D. Gustav Mahler and Emanuel Libman: Bacterial endocarditis in 1911. BMJ. 1986; 293:1628-1631.
  17. New York Times 1946. June 28. p.19.
  18. Paul Stefan-Gruenfeldt. Gustav Mahler: A study of his personality and work (transl. Clark TE). Charleston, SC: Nabu Press; 2010: p.119.
  19. Schiff D. Mahler’s body. The Nation 2009. July 13.

SALVATORE MANGIONE, MD is a clinician-educator with a long interest in physical diagnosis and active involvement in undergraduate and graduate medical education. Located at Jefferson Medical College in Philadelphia, he is currently associate professor of medicine, associate program director for the Internal Medicine Residency, and director of the second year Physical Diagnosis course. He also directs the Jefferson History of Medicine series and the Jefferson Medical Cineforum, a movie club on films with medical backgrounds.

Highlighted in Frontispiece Winter 2012 – Volume 4, Issue 1

Winter 2012



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