Len Fehskens writes:

>I thought it was generally accepted that Mahler died of bacterial
>endocarditis and probably would have lived had penicillin been discovered
>sooner.

I have not heard this.  The questions I would have are firstly what the
source of clinical information was upon which the diagnosis was made are
and then whether there was enough data there to be sure of the diagnosis.
As an academically inclined physician I can generally find fault with some
of the accounts one reads of the presumptive diagnoses made on the basis of
patchy clinical information from the early or pre-modern era of medicine of
various composers.  However endocarditis definitely is a possibility.

It's a lot more complicated than it seems however. I wrote:

>Rheumatic valvular heart disease (as well as syphilitic aortic valve
>disease) was rampant in those days so I wouldn't have been surprised if he
>needed a valve replacement too.  Valvular disease can certainly exacerbate
>any coexisting angina which otherwise may not have been symptomatic...

If Mahler did die of infective (it can also be bacterial, viral, fungal,
mycobacterial, or rickettsial ie other bugs cause it too) endocarditis the
reason why he would have had it in the first place was because as a general
rule of thumb this is a condition which really only occurs on abnormal
valves.  The commonest reason for valvular abnormality during this period
in history was rheumatic valvular heart disease due to rheumatic fever in
childhood.  Rheumatic fever is a social disease related to overcrowding and
poor hygiene especially in the pre-antibiotic error.  Of course Mahler's
father was a barman and he grew up in a large family in impoverished social
conditions.  So it all fits!

Once you have a valvular abnormality haemodynamic changes occur which put
a strain on the blood supply to the heart.  the result is sometimes angina
pectoris.  Thus even relatively moderate coronary artery disease can start
to become symptomatic which might not have not otherwise have been a
problem.  Thus I wrote:

>Those interested might want to know that descriptions of Mahler changing
>his once very vigorous and athletic conducting style to one of much greater
>reserve due to the occurrence of chest pain on exertion sounds to me a lot
>like angina pectoris.  There are descriptions of him being doubled over
>with chest pain during rehearsals.

The symptom of chest pain on exertion (exertional angina pectoris) which
forced him to adopt a more reserved conducitng style seems to have come on
at least a few years before his death.  This is way too long a period of
time for even subacute bacterial endocarditis.  You would usually be dead
within a couple of months if that was the problem.  And yes, you are right
penicillin is usually the right drug for subacute bacterial endocarditis.

If Mahler had such severely damaged valves from childhood rheumatic fever
that he got breathless and experienced chest pain then I would not have
been surprised if the only way to have saved his life after getting
subacute bacterial endocardits on top of his pre-existing badly damaged
valve might have been a valve replacement.  He may well have needed a
concurrent coronary artery by-pass operation too, and indeed we routinely
work patients up for this when we recommend a valve replacement.

So there you go - you asked for it!  The nice thing about cardiology is
it's all just so simple compared to other areas in Internal Medicine...
But I'd be interested in knowing what the basis of the diagnosis of
infective endocarditis was based on though.  There are early description
in early nineteenth century textbooks by the likes of Sir William Osler
of subacute baterial endocarditis so it may even be possible that Mahler's
own physician/internist may have made the diagnosis.

ps I recently found myself in a clinical guess the diagnosis session of a
patient admitted to my hospital with seizures and progressive deafness.  I
thought BINGO: Bedrich Smetana!  Of course I was dead right - the patient
had neurosyphilis.

Satoshi Akima
Sydney, Australia
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