h~jury(1989) 20,327-330 Pritid in Great Britain 327

D-id Mozart have a chronic extradural haematoma?

B. Puech’, P-F. Puech’, P. Dhellemmes3, Ph. PellerW , Fr. Lepoutre4 and G. Tichf
10phthalmology, Hbpital Regional de Lille, France
Wehistory laboratory, Mu.& de l’homme, Paris, France
‘Pediatric Neurosurgery, HGpital Regional de Lisle, France
‘Plastic Surgery, Hapital Regional de Lille
-7nstitut fiir Geowissenschaften, Salzburg, Austria

dm’ng the ia2nt1jimtion

zyxwvutsrq
W hen M ozart diedat the uge of 36, was he sufferingfrm the belated
ofa ualc$edextraduralhaematoma?Thistheorytookshape
complications
processof the skull owned by the Momrtm,
whentheprintofcalcijied
exfnadural haematomams discoveredon thele#
inmr fmrporoparicalcalvarialswjbc-5of the skull. Thisprint look3like a
m&e, with three distinctwncenhicarem. 7’hefirst outerareais striated,
thcsecondmiddleoneisgmnularand~~~withbonydeposik, the
thirdcentraloneismmkedm~fhvm&rgrooves.

M aterials and methods

The legend has it that Mozart’s body anonymously disap-
peared in a pauper’s grave in St Marx cemetery in Vienna
since the grave-digger in charge of Mozart’s burial was
unable to remember where the musician had been buried.
Yet, in Salzburg, there exists a skull coming from St Marx
cemetery in Vienna, which is believed to be that of Mozart,
and which belonged to Joseph Hyrtl, the famous Viennese
anatomist. The history of this skull is well-known. Obtained,
in 1842, from the grave-diggers of this cemetery by the
brother of Joseph Hyrtl, it remained within the family until
18399.After the death of Joseph Hyrtl’s widow and 2 years
of judicial investigation, it became, on 6 October 1901, the
property of the city of Salzburg. For many years, it was on
display in Mozart’s birthplace (a museum) in Salzburg and is
now to be found in the Salzburg Mozarteum.
It is the skull of a young man, an ultrabrachycephalic
Central European Caucasian, with widely separated frontal
eminences, a vertical frontal bone, a nasomaxillary pro-
trusion, reduced orbits and a marked medial supraglabellar
prominence (Fig.I). The base of the skull has been sawed
along a line parallel to the Frankfurt horizontal plane, across
the external auditory meatus. The sawed-off base has been
lost, as well as the mandible which still existed in the last
century. Of greyish-yellow colour, it is covered in some Figure I. Photograph of the skull. Front and left lateral views.
areas with organic residues of collagen, meninges and small Four arrows show the linear fracture. On the top of the frontal
vascular pedicles emerging from the foramina of the bone. bone, the following inscription can be read: ‘Joseph Rothmayer, a
The pathology of the skull is rather complex since, apart grave-digger, remembered the place where he had buried M ozart
from the injury, a mild craniofacial dysmorphism exists and preserved this skull at the tie of the disinterment and
secondary to a premature synostosis of the metopic suture replanning of the graves in 1801. He gave it to his successor
(PSMS) which is the subject of another article (Puech et al., Joseph Ratchoff who, in turn, gave it to my brother Jacques.
1989). These characteristics can be traced in Mozart’s HYRTL’.

0 1989 Butterworth & Co (Publishers)Ltd

0020-1383/89/060327~4 $03.00
328 Injury: the British Journal of Accident Surgery (1989) Vol. 2W No. 6
Figure 2. Print of the EDH on the inner calvarial surface. Notice
the broadened groove of the anterior branch of the middle
meningeal vessels and the left semicircular canal sectioned by the
saw (arrow).
Figure 3. Left and right inner calvarial surfaces. The grooves of
the middle meningeal vessels are clearly visible, as well as the
Sylvian crest (shown by arrow) on the right side.
portraits at all ages of modelling, which again corroborates
the authentic nature of the skull.
The outer left side of the skull reveals a linear fracture in
the temporoparietal area, 10 cm long, starting from the left
parietal eminence and radiating anteriorly and downwards,
Figure 4. Underlined print after shading with coloured powder.
The outer (I) or striated collarette, the intermediate area (2) with
bony concretions, the inner area (3) with residual or neoformed
vascular grooves and fracture (arrows).
zyxwv
towards the base with a bayonet-like shape at the parieto-
temporal junction (Figure I, lateral view). The bone has not
been displaced; the frachxe is perfectly consolidated in all its
length.
A visual examination of the inner calvarial surface of this
left side leads to the discovery of lesions which can be
noticed through the modification of the relief of the bony
surface (Figure 2). At the level of the parietal fossa and on the
underside of the most visible portion of the fracture, an oval
area of 8 x 6 cm obliterates the groove of the posterior
branch of the middle meningeal vessels and covers more
than one-third of the inner calvarial surface of the parietal
bone; the obliteration of the posterior branch of the middle
meningeal vessels is all the more conspicuous if the left side
is compared with the right side of the skull (Figrtre 3 ). The
edges of this bony print are slightly raised and striated (the
striations are oriented towards the centre of the oval area
and form an insertion collarette); the outlines of this col-
larette are polycyclic, well raised in the upper part of the
oval area (Figured). These outlines slowly fade out as they
run into the bottom of this area and are visible in the lower
part of the oval area only through the interplay of light and
shadow over the inner calvarial surface. A few bony irregu-
larities emerge from the striated edge and correspond to
ossification phenomena which have thickened the inner
table. This area is the testimony of the modifying adherence
of the dura mater on the underside of the fracture. The
striated collarette corresponds to a dura mater area, at first
stripped and partially lifted up, then reapplied and strongly
adhesive, yet becoming the seat of stretching and inflam-
matory ossification-inducing phenomena. Below this col-
larette, towards the centre of the lesion, it is possible to
notice an intermediate area, slightly uneven to the touch,
covered with irregularities and bony deposits. In the very
centre, i.e. in the middle of the oval area surrounded by the
collarette and the intermediate area with its uneven surface,
there remains an area of 2.5 x 4 cm where the grooves of
either meningeal (initial grooves) or neoformed vessels can
be distinguished. Along the edges of this central area, at the
junction with the granular intermediate area, a perfectly dis-
tinguishable insertion line provides evidence, together with
the irregularities of the striated collarette, of the adherence in
Puech et al.: Did M ozart have a chronic extradural haematoma?
this area of the thickened dura mater and/or a calcified neo-
membrane.
This print has modified with time since, in the outer part
of the lesion, at the level of the pterion, the main trunk of the
middle meningeal vessel and its bifurcation towards the
anterior and middle branch presents an altered groove as
compared with the right side. The perfectly distinguishable
groove is, however, broader, as if split into two; its edges are
blurred. On the outer edge of the print, they seem to have
been lifted up, then reapplied, thus broadening their initial
bed, with the anterior branch slightly shifted and with the
middle one marking again the thickened inner table at the
level of the striated collarette.
In our opinion these bony modifications on the underside
of the most visible portion of the fracture indicate the
presence of a chronic extradural haematoma (EDH) which
shrank and calcified as a secondary phenomenon. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Discussion
The linear fracture in the temporoparietal region, is oriented
anteriorly and downwards, without displacement. This type
of fracture may have been the consequence of a single fall:
perhaps after slipping on ice or down a flight of stairs. This is
a common accident. In 1985, falling was the second
commonest cause of accidental deaths in the USA (National
Safety Council, 1989).
The linear fracture in the temporoparietal region suddenly stretched up on his bed and bent his head towards
obliquely crosses the insertion site of this EDH and the
probable track of the posterior branch of the middle
meningeal vessels. Thus, it is highly probable that the
haematoma could have been secondary to an injury of the
meningeal vessels on the underside of the fracture; however,
the haematoma has appeared in a region where the dura
mater is anatomically easily detachable, and the haemor-
rhage may have started in any portion of this detachable
region.
The headaches did not appear immediately but after a
period of a few hours, a few days or may be even more, and
may have lasted only a fortnight or so.
Obviously, the patient has survived for a long period,
since the fracture is consolidated and the EDH has had the
time to leave its prints. In addition, the EDH has resolved,
partially at least, and over a period of time allowing for the
reshaping of the bone, since:
(a) The left Sylvian crest has disappeared zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
(Fig. 4),
(&I The markings of the cerebral convolutions on the left
temporal bone are obliterated.
(c) The main trunk of the left middle meningeal vessels
and bregmatic branch, close to the coronal suture,
have been lifted up and have broadened their bed
when reapplied.
What caused Mozart’s death? According to Carl Bar, Dr
T. F. Closset who was Mozart’s family doctor, established
the diagnosis of high miliary fever’ which was entered in the
register of St Stephen Cathedral in Vienna in 1791 (Bar,
1966). In 1830 Richard Wagner wrote that ‘most musicians
in Vienna believed that Mozart had been poisoned by Sal-
ieri’. In 1984, Dr Peter J. Davies published a thorough study
of ‘Mozart’s illnesses and death in which he attributed the
musician’s death to a Schonlein-Henoch purpura syndrome
(purpura rheumatica) complicated with nephropathy and Dr Hansjijrg Schmoller, Professor Dr Klaus Albegger, Dr
terminal mass brain haemorrhage (Davies, 1984).
Historically, we know that Mozart suffered from bad
headaches in the spring of IW O, more than a year before his
death, that he imputed them to a rheumatic fit and that, to
329
alleviate the pain, he lived with his head encircled with
bandages (Massin and Massin, 1985). His headaches disap-
peared but all the specialists of Mozart’s biography insist on
the fact that there had been a black year in the musician’s
creativity which lasted till December 1790. Mozart resumed
musical composition at the beginning of 1791 but he was ill.
He had some obscure organic premonition of his own death;
in August 1791, he fell ill again and was obliged to seek
constant treatment. In September, he was completely
exhausted and lost all his strength. Did he then have fainting
fits or short seizures?: ‘All at once, he would fall down
exhausted and we had to carry him to bed. (Nissen quoted
by Massin and Massin, 1985). In a letter to his friend Da
Ponte, in September 1791, he wrote My head is lost (ho il
cape frastomato), I am completely exhausted and cannot
take my eyes off the image of this stranger.. . I no longer
have to tremble; I can feel something that proves the hour of
my death is striking; I am close to death. At the end of
October, he confided to his wife: ‘I feel all too well that I am
not far from dying. I must have been poisoned. (Niemtschek
quoted by Massin (Massin and Massin, 1985)). On 20
November, Mozart had fainting and vomiting fits, his limbs
became rigid and partially paralysed; he fell onto his bed and
never rose from it again. He could not turn round on his bed.
The canary’s song was too loud, he had the bird removed
from his bedroom. On the eve of his death, he vomited black
blood (vomit0 negro?). On 5 December, at midnight, he
the wall, then fell into a comatose state. Fifty-five minutes
later, Mozart was dead (Massin and Massin, 1985).
In 1824, Giuseppe Carpani, who was Haydn’s biogra-
pher, vigorously defended Salieri and, in order to dispel the
suspicion that Mozart had been poisoned, published a letter
sent to Dr Guldener von Lobes who had been appointed to
conduct an investigation into the cause of Mozart’s death:
I am pleased to communicate to Your Highness everything that I
know about Mozart’s death. In the autumn, he was seized by an
inflammatory rheumatical fever which, at the time, was quite
common and which afflicted a large number of people. I heard of it
only a few days later when his state had already greatly worsened.
Out of sheer discretion, I did not pay him any visit but I was kept
informed by Dr Closset whom I saw every day or so. The latter
considered that Mozart’s disease was extremely dangerous and
feared the worst, that is a deposit into the head. One day, he met
Dr Sallaba (the Chief of the General Hospital in Vienna) and told
him straightforwardly: ‘Mozart is lost. A deposit cannot be
avoided. Sallaba immediately told me the news and, as expected,
Mozart died a few days later with all the symptoms which are
usually entailed by a deposit into the head. His death caused a
commotion but nobody ever suspected the possibility of a
poisoning.’ (Robbins Landon, 1987).
Since, at that time, there was no differentiation between
intracranial hypertension and meningism, how extra-
ordinary it is to discover, 200 years later, that the pathology
of Mozart’s skull from Hyrtl corroborates Dr Closset’s own
diagnosis.
Acknowledgements
We are indebted to Professor Dr Helene Matras, Professor
Johan Beck-Mannagetta from the hospital of Salzburg, Dr
Fritz Muhltau (Eugendorf) for the CT scans and radiographs
and Mrs Pascale Gugenheim for assisting in the preparation
of the manuscript.
330 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONML
Injury: the British Journal of Accident Surgery (1989) Vol. zyxwvutsrqponmlk
20/No. 6 zyxwvuts

dysmorphism in Mozart’s skull. J. Fore&c sci. 34,487.

References
Robbins Landon H. C. (1987) 1791, Mozart’s Last Year. London:
B5r C. (1966)Mom-f: Kruddeif Ed, lkgruhis. SaIzburg: Schriften-
Thames and Hudson.
reihe der Internationalen Stifung Mozarteum.
Davies P. J. (1984) Mozart’s Illnesses and Death, zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
M usical Em, Paper accepted 16 June 1989.
Cxxv.
Massin J. and Massin B. (1985) Mozart Fayart, 516-575.
National Safety Council (1989) Time 27 March, 27. Requestsfor reprintsshould be aaihsed to: Bernard Puech, 109
Puech B., Puech P. F., Tichy G. et aI. (1989) CraniofaciaI zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA
Avenue de la Mame, 59700 Marcq en Baroeul, France.