Thursday, October 15, 2015


Rebuilding a Curriculum of Caring for Healthcare

Vincent P. de Luise,  M.D., F.A.C.S.

Embedding a foundational  "toolkit" of  compassion in present and future physicians  is essential for  improved patient-physician engagement and communication, for physician professional satisfaction, and to prevent physician burn-out. This essay was written as a project paper for the Harvard University Advanced Leadership Initiative in which I was a 2013 Fellow.

          "May I see in all who suffer only the fellow human being" 
The Problem

Healthcare is broken and doctors are burning out.

That is the current mantra. Healthcare has gotten too expensive and impersonal, and there is inconsistent access to that care. Doctors are increasingly stressed and do not seem as engaged. Patients complain that their doctors are too busy and no longer listen. They ask, “Who will take care of me as a person and not just as a bunch of x-rays and lab test results?” I trust my doctor, but why does she seem so distracted and disengaged.” With all the technological advances of the last several decades, with genomics and PET scans, MRIs and super-subspecialists for every conceivable body part, what in the world is happening to the very doctors who care for us?  We have all this “High Tech,” but, where is the “High Touch?”  Is being a physician no longer a calling?  Has it become just another job?  Have patients become commodities? Why has doctoring gone astray?   


The American system of medicine has become organized largely as a disease-management system, and not as a health-care system, with diagnoses and treatments now reduced to an impersonal set of numerical codes. The concept of “caring” is no longer central to a discussion of “health care.” Patients are being viewed by their health care providers more as the sum of their diagnostic testing, or as the "I-patient," to use the term coined by Abraham Verghese M.D. of Stanford University, which is to say, the "virtual" patient, seen by the physician more through the lens of that physician’s pda, laptop or computer screen, and not as the real, live, hurting individual in front of them.

Of course, this is an oversimplification. There are legions of dedicated doctors who are serving an ever larger and aging population, and who do so with empathy.  But we as a society have indeed reached a watershed moment, a saturation point on many fronts. We now live ever more hectic and hurried lives, with hardly a moment to stop and reflect. With increasing demands on our time and resources, we have become more anxious, are getting less sleep, and are making poorer dietary choices. The cumulative effect of this leads to illness. However, when we get sick, we still want help, and we have come to expect that help to be prompt and caring. Yet, even when we do find that help, it seems to have become curiously robotic and disengaged.

It is crucial for the health care profession – now a health care system, comprised of collaborative teams of physicians, nurses, PAs, social workers, ethicists, and even economists – to remain focused, engaged, vibrant, and committed to caring. We cannot have it any other way. We cannot be a healthy society, with healthy citizens contributing to the success and happiness of that society, without an engaged health care team. We need to (re)-train physicians for a lifetime of caring, so that they continually demonstrate empathy in their work, and so that they themselves remain energized and happy in their careers, as this will improve patient outcomes over time.

Physicians cannot heal without caring, and they cannot care without first being informed by a core set of ideals that will carry through their training and into their professional careers.  Medical schools are set up to train physicians, and at many of them, there is already an awareness of these problems which I have outlined, and some initiatives are in place. But the system, engrained and with its own cultures and rituals and focused on disease management, has lost sight of its ideals, the ideals embodied in the Hippocratic Oath.
A Solution: Frameworks in Medical Humanities

We must re-embed a pathway of caring in our health care providers and transfer a lifelong set of skills that will inform them throughout their careers, certainly in the physicians who still lead the health care team. What is needed is an overarching and cohesive rubric, which I have entitled The Course in Compassion: A Curriculum of Caring (The Course). These skills can be identified, quantified and measured, and will populate The Course.  The Course will be divided into modules, and taught using an accepted paradigm in most medical schools, the Problem-Based Learning (PBL) format. Six core modules, which are termed “Frameworks in Medical Humanities,” would be taught over the four years of medical school in weekly two-hour sessions:

                Sensory experience                      Motor task

           Dance and Movement                  Motion Research

           Music Appreciation                      Rhythm/Melody-Making


           Narrative & Reflective writing       Diary-Keeping

           Mindfulness and Spirituality          Yoga/Meditation 


           Art & Aesthetic Appreciation        Drawing/Sketching

           Empathy Training & Acting          Care-Giving


Patients, physicians and physicians-in-training (medical students and house officers), medical school administrators, curriculum designers, The Association of American Medical Colleges, state licensing boards, and insurance companies – each of these entities is a stakeholder with a say in physician education. Adopting  The Course will require hours of time to teach its principles, hours that will have to be taken in part from existing core disciplines as anatomy, biochemistry, pathology, physiology and microbiology, as well as from time already assigned to the medical students for hospital wards and outpatient clinics. Conversations will need to occur at many levels to allow stakeholders to “buy-in” to  The Course as a foundational aspect of medical education.

However, The Course does not have to be built “from scratch.”  There exist a number of programs which have pilot projects aligned with my vision and ideas. A number of medical schools (Harvard, Yale, Weill Cornell, Johns Hopkins, Stanford, UCSF, and Columbia, inter alia) offer courses which champion aspects of  The Course. These existing initiatives are already testing the “proof of principle” of The Course. They are virtually all elective (that is, they are not required to graduate), but they exist. Therefore, it is not necessary to “reinvent the wheel” to populate the syllabus of The Course. Rather, The Course would be populated with “best practices” from existing efforts in addition to new initiatives I would add that have not yet been created or tested.

As Harvard Business School Professor Rosabeth Moss Kanter has written, change is often a result of Big Vision and Small Steps.” The Big Vision is creating and curating The Course in Compassion: A Curriculum of Caring (The Course). The small, essential and crucial steps are to pilot a series of medical humanities courses in all six modules, and, utilizing longitudinal data analysis, create metrics to measure patient outcomes and satisfaction over time, and physician satisfaction through their careers.

“It is far more important to know what person the disease has than what disease the person has.”  
Medical humanism is a core set of ideals that should be taught from college through medical school, internship and residency, and that should continue to inform a physician through their career. Medical humanism serves as a beacon and lodestone for how physicians listen, respond and care for their patients, as well as providing a road map for the well-being of a physician’s own mind and body over the course of their professional lives. The Course in Compassion will be a foundational paradigm around which physicians can be better engaged, and more motivated and passionate about providing care. Patients will achieve better outcomes, and physicians and their healthcare teams will enjoy longer and more fulfilling careers. This is an initiative which can no longer be fragmented, ad hoc and elective. The Course must become the epicenter of medical education and professional practice.

©   Vincent P. de Luise MD FACS

Friday, September 25, 2015


Vincent P. de Luise MD

What is pleasure?  

Pleasure can mean different things to each of us. For some it might be doing a sport, while for others it could be practicing yoga, eating ice cream, meditating,  sailing  a boat,  intimate contact with a loved one, having a religious experience,  or simply lying on a beach.
The Greeks talked of a dialectic of happiness being the combination of hedonia (pleasure) and eudaimonia (self-improvement and "doing good work: for others).

Certain pleasures have been studied neurologically, using a non-invasive brain scan called functional magnetic resonance imaging, or fMRI. An fMRI scan tracks changes in blood flow (hemoglobin) to various brain regions as a result of a stimulus. The more hemoglobin (and therefore, the more oxygen) to a specific brain site, the more activity.

A significant body of scientific research has been published evaluating brain responses to four specific pleasurable stimuli: eating chocolate, listening to music that causes “frissons," those thrilling “goosebumps” and “chills down the spine”  one gets to certain music), sexual climax,  and,  for those who unfortunately have a need for them, taking addictive drugs, i.e., drugs like cocaine and heroin that stimulate the brain’s so-called mu-opioid or cannabinoid systems. All four of these distinct, pleasure-inducing stimuli (chocolate, music, orgasm, addictive drugs) activate the same areas of the brain, anatomically adjacent to each other in a region called the medial forebrain (MFB)  

These MFB areas are:  1) the ventral tegmental area (VTA) ( specifically a little blob of neurons in the VTA called the nucleus accumbens); 2) the prefrontal cortex; 3) the anterior cingulate cortex (especially its subgenual area, above the nucelus accumbens (not shown));  and 4)  the amygdala.  

Axial transection of human brain       from

Pleasure, Reward and the Happiness Trifecta
These four brain areas are part of what cognitive neuroscientists describe as the Reward-Pleasure System. What we feel as desire and pleasure occurs in this system, which is also sometimes referred to as the Wanting/Liking System. This system tells the memory centers in the brain to pay attention to everything associated with that experience, so it can be repeated in the future. The Reward-Pleasure System is activated and controlled by molecular neurochemicals called neurotransmitters, specifically dopamine, serotonin, and oxytocin. Evolutionarily, the Reward System is an ancient pathway; the use of dopamine neurons to interconnect behavioral responses to natural rewards has been observed in various species of worms and flies, whose ancestors were around two billion years ago!

These three neurotransmitters - dopamine, serotonin and oxytocin - mediate every pleasurable moment, including the “giving experience,” so much so that Eva Ritvo M.D., vice-chair of psychiatry at the University of Miami School of Medicine, has termed them the “Happiness Trifecta.” 
Dr. Ritvo asserts that "giving is a powerful pathway for creating more personal joy and improving health. Any activity that increased the production of these neurotransmitters will cause a boost in mood and cause happiness. "Dopamine is connected to motivation, reward and arousal. Serotonin is connected  to memory, learning, sleep and appetite.  Oxytocin, nicknamed "the cuddle hormone," has a powerful effect on the brain and the body. When oxytocin begins to flow, blood pressure decreases, bonding increases, social fears are reduced, and trust and empathy are enhanced” Dr. Ritvo explains. 
Giving to others triggers a release of oxytocin, which boosts mood and counteracts the stress hormone, cortisol. The  higher the level of oxytocin, the more one wants to help others, Interestingly, when oxytocin is boosted, so are dopamine and serotonin. According to Dr. Ritvo, "even small repeated boosts of the Happiness Trifecta will produce a benefit. Donating money or time... are wonderful ways to give. When we step outside of ourselves long enough to help someone else, something wonderful is waiting for us when we return: the Happiness Trifecta neurochemicals are all boosted!"

Nerve-nerve cables, called neural networks, interconnect the pleasure centers. These neural networks work electrically, as well as chemically through the neurotransmitters.  When we experience pleasure, we are, in essence, getting a reward.

Much of pleasure has to do with what cognitive neuroscientists call the "Wanting/Liking" system in the brain, which is part of the "Reward-Pleasure" circuit.

Hedonic Hotspots, Enkephalins and Anandamides

Things are actually a little more complicated than the Happiness Trifecta of dopmaine, serotonin and oxytocin. Researchers Morton Kringelbach, Terry Robinson and Kent Berridge at the University of Michigan have discovered that there are neurochemical differences in our brains between “wanting” something and “liking” it.

The “Wanting”  or "Desire" part of the system is largely mediated by dopamine, the same neurotransmitter that is involved in drug addiction with cocaine and heroin, for example. Dopamine, according to Berridge, contributes more to motivation ("Wanting") than to the actual sensation of pleasure ("Liking") itself.
The “Liking system” in the brain is different from the “Wanting” system. The “Liking”, or “Pleasure" part of the "Wanting/Liking" system, is mediated by  neurotransmitters called enkephalins and anandamides; and there specific areas in the brain which  are full of these neurotransmitters and serve as way stations for "Liking."  Berridge calls these “Liking" system brain areas “hedonic hotspots.”   (The word “hedonic” means "pleasant", (remember the ancient Greeks and hedonia and our modern-day notions of  hedonism).
 The enkephalins bind mostly to what are known as opioid (mu-opioid) receptors in the brain. The anandamides, in contrast, bind to cannabinoid receptors (called this way because they are similar to  molecules in the cannabinoid series, which are also contained in marijuana). Yes, we humans make our own opioids and cannabinoids in our brains, in much smaller concentrations than if they are taken externally. Nonetheless, isn't it curious that opioids and cannabinoids are endogenously manufactured in our brains !?
Two key hedonic hotspots in the brain are a specific region in the nucleus accumbens called its medial shell, and another area, the ventral pallidum, which is right below the nucleus accumbens (and different from the ventral tegmental area discussed earlier).
A bite of chocolate, for example, prompts neurons in these hedonic hotspot areas to release neurotransmitters in the encephalin family,  which are endogenous opioids that are made in our brains. According to Berridge, these enkephalins then interact with receptor proteins that cause the release of anandamide, our brain’s own home-made version of a marijuana cannabinoid. The anandamide, in turn, can interact with the neuronal receptors, producing more enkephalin and intensifying the pleasurable experience.
Interestingly, these anandamide (cannabinoid) receptors are located much more densely in the cerebral cortex ("the "thinking brain") than in the limbic system in the mid-brain (the "subconscious brain"). What does this all mean? It means that when we desire, seek, or are motivated for pleasure, we release lots of dopamine to get what we want, and when we get what we desire ("sex, drugs, rock and roll," and chocolate), we really like it, through the release of enkephalins and anandamides.
It is fascinating, and not coincidental, that music is as powerful a motivator and engages the very same receptors and brain loci, as drugs, sexual climax and chocolate. Music may have a foundational, evolutionarily adaptive role in our brains.

That is the topic for the next A Musical Vision essay.
@ Vincent P. de Luise MD 2015

Kringelbach, M. and Berridge, K., The Joyful Mind, Scientific American, August 2012.


Friday, August 28, 2015


I presented this talk at a Harvard University  "Think Tank" on Health and Aging on April 13,2013. The two-day conference, held at the Charles Hotel in Cambridge, Massachusetts, brought together prominent scholars from the Harvard School of Public Health, as well as global experts in economics, health care policy and longevity, for a fascinating and thought-provoking colloquium on the demographics and consequences of aging in all societies.

It remains difficult for physicians to confront and accept end-of-life issues in their patients, because our professional education and ethos inform us to do all we can as doctors to fight disease and prolong life. Can we afford to continue to do so with no limits and constraints? Even if we could, should we? Those are the moral and existential questions which confront us today.

For ophthalmologists, it is extremely difficult to accept end-of-sight issues in our patients. 

Over the decades, our specialty has proudly trumpeted its splendid and  life-enhancing victories over various causes of visual loss: certainly against cataracts, where we can safely and permanently remove them, replace them with a plastic intraocular lens, and restore sight, and we have been performing that miracle for years. We have been less successful, however, in the management of glaucoma, macular degeneration and diabetic retinal disease, the other three leading causes of blindness, not only in developed societies, but increasingly in less developed ones as well, as the world's population is aging. These are diseases which we cannot yet cure, and over which we are only beginning to have some control. 

Based on cross-sectional studies, in the United States alone, almost three million people have advanced macular degeneration, my own mother being one of them, and over a million more have end-stage glaucoma or advanced diabetic retinal disease. There is a race, indeed a heated one, between research and development to bring new therapies to bear against these diseases, and the increase in their prevalence as we live longer lives.

The burden of those three diseases – glaucoma, macular degeneration and diabetic retinal disease - continues to loom over us, as they affect an elderly population which grows ever larger. The economic burden of these diseases thus continues to increase, as their progression causes more visual loss and medical visits, and more costly rehabilitation, low vision services and custodial care.  And what about the emotional burden? The emotional burden, for the patient and their family, is incalculable.

What is the price of vision, which is to say, what is the price of not going blind?

A 2012 global eye health survey performed in Spain, Russia, China and the US found that almost 70% of respondents in each of those countries would rather lose a limb, or ten years of life, than lose their sight.

Of course, eye specialists constantly preach preventative measures: annual eye exams for those over age 50, cessation of smoking, wearing UV-coated sunglasses when outside, weight loss, and eating a balanced diet, as the food journalist Michael Pollan reminds us, of real (that is, not processed) food, mostly plants, and not too much. To this I would also recommend the eating of cold water fish, in moderation, for their salutary omega-3 fatty acids, and to supplement with safe doses of Vitamins C and E, and the co-enzymes zinc, lutein and zeaxanthin. 

But we don’t always see the results of these strategies in clinical practice. At times, we face other more painful realities. 

So, how does an eye specialist deal with the patient and their family when that patient, who has end stage macular degeneration, glaucoma or diabetic eye disease, says to us, fearfully and plaintively, “Doctor, am I going to go blind?” ?

Our knee jerk reaction is, of course, that there must be something else to offer: to add another drop, to try one more injection, one more procedure, one more surgery. While we have been able to transplant corneas for over a century now, we cannot yet successfully transplant retinas or optic nerves, let alone whole eyes. So there are limits to our current technology, and when we do have to say to that patient, “I am sorry, there is nothing more to offer,” then what happens? Where does that conversation go? 

That patient is usually already infirm, perhaps with degenerative joint disease or rheumatoid arthritis, or suffering from the relentless consequences of bad choices over a lifetime, such as smoking and poor dietary habits, which have led to pulmonary disease and the metabolic syndrome of atherosclerotic cardiovascular disease, diabetes, and hypertension.

Yes, the patient is certainly alive, but what will the quality of that already difficult life become now, as they progressively lose vision? How will that patient now imagine their grandchildren, whose faces they have blissfully enjoyed seeing, often too infrequently? How will they drive their car, watch their favorite television shows, do their puzzles and sudokus, read their books and e-mails, or call their friends, all those comforting activities that stem the tide of the loneliness, and now the darkness too, that inexorably envelops them? For a few patients, as I have poignantly witnessed over the decades, end-of-sight becomes a life no longer worth living. One such narrative documents the arc and trajectory of one person's vision, and at once is a constant reminder to me of why I became  a physician and surgeon in the first place:

In 1995, I had the privilege of assuming the eye care of a prominent modern artist, a brilliant and inquisitive man, vibrant and trim and athletic even in his late 70s. His artistic style could be described as a wonderful amalgamation of the freedom  and gesture of the abstract expressionism of Pollack with the monumentality of the cubism of Cezanne and Picasso.

He had been diagnosed with cataracts, and was despondent because the cataracts had made it increasingly difficult for him to actualize his artistic vision and creations. I performed cataract surgery in both eyes, a few months apart,  and he and his art seemed to flourish afterward; indeed his palette regained the blues and purples and an overall vibrancy that the cataracts had stolen.  I remember giving a lecture on art and visual perception about a year after his cataract surgery, and he graciously came to that talk to explain to the audience the changes in his visual perception and his art before and after the eye surgery.

About five years later, for no explicable reason, he developed a condition called ischemic optic neuropathy (a "stroke" of the the optic nerves) in both eyes, a few months apart, with rapid and profound visual loss. The optic nerve is part of the central nervous system, an extension of the brain, and cannot regenerate if damaged. I sent him to the best neuro-ophthalmologists for subspecialty care.

A few months later, after extensive evaluations and treatments, he came back to me for follow-up, still with substantial loss of vision in both eyes. As I examined him, he leaned in and said to me, almost in a whisper, “Vincent, if I cannot paint, I cannot live.” About six months after that second eye had sustained profound visual loss from the stroke, he passed away. 

The memorial service was held in New York City, about a hundred miles from my office. As life would have it, I was scheduled for a busy  surgery session that day and I did not make it down for that very personal event.

About a month after the memorial, I received a note, which I still have on my desk. The note was from the artist’s spouse, herself a leading voice in American literature. lt read, “Dear Vincent,  He was so devoted to you. You were the architect of his eyes.” She told me that he had fallen, was hospitalized, and died of complications, yet I still wonder about the last days and thoughts of that wondrous mind and spirit.

No, ophthalmologists cannot accept end-of-sight.  Not easily at all. And that is how it must be, as it will continue to catalyze us to find cures for all causes of visual loss, and so that our patients, and at some point we are all patients, can enjoy all the beauty of this world while we are still here.

@ Vincent de Luise MD  A Musical Vision

Monday, July 6, 2015

Mozart in Retrospect

This essay was originally published as  "Perspectives on Mozart" in The Friends of Mozart Newsletter, Spring 2011. I have updated the research to include new findings and am republishing the essay here.

Wolfgang Mozart at age 26
by Joseph Lange (Mozart's brother-in-law)
(The  unfinished 1789 oil portrait,
 with the head cut and pasted here
from the orinal and completed1782 oil)

Who was Mozart?

Of course, we all know his music. The music ! That music, so refined and richly textured, melodic, timeless, ineffably beautiful and sublime.

But, who was Mozart? Who was the man behind those genius creations? So much has been written and said about Johannes Chrysostomus Wolfgangus Theophilus Mozart, much true and vetted, yet  more than a little hyped, hyperbolic and apocryphal. There are so many paradoxes with Mozart; for example, that posterity calls him  "Amadeus" when that wasn't even on his birth certificate and a name he never used in his lifetime.

There are many Mozarts. There is the 18th century Mozart, the undiscovered and neglected artistic genius.  There is also the re-imagined 19th century Mozart, a perfect porcelain musical god on a pedestal;  and now the truer and deconstructed 21st century Mozart, the first  "free-lance" musician, recognized as peerless and a foundational composer for so much that came after him. For many listeners, one or another of the above "historical" Mozart remains their truth, regardless of The truth.

Can we ever know Mozart only by his music, someone whose music seems at once so joyous, and yet is always tinged with sadness? Perhaps not. So, let us look at Mozart, the man, by revealing him through aspects of his physiognomy and personality, and by his legacy and "effect," gaining in the process  insight into this most wondrous of stars star in the musical firmament. 

The observations below are derived from the vetted written literature and scholarship. They paint a portrait of a man with all the imperfections and warts of humanity, who at the same time possessed a gift so rare  andso extraordinary, that its output, that music which we so adore, has been likened to the melodies and rhythms that underlie the universe itself.

W. Mozart
by Barbara Kraft
The posthumous portrait of 1819
Gesellschaft der Musikfreunde, Wien
What did Mozart Look Like?

More than any other composer, Mozart's image remains one of the least certain. An influential German biographer of the early 20th-century, Arthur Schurig, asserted that, "Mozart has been the subject of more portraits having no connection with his actual appearance than any other famous man; and there is no famous man of whom a more worshipful posterity has had a more incorrect physical picture than is generally the case with Mozart." Can any painter truly capture genius in a portrait? The answer is self-evident.

Given this perspective, descriptions by Mozart's contemporaries are the most illuminating. His sister Maria Anna (Nannerl) commented that "my brother was a rather pretty child," but after a bout of smallpox that both siblings sustained in 176l  (he, age 11; she, age l6),  his looks were permanently disfigured by scars. Nannerl went on to describe Mozart in her reminiscences in 1792, a year after his death, as being "small, thin, and pale in color and entirely lacking in any pretensions as to physiognomy and bodily appearance."

Mozart at age 14, with the Order of the Golden Spur
The 1777 copy of the lost 1770 original oil
(anonymous painter,
Accademia Filarmonica, Bologna)

Mozart is said to have suffered a temporary "blindness" as a result of the marked inflammation of his eyes (this could have been from a keratitis (a corneal inflammation) secondary to the Vaccinia virus of smallpox) and developed facial scars. Yet, in 1770, three years after that same smallpox epidemic,  the composer Johann Adolph Hasse wrote that "the boy Mozart is handsome, vivacious, graceful, and full of good manners." 

Michael Kelly, the tenor much beloved by Mozart himself, and the man who sang the roles of both Don Basilio and Don Curzio in the premiere of Le Nozze di Figaro (The Marriage of Figaro), famously reminisced about Mozart in 1826: "He was a remarkably small man, very thin and pale, with a profusion of fine hair, of which he was rather vain. He always received me with kindness and hospitality. He was fond of punch, of which I have seen him take copious draughts. He was kind-hearted and always ready to oblige; but so very particular that when he played, if the slightest noise were made, he left off."

Thomas Attwood, who was Mozart's composition student between 1785 and 1787, recalled his teacher being "of cheerful habit, though lacking a strong constitution." Attwood also remembered that  "in consequence of being so much over the table when composing, he (Mozart) was obliged to have an upright desk and stand when he wrote."
There is evidence that Mozart was small in stature; it has been calculated that he stood about 1.63 meters, or five feet, three inches in height. Mozart himself corroborated this when, as a 14 year-old in April 1770, he wrote to his sister from Rome about a visit to St. Peter's Basilica, stating that "I had the honor of kissing St. Peter's foot in the church, and having had the misfortune of being so small, I, that same old dunce Wolfgang Mozart, had to be lifted up." 

In 1777, at Mannheim, Mozart first met the Webers, the family of musicians who would figure greatly in his biography. Although he later married Constanze Weber, he fell initially in love with her elder sister, Aloysia, who spurned him. Many years later, Aloysia was asked why she rejected so famous a man as Mozart, to which she purportedly replied, "I did not know, you see... I only thought...well...he was such a little man."

Mozart himself may have put it best when he stated, "Mozart magnus, corpore parvus" ("Mozart the great, small in size.")

What Ailed Mozart? His Health and lllnesses

For someone possessed of such remarkable productivity, Mozart was often quite sick. To be sure, his ill health was in large part a consequence of his era,  to the endemic diseases and epidemics to which he was inevitably exposed as a result of extensive travels, particularly those undertaken in childhood and youth. For example, in the fall 1765, while on the grand tour that included the Hague, first Nannerl, then Mozart, contracted typhoid fever, and both children almost died.

There is a large body of  literature regarding Mozart's illnesses, much of it conjecture (as an autopsy was never performed). The following is a partial summary of what Mozart may have contracted during his life, as deduced by a careful reading of the primary medical literature (in German) of his physicians, and by the writings of friends and observers:  recurrent streptococcal infections, erythema nodosum (a nodular and painful skin disease related to a systemic inflammation),  typhus, variola (smallpox), quinsy (tonsillar abscess), recurrent bouts of acute rheumatic fever and  renal (kidney) disease.

Some of these illnesses may have led to  chronic endocarditis (heart disease) and chronic renal   disease, specifically a post-streptococcal glomerulonephritis, which in turn could have led to renal failure. Mozart may also have had antimony over-dosage (he  was self-medicating with this potential poison), a subdural or extradural hematoma (vide infra) and hypertension. There is also the possibility that he had acute trichinosis (Hirschmann Arch Int Med 161:1381-1389, 2001.  Indeed, Mozart wrote to Constanze in  October 1791 that had eaten some under-cooked pork cutlets).

Dr. Peter G. Davies, a gastroenterologist and Mozart and Beethoven biographer from Melbourne, has posited   that Mozart also suffered from the manic-depressive disorder cyclothymia (J. Roy. Soc. Med. 1991). The possibility of cyclothymia, quite common in many creative types, would explain some of Mozart's bursts of extraordinarily intense creativity, such as in the summer of 1788, when he wrote the last three symphonies, his greatest in the genre, works that were composed with no known commission, nor which Mozart ever heard performed except in his imagination. On the other hand, such an explanation must be weighed against several periods of sustained productivity; witness the years 1784 to 1786, when Mozart created an extraordinary number of masterworks in every musical genre.

A  distinction should be made between these chronic illnesses and Mozart's presumed medical conditions which were immediately proximate to and causative of his abrupt and early demise.  Dr. Davies has suggested that Mozart died of  the consequences of a cerebral hemorrhage resulting from hypertension secondary to an acute nephritis (kidney inflammation) from Henoch-Schönlein purpura, a rare disease which can result from streptococcal infection; Mozart was likely severely anemic and already in uremic coma; to compound matters, his physician,  Dr. Thomas Franz Closset (one of the best in Vienna), bloodlet him of almost a liter of blood, which only served to exacerbate the anemia and hastene his demise.)

Mozart's death certificate (as mentioned above,  there was no autopsy) stated “hitziges Frieselfieber” (“heated miliary fever”), a common clinical diagnosis of that era, but one which is far too non-specific a term on which to opine a diagnosis; it may relate to the inflammatory rash of rheumatic fever, which in turn may have been a result of Mozart's presumed repeated streptococcal ("strep") infectionsRichard Zegers M.D. (Ann Int. Med. 2009) reviewed the records of 5,011 Viennese adults who died in the two months before and after December 1791, and compared that data to comparable months in 1790 and 1792,  finding a much higher than normal rate of death from an epidemic of presumed streptococcal infection.    

In early 1791, Mozart fell , landing on his left temple, and as a result, may have sustained an extradural hematoma (a blood clot outside the brain membranes) that manifested itself in a fracture to his skull (M. Drake,  Neurol 43: 2400-2403, 1993).

The putative Mozart calvarium (a a skull missing its mandible)
in the Mozarteum, Salzburg

A skull in the possession of the Mozarteum in Salzburg, exhumed in 1801 by the successor of the grave digger who buried him on December 1791, and whose condition reflects such a trauma, may be that of Mozart, but forensic examinations in 2006 were inconclusive.
Haydn on Mozart, and the author Katherine Pilcher on them both

Franz Joseph Haydn recognized Mozart's genius during his lifetime and before most anyone else had realized this. Haydn said as much to Leopold Mozart at a February 12, 1785 string quartet party at which the last three of Mozart's six string quartets dedicate to Haydn were performed. Haydn said:  "I tell you before God, and as an honest man, that your son is the greatest composer known to me in person or by name.He has taste, but above all, he has the greatest knowledge of composition." 

After Mozart's death, Haydn wrote to his friend Michael Puchberg in 1792, that, " for some time I was quite beside myself over his death, and could not believe that Providence should so quickly have called away an irreplaceable man into the next world. Haydn went on to write that "posterity will not see another talent as his in a hundred years."

The author Karoline Pilcher was a contemporary of Mozart and Haydn, and knew both of them personally. In the 1820s, in her reminiscences, Pilcher writes this about them (trans lated here from the German):
"Mozart and Haydn, whom I knew well, were men who displayed in their personal intercourse no other outstanding mental ability and almost no sort of intellectual cultivation of a learned or higher education. Everyday character, flat humor and with the first (Mozart) a scantly sensible lifestyle, was all they publicly manifested, and yet, what depths, what worlds of fantasy, harmony, melody and feeling, lay concealed within these modest exteriors ! Through what inner revelation came to them this understanding, how they must have seized it, to bring forth such powerful effects, and express in tones, feelings, thoughts, passions, that every ear must feel with them, and be spoken to us as well as from greater depths."

The Mozart Effect

Almost as abundant as the research and speculation devoted to Mozart's health, illness, and death, is the literature on the physical, cognitive, and psychophysiological effect of Mozart's music on the listener. This discussion, originally grounded in rigorous scientific study, has formed the basis of later, pand opular claims revolving around the so-called Mozart "effect."

The French otolaryngologist Alfred Tomatis coined the term, the Mozart "effect"  in a 1991 book entitled, Pourqoui Mozart?   Tomatis developed the concept of auditory processing integration. While examining opera singers who were having trouble reaching and singing certain notes in tune, he discovered that those singers all had a coincident hearing defect in the same frequency as the vocal problem.

This relationship between audition (hearing) and phonation (voicing) had never been observed or reported previously. Tomatis posited that "the voice can only reproduce what the ear can hear." He subsequently focused his audiological research using Mozart's violin concertos, as well as Gregorian plainchant, at different hearing frequencies, to improve auditory processing, to "retrain the ear," if you will, of patients who had acquired sensori-neural hearing loss. Among those who gained improvement not only in their hearing as well as in their "voicing" by this technique were the actor Gerard Depardieu, the baritone Benjamin Luxon, and the popular singer Sting (Gordon Sumner).

In 1993, the researchers Frances Rauscher, Gordon Shaw and Katherine Ky ,working in the department of neurobiology at the University of California, Irvine, further investigated a “Mozart effect" in an experiment which was published in the October 14, 1993 issue of the scholarly scientific journal Nature , under the title: "Music and Spatial Task Performance." 

The Rauscher team found that a group of students who were "pre-treated" for ten minutes by listening to the first movement and part of the second movement of Mozart's two-piano sonata in D major, K. 448, performed better on a spatial-task reasoning Stanford-Binet test than when the same students were pre-treated with a "relaxation tape" or after thy had sat in silence for ten minutes prior to testing. (Stanford-Binet testing is a form of IQ test, which measures aspects of verbal and non-verbal reasoning. In the Rauscher study, the students were given a paper folding and cutting test: a piece of paper is folded several times and then cut. The students had to mentally "unfold" the paper and choose the correct shape from the numerous examples that they were given).

These results were temporary, lasting only through the time taken for the experiment, about fifteen minutes, and were specifically related to visual-spatial task reasoning, and not to other measures of intellect. More recent research has both confirmed and contradicted the results of the Rauscher  study, among them "Arousal, Mood, and the Mozart Effect," Psychological Science (2001; l2l3); "Re-examination of the Effect of Mozart's Music on Spatial Task Performance," Journal of Psychology (1997; 13l/4); "'Brain-Based"' Learning: More Fiction than Fact," American Educator (2006; fall issue); and "Prelude or Requiem for the Mozart Effect," Nature (1996).

The music educator and researcher Don Campbell was influenced by Tomatis' work and the results of the Rauscher study, and went on to write the best-selling 1997 book The Mozart Effect: Tapping the Power of Music to Heal the Body, Strengthen rhe Mind, and Unlock the Creative Spirit.

Campbell's claims went far beyond spatial intelligence improvement to include notions that Mozart's music improved mental health and cognitive ability.  Over the decades, the Mozart "effect" as put forth in Tomatis's original work, and subsequent misinterpretations of the Rauscher  study  have devolved into an assertion that early childhood exposure to classical music (specifically, Mozart's music) can ipso facto bestow a beneficial effect on mental development, leading to advantages and a range of lifetime achievement.

However, there a kernel of scientific fact in the studies. As an ophthalmologist with knowledge of the neuroanatomy of the sensory system, I agree with the findings that there is a feature of the music of Mozart (and several other composers, see below), which modifies or enhances brain function (J. Jenkins, Royal Society of Medicine, 2001).

Neurologists John Hughes and John Fino at the University of Illinois subjected to computer analysis fully 8l works by Mozart, 67 of Johann Christian Bach, 67 of J.S. Bach, and 150 works by 55 other composers. They found that the music of Mozart. as well as that of J.S. and J.C. Bach, but not the music of the other composers, contained a very high degree of long-term periodicity. They hypothesized that these specific harmonic patterns and chordal repetitions, found especially in the music of Mozart, J.S. and J.C. Bach (the latter was an influence on the young Mozart) have a function in brain coding: they act to align or "symmetrize" neurons in certain regions of the brain involved with auditory processing and memory (specifically the parieto-occipital cortex and right pre-frontal cortex) and which can lead to heightened mental capacity and function, even if only temporarily. There is neurophysiological evidence for a Mozart "effect" (as well as a "J.C. Bach effect" and a "J.S. Bach effect").

There are fundamental and physiological aspects that underlie the "Mozart effect" and to the music of Mozart in general - the pleasure, felicity, and depth of emotion of his music can provoke and stimulate a heightened intellectual, even spiritual awareness, and rapture.  Perhaps the timeless remark, ascribed to the Nobel-prize winning physicist Albert Einstein, himself a genius, resounds most compellingly to us today, that "Mozart's music is of such beauty and purity that one feels that he merely found it, that it has always existed as part of the inner beauty of the universe waiting to be revealed."
Vincent P de Luise, M.D.
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