What would you do if you were one of the smartest and most beautiful women in Europe and you were married to Gustav Mahler, a famous classical music conductor and composer who was 19 years older than you, a workaholic, chronically depressed and impotent?  

His Early Years and Education
Gustav Mahler was born in 1860 in Bohemia (now the Czech Republic) to German-Jewish parents who were children of street peddlers.  That set the stage for his lifetime of always feeling that he did not belong in the society in which he traveled.  His father rose above his impoverished upbringing by opening a successful distillery and tavern.  They had 14 children, as was the custom for Jewish parents at that time, but nine of Gustav's siblings died in childhood. By age five, Gustav was an accomplished piano player and at 10 he played many public performances.  By age 15, he was such a good pianist that the famous piano virtuoso, Julius Epstein, accepted him as a pupil at the Vienna Conservatory. In the orchestra there, he played the drums.  After receiving a degree, he supported himself by giving piano lessons and at age 20 he was hired as an opera conductor.  
A Stormy Musical Career 
At age 25, he received a six-year contract with the prestigious Leipzig Opera, but he resigned the next year to become an assistant conductor at the Neues Deutsches Theater in Prague. He then went through a series of conducting jobs and had frequent disagreements with the orchestra members and fellow conductors.  
In Leipzig, Mahler met Carl von Weber, grandson of the composer Carl Maria von Weber, who commissioned him to write a revision and conduct his grandfather's unfinished opera Die drei Pintos ("The Three Pintos").  He fell in love with von Weber's wife Marion, which eventually estranged him from both husband and wife, and at age 28, he had an argument with the management of the opera and resigned his appointment.  He then went to work in Prague to direct a revival of Die drei Pintos and was subsequently fired for arguing with orchestra members and soloists during rehearsals.  He then conducted several operas at the Stadttheater but was forced to resign because of lack of funds from poor attendance at his concerts.


Conversion to Catholicism
He realized that as long as he was a Jew, he would never be appointed conductor of a major European orchestra. In 1897 at age 37, he converted from Judaism to Catholicism, even though he had spent most of his life denying the existence of a god.  Two months later he was appointed conductor of the prestigious Hofoper in Vienna. That same year, the city of Vienna elected an anti-Semitic conservative mayor, Karl Lueger, who publicly stated: "I myself decide who is a Jew and who isn't."   Mahler introduced 33 new operas and renewed 55 more but he continued to fight with singers, orchestra members and management.  In December 1907 at age 47 he was arguing with everyone, so he accepted the job of conducting the New York Metropolitan Opera part time.
His Marriage to Alma
In November 1901, when he was 41, he met Alma Schindler, a beautiful Viennese socialite.  He proposed to her three weeks later but her parents tried to dissuade her from marrying him because he was born Jewish and was 19 years older than Alma.  They married March 9, 1902 after she became pregnant with their first daughter.    The marriage was rocky from the start because Alma wanted to be a composer and poet, and Mahler insisted that only one composer could exist in a family.  He worked all the time and expected utter devotion from his wife. She gave up composing, but she loved to party, so she spent a lot of time with Gustav's colleague Hans Pfitzner and her old lover, Alexander Zemlinsky.  Gustav's work habits depressed her so much that she entered a sanitarium to recover from her loneliness.  There she met and had an affair with architect Walter Gropius.  They continued their affair long after they both left the sanitarium. 
Gropius "mistakenly" sent a love letter to Alma that was addressed to Gustav Mahler. Mahler was hurt and furious and was so depressed that he consulted the father of modern psychiatry, Sigmund Freud.  A discussion of the interaction between Freud and Mahler can be found in Australas Psychiatry (Jun, 2013;21(3):271-5).  Today Mahler's genius would be linked to bipolar disorder in which he created brilliant music when he was manic and could not create at all when he was depressed (Orv Hetil, 2004 Aug 15;145(33):1709-18).  Freud told him to choose love over creativity (Psychoanal Stud Child, 2000;55:87-110) and Mahler regained his potency, stayed in his marriage and encouraged his wife to return to composing her own music. He edited her songs and published them for her. He dedicated his Eighth Symphony to her.  She responded by saying she would stop seeing her lover, but did not keep her promise. Throughout her marriage she continued to have affairs, but never divorced her husband.  


Medical Problems
He suffered all his life from hemorrhoids that required at least three surgeries, and from "migraines that are common in anxious, striving, perfectionistic, order loving, rigid…..people." (Cecil Loeb Textbook of Medicine. Saunders 1967, p1477).  At age 29, he developed a chronic and recurrent sore throat that would eventually kill him.  That same year, his father, mother and his sister Leopoldine all died.  When he was 35, his younger brother Otto committed suicide.  
In 1907, both of their daughters developed scarlet fever from a strep infection.  Anna recovered, but Maria died.  Gustav then developed chest pain that was diagnosed as a heart infection and was told not to participate in any vigorous activity.
Final Illness and Death
In November 1910, the Mahlers were in New York for a very busy New York Philharmonic season of concerts and tours. His sore throat worsened, and in February 1911, his temperature rose to 104 F, but he still conducted what would be his last concert (Trans Am Clin Climatol Assoc, 1971;82:200-17).  He consulted Dr. Emanuel Libman who drew blood and cultured a streptococcus that was causing his heart infection (Med Clin (Barc), July, 2003;121(5):184-5). Mahler was one of the first people to receive an accurate microbiological diagnosis for his fatal illness and he was given an experimental antistreptococcal immune preparation. The serious strep infection in his heart damaged his heart valves (Br Med J (Clin Res Ed,)1986;293:1628–1631) and there were no antibiotics at that time, so there was no cure.  He was told that he was going to die.   On April 8, the Mahlers boarded a ship for Europe and on May 18, he died in Vienna. Alma did not attend his funeral but many of the most famous people in classical music did, including Arnold Schoenberg, Bruno Walter, and Alfred Roller.  One of Alma's former lovers, the painter Gustav Klimt, was also at the funeral. 


After His Death 
Alma Mahler survived her husband by more than 50 years, dying in 1964. She married Walter Gropius in 1915, divorced him five years later, and married the writer Franz Werfel in 1929. In 1940 she published a memoir of her years with Mahler, entitled Gustav Mahler: Memories and Letters.  Their daughter Anna Mahler became a well-known sculptor who died in 1988.
According to her memoirs, Alma had affairs with:
• her music composition teacher Alexander Zemlinsky, who also taught composer Arnold Schönberg
• Walter Gropius, a world famous architect who founded The Bauhaus Design School in Weimar in 1919 and also was chairman of the department of architecture at Harvard University
• artist Gustav Klimt
After Mahler died, Alma was a rich widow thanks to her widow's pension and his inheritance. 
• She had an affair with composer Franz Schreker 
• She rejected  a marriage proposal from Joseph Fraenkel, Mahler's doctor. 
• She had an affair with world-famous biologist Paul Kammerer, and when she left him, he threatened to shoot himself at Mahler's grave.
• The famous painter, Oskar Kokoschka, painted a picture of her and immediately fell in love with her.  Over the years, he sent her more than 400 love letters.  They started a world-famous affair in which he painted her whenever they stopped making love.  She soon became pregnant and had an abortion. 
• While she was still living with Kokoschka, she wrote to Walter Gropius: "I long for a will that would wisely guide me away from what I've acquired, back to what is inborn."   Gropius was ecstatic and asked her to marry him.   They married and had a little girl. He worked all the time and he complained bitterly throughout their marriage about her affair with the crazy Kokoshka.
• She responded to his complaining by writing to the famous author, Franz Werfel, who had written several poems that she adored.  In 1917, the 27-year-old Werfel, 11 years younger than Alma, went to her salon (evening meetings of writers and other intellectuals) and fell in love with her.  In 1918, he got her pregnant while she was still married to Gropius.  
• In 1920 she divorced Gropius, when she had already been living with Werfel for more than a year.  She married Werfel because, unlike Gropius, Werfel did not bring up her past affairs, and he knew a lot about classical music.  She soon tired of him and wrote in her diary: "I don't love him anymore."  She did not divorce him, probably because she had spent virtually her entire life living in a relationship, but they lived apart much of the time. 
• She supported the Nazis and had an affair with Johannes Hollnsteiner, a 37-year-old theology professor and priest who supported Hitler. 
• While still married to Werfel, she spent a lot of time with conductor Bruno Walter.  Her other affairs included composers Arnold Schoenberg, Alban Berg and Hans Pfitzner, and pianist Ossip Gabrilowitsch.   
• She was impregnated six times by four men: three times by Mahler, and once each by Kokoschka, Gropius and Werfel. 


After her death in 1964, Alma Mahler became known to college students everywhere through a song written by Tom Lehrer, a Harvard mathematician who was my hero.
Lessons from Mahler's Story
• Don't ignore a lingering sore throat. It could be a strep infection that can damage your heart and kidneys and kill you. It is easily cured with antibiotics.
• Genius can be associated with manic depression.
• Promiscuity can expose you to many different contagious diseases.


July 7, 1860 – May 18, 1911