Loe raamatut: «The Disease of Chopin. A comprehensive study of a lifelong suffering»

Cover designer Julia Kravchenko

© Victoria Wapf, 2017

© Julia Kravchenko, cover design, 2017

ISBN 978-5-4483-1531-2

Created with Ridero smart publishing system

Acknowledgement

This book wouldhave been impossible to complete without a great deal of help and support ofmany people from around the world. That is why I am glad to seize thisopportunity and express my gratitude to those who, in one way or another, helped me to reach the goal.

First of all I want to thank my family. They have not only granted me spare time to work on the manuscript, but also kept encouraging me along the way, nurturing my confidence and scientific curiosity.

Many thanks to Professor Tadeusz Dobosz, Head of the Molecular Techniques Unit of the Forensic Medicine Department at the Medical University of Wroclaw (Poland) – for his precious comments and deep appreciation of my work.

Sincere gratitude  to Mr. Piotr Mysłakowski, publisher and researcher in the field of genealogy and biographical sciences, a renowned architect and designer – for his valuable notes and corrections in regard of Chopin’s genealogy.

I am thankful to Dr. Lorenzo Käser from the Department of Graduate Education in Human Medicine, Zurich University – for providing an excellent learning and teaching environment and serving as a brilliant example of a physician, mentor and educator I always wanted to be.

A special thanks go to Prof. Wolfgang Jungraithmayr of the University Clinic of Thoracic Surgery in Zurich. A talented pianist and violinist, he infected mewith the idea to research the medical history of Frederic Chopin.

And, of course, I can not thank enough Julia and Maria, who assisted me with proofreading and graphicdesign, because without them all my efforts would be worthless. Both of themput every effort to create a book of a truly good quality.

I also thank my dear friends and colleagues Dr. Maria Bär, Dr. Iryna Cranny, Dr. Alexander Garmaev, Dr. Heiko Frühauf, Dr. Ursina Jansen, Dr. Yves Jaccard, Prof. Dmitry Kazakov, Ina Ladnar, Dr. Barbara Lütolf, Fahim Mozaffari, Nora H. Gräni, Dr. Elisabeth Hohenstein, Prof. S. Vavricka, Dr. Elisabeth Rushing, Bota Tynybekova, Philip Twaites, Dr. Matthias C. Walter, Cyril Wechsler, Pamela Wible, Priyatharsan Yoganathan und Nishanththan Yogarajan – who appreciate and support my eagerness to learn new things every day.

Abstract

Introduction

The life of the Polish-French pianist and composer Frédéric Chopin (1810—1849) was, to a great extent, influenced by his disease. Nevertheless, the diagnosis and differential diagnoses of his suffering remain a matter of debates in numerous biographical studies on the composer’s life. This study shall conduct a systematization and overview of Chopin’s medical history, in an effort to outline pathways to his most probable diagnosis.

Overview of methods

In this paper, the medical literature on Chopin’s disease was examined to weigh up the existing evidence in the light of today’s medical knowledge and to define possible ways to extend such evidence with modern diagnostic methods. The literature search included three steps. First, a thorough search for available publications was conducted to identify and acquire all medical documents describing F. Chopin’s status and disease (s). The second step involved sifting of the reference lists in the articles retrieved from the first step. The third step was aimed at the retrieval of complementary documents of interest (for example, biographic, demographic or historical documents authored by specialists other than medical professionals) that may help to understand Chopin’s disease in its historical, cultural and social context.

Results

Based on the existing data, it was found that the diagnosis of tuberculosis still outweighs the cystic fibrosis version in Chopin’s case. However, various noxious factors during his life may have shaped the course and severity of the disease. Fully inadequate – by today’s standards – and often potentially harmful treatment (including bloodletting, herbal remedies or other potentially toxic substances) as well as a prolonged exposure to tobacco smoke (passive smoking) could have played a crucial role in Chopin’s pathology, bringing the pianist and composer closer to his death.

Conclusions

The total body of evidence gathered from the current and historical literature allows for a strong presumption of tuberculosis as Chopin’s diagnosis. However, other primary diagnoses, comorbidities, as well as consequences of an iatrogenic exposure should still be regarded and may not be fully discounted.

An analysis of existing tissue specimens could yield additional valuable information and help to resolve the decades-long discussion about Chopin’s diagnosis.

List of abbreviations

AAT – alpha-1-antitrypsin

ABPA – allergic bronchopneumonic aspergillosis

CF – cystic fibrosis (mucoviscidosis)

CVID – common variable immunodeficiency

EGPA – eosinophilic granulomatosis with polyangiitis

GPS – anti-glomerular basement membrane disease (Goodpasture’s syndrome)

HHT – hereditary hemorrhagic telangiectasia

PAH – pulmonary arterial hypertension

PAVM – pulmonary arteriovenous malformations

PCD – primary ciliary dyskinesia

PH – pulmonary hemosiderosis

PID – primary immunodeficiency

SERPINA – serine proteinase inhibitor

GPA – granulomatous polyangiitis

Key words: Frederic Chopin; tuberculosis; cystic fibrosis; lung diseases; differential diagnosis.

Introduction

Chopin – again not seeking gain

But improvising off the wing —

Alone works with chance and clay

From likelihood to one true thing.

B. Pasternak, 1935

Mortui vivos docent

(“the living learn from the dead”)

Latin saying.

Both life and creative endeavors of Frédéric Chopin (1810—1849), a pianist and composer of French-Polish origin, were in many ways shaped by his disease. Chopin’s chronic condition still remains not clearly identified and evokes debates. Given the scarcity of medical-biographic data, Chopin’s symptoms provoked a number of thoughts and discussions both in the historical and medical community. However, despite the obvious interest in this topic, and a number of recent publications – especially around the recent bicentennial (2010) of the pianist/composer – there were no broad review of his possible and probable diagnosis in the recent time. The classic work, Chopin’s pathography by Edmond R. Long (1956)¹ was focused on tuberculosis only. Later scholars explored further possible diagnoses, with cystic fibrosis (O’Shea, 1987)² being the most known. Nevertheless, virtually all reports on the composer’s life and disease were centered on one or two possible pathologies only. In this comprehensive review, the medical and historical literature on Chopin’s disease and on the medicine of that era was examined to evaluate tuberculosis and cystic fibrosis, as well as other possible conditions for their significance in influencing the health of the innovative musician during his lifetime. It was found that though tuberculosis remains the usual suspect, several other hypotheses cannot be discounted either, especially if further exploratory methods may potentially become available. Chopin’s situation is unique, because in his case a tissue specimen could possibly shed further light on his disease, and, consequently, on our understanding of his life and works.

Moreover, the study of Frédéric Chopin’s medical history is an exciting opportunity to gain additional insights into the nineteenth century medicine, in the physician-patient relationships, and to see how the progress of medical science in the newer times has contributed to diagnostic and treatment of formerly fatal diseases. While working on this review, clear preference was given to the studies and interpretations of Chopin’s life and disease done by medical professionals – physicians, medical historians and pathologists. Other sources, such as personal communication of Chopin himself and his family and friends were used as well.

This study is divided into several chapters. It starts with a nearly forensic review of Chopin’s medical history, following a standard pattern of a patient examination. The primary purpose of this chapter is to provide as many clinically relevant data as possible in order to lay a foundation for diagnosis and differential diagnosis. The following two chapters contain information about Chopin’s physicians, their professional profiles, and modes of treatment. A profound understanding of Chopin’s disease history would only be possible with knowing on who treated him and which principles each treatment was based on. As it is often the case throughout the whole human and medical history, a treatment itself may become an aggravating factor or even the cause of the patient’s suffering. Chopin, as a patient with chronic disease (s), had an extensive list of medications, many of them with a potential for toxicity or interactions. That is why his treatment deserved a separate chapter here.

Following the examination of Chopin’s medical history is a discussion on the terminal period and post-mortem exploration of the composer’s disease. Chopin’s case is standing out because at least in theory, a further exploration with today’s instrumental methods is technically possible thanks to the existence of the tissue specimen.

The next chapter is the most crucial one. It is focused on the diagnosis and differential diagnosis of Chopin. Beginning with an outline of two leading hypotheses for Chopin’s most suspected diagnoses, namely tuberculosis and cystic fibrosis, other, less known or less probable diagnoses and discuss possible comorbidities will be reviewed and described in detail. Finally, an attempt to lay out an examination plan with the twenty-first century methods of analysis will be undertaken in order to advance our understanding of Chopin’s disease.

1.1 Methods: detailed description

The literature search for this study involved three steps: the search criteria, the timeframe and what information to extract – all this was set prior to the start of the study. The first step of the literature search took place between October 16^th and November 16^th 2013 and had the following objectives:

– databases search and retrieval of relevant documents

– quality assessment of those documents

– weighing up the total volume of evidence for CF and TBS

– identification of knowledge gaps, i.e. subjects of search at the step III.

At this step, a search for available publications was conducted to identify all medical documents describing Chopin’s status and disease (s). The following search criteria were employed with strong preference for academic journal articles as sources:

– records by attending physicians – if any such exist;

– records by other medical and/or paramedical professionals (coroners, pathologists etc.) – if any;

– publications at the PubMed and other medical/scientific databases (Questia, Science Direct, MedlinePlus, Cochrane Library, CHBD (Circumpolar Health Bibliographic Database), the Directory of Open Access Journals, Web of Knowledge, Worldwide Science, and Index Copernicus);

– other relevant publications by medical professionals (such as biographic, demographic or historical documents);

The search languages were English, German, French, Polish, and Russian. Though valuable and interesting publications exist in such languages as Norwegian and Hebrew, they remain outside of the scope of this review. Since it would be obviously technically challenging to do a comprehensive search in a greater number of languages, this search was limited to those languages spoken/written by Chopin himself. Following words were used for the search in all databases: <Frederic Chopin disease>, <Fryderyk Chopin disease>, <Frederic Chopin Krankheit>, <Frédéric Chopin maladie>, <Fryderyk Chopin choroba>, <Фредерик Шопен болезнь>. Additionally, the PubMed database was searched for <Frederic Chopin> and for <Frédéric Chopin>. Following information was set to extract: symptom descriptions, treatments descriptions, dietary preferences, lifestyle details, quality assessment of studies. Inclusion criteria at the first step were: date of publication later than 1948 (the year when Chopin’s heart tissues were made available for research); a provision of justified (i.e. based on official archive documents or similar sources) hypotheses. The first step’s exclusion criteria were lack of references, languages other than those ones listed above, wrong author (not a medical professional or a medical historian or a related official, for example a coroner). Hence, the standard set of reasons of rejection included wrong topic, wrong specialist, and wrong language.

The next (second) step involved sifting of the reference lists in the articles retrieved from the first step. The inclusion criterion at this step was a provision of justified (i.e. based on official archive documents or similar sources) hypotheses. At this step also publications by authors other than medical professionals were included (for example, biographic, demographic or historical documents authored by specialists or family members). The step II exclusion criteria were a lack of references and wrong languages (i.e. other than those listed above).

Finally, the last step of search was aimed at a retrieval of additional documents of interest that may not fit into the step I and II criteria, but may help to understand Chopin’s disease in its historical, cultural and social context. A hand search was attempted for the genealogical data and for original publications by Chopin’s attending physicians.

The first step of the literature search (between October 16^th and November 16^th 2013) was aimed at identifying of all medical documents describing Chopin’s status and disease (s). Six publications were found at PubMed³. Sixteen publications were found with additional key words at PubMed: “Frederic Chopin^”4. With a “related citations” option: 152 publications were found in a PubMed search⁵. Both PubMed and Go PubMed searches yielded the same results as the PubMed search. A Cochrane library search brought no results, as well as the CHBD (Circumpolar Health Bibliographic Database, the Directory of Open Access Journals, Worldwide Science, Index Copernicus (this database includes over 700 journals from Poland), and the Medline Plus. A search in the Questia database yielded twenty-two books and two academic journal articles⁶. A search at the Web of Knowledge: twelve results⁷. Sixty-two more results were found at the Science Direct database.

After this three-step search was completed, the gathered information was systematized in a form of medical history.

Medical history

1.2 Identification and demographics

Frédéric François Chopin (Frydrych Franciszek Chopin, Fryderyk Franciszek Chopin) was born on the 22nd of February or [битая ссылка] 1st of March or 5^th of March⁸,⁹ to a Polish mother – Justyna Chopin and a French father, Nicolas Chopin. Multiple name versions originate in the differences of pronunciation and spelling in Polish and French languages. Most Chopin’s biographers agree upon the 1^st of March as the birth date of the composer, although his baptism certificate states 22 February as his birthday. As a regular practice at that time the baptism certificate was issued on the basis of mere recollections of his father. Justyna Chopin, on the contrary, insisted that March 1 was his birth date¹⁰. Not only there are controversies regarding Chopin’s day of birth, but even his year of birth is not entirely free of doubts: though 1810 is the birth year mentioned in most biographic studies, some scholars suggest that Chopin could possibly have been born in 1809¹¹.

Chopin’s birthplace, a village named Żelazowa Wola, belonged to the Duchy of Warsaw, in 1810 the Duchy was a semi-independent political entity, ruled by a Prussian king, Frederick Augustus I of Saxony based on a peace treaty with Napoleon.

1.3 The case description

A reconstruction of Chopin’s medical history today is based on scarce archive documents that include personal letters and official documents, but few, if any, medical records that survived till our days.

Perinatal period

No known sources describe Justyna Chopin’s pregnancy course. Chopin was not a robust healthy newborn. Most likely he has had serious health problems that threatened his life right at its dawn. His baptismal certificate issued on 23rd of April 1810 states that an earlier christening ceremony was already held at home. Such home baptizings were performed if the baby could die shortly upon birth¹².

Chopin was born at home, in his parents’ bedroom in the presence of a midwife. This was the most common setting for a delivery at that time. The midwifery and obstetrics in early 1800s has just started to gain moment for the further development. Following the Thirty Years War (1618—1648) the Europe was faced with a threat of depopulation. A human life – and a newborn’s life in particular – gained in perceived societal value. At the same time mass prosperity grew along with increased industrial productivity. As a result many larger cities in Europe took efforts to reform midwifery provision and to improve the perinatal care. One of the midwifery textbooks of that era, the “Burn’s Principles of Midwifery: including the diseases of women and children”, published in London in 1809 and in Philadelphia in 1810¹³, provides important insights into what kind of treatment Chopin and his mother might have received. Though archaic and even harmful from today’s viewpoint (for example, a bleeding is strongly recommended there for pain relief), the “Burn’s Principles of Midwifery…” is certainly an example of an effort to improve the midwifery training and to streamline the care.

A glimpse into the midwife’s records or recollections of Chopin’s family members on the circumstances of his birth would be of an enormous help. But in the absence of such documents it is not possible anymore to elucidate what exactly perinatal issues may have led the parents to believe that their newborn was at risk of dying and to perform a quick christening at home.

Childhood and adolescence

Virtually all biographers agree that Frederic was a delicate, thin, sensitive child, who tired easily and had low tolerance for strenuous physical activities – such as walk excursions in the countryside¹⁴. However, it is interesting that various narrators have sometimes polar views of Chopin’s health condition in his early years. The majority of Chopin’s biographs believe that he was not seriously ill, but Dr. Wilms has challenged this view in 1934¹⁵, pointing out that Chopin was such a frail child, that he wasn’t even allowed to attend a school due to the health concerns and was home-schooled till the age of 13.

Marek (1978)¹⁶ stated that from his earliest years Chopin was “attended by doctors and did not enjoy good health”. Breitenfeld (2011) also mentions symptoms “associated to the lung”, such as hemoptysis, fever, headache, bronchitis, laryngitis, cough, recurrent diarrhea and body weight loss yet in childhood¹⁷. Gomis (2011) adds that “from an early age [Chopin] carried out a daily bronchial toilette… and suffered from arthralgia”¹⁸. Majka (2003), referring to Sieluzycki (1981), depicts Chopin’s frail health and multiorgan complaints that started early in the childhood and were accompanied by frequent respiratory tract infections¹⁹.

Still, Franzen (2010) holds a slightly different opinion:

“During his childhood and adolescence no abnormalities found in Chopin’s medical history. This [was] despite of colds, rhinitis and “catarrhal affections”, frequently mentioned in Chopin’s letters²⁰.

Ganche (1935) describes a fourteen years old Frédéric as having a frail body and a bony face, emaciated and white²¹. Ganche quotes the first letter of adolescent Chopin, dated by the 10^th of August 1824 where the boy reveals that a bottle of pills is sent to him by his parents during his stay in the countryside, and it should last for almost a month.

Further authors draw a line upon those accounts: “From 15 years of age the composer was never without some evidence of respiratory disease… foggy or wintry weather provoked both respiratory disease and paroxysms of coughing²², with significant frontal headaches and respiratory symptoms²³. Also Erlinger (2010) refers to 1826 as the year of the first exacerbation of Chopin’s illness²⁴. Erlinger lists following clinical symptoms:

“…repeated episodes of productive cough, asthenia, fever and hemoptysis…at that time, he has an illness lasting 6 months, with respiratory complaints, and severe headaches”.

Kubba and Young (1998), describing the same episode, noted that this illness has even endangered Chopin’s life²⁵. Chopin was described as “frail, slim, with sunken cheeks”. He was said to “die early as many geniuses before him did”, and he was always coming after physical activity “tired and without any breath”²⁶. On February 12^th 1826 Chopin writes to his friend Jan Bialoblocki that he is sick (as “everybody else”) and his glands are swollen²⁷. However, Chopin fully recovers from this ailment and his swollen glands (that were interpreted by some authors as cervical lymphadenopathy²⁸) are healed by September 1826 without sequelae. His later episodes of illness tend to take the same course – always a full recovery, but the next strike of a disease follows after some time.

On November 2^nd 1826, in another letter to Jean Bialoblocki²⁹, Chopin writes that he is not going to school and that he finds it a pinnacle of absurdity to rest for six hours a day, while the German and Polish-German doctors have prescribed him as many walks as possible. This letter also gives a glimpse into Chopin’s treatment: emetic drinks (upon a prescription by Dr. Malcz) and a diet of oatmeal. Chopin’s therapies will be further discussed in Chapter, “”.

In 1830, Chopin left Warsaw for a trip, including Vienna, Munich, and Stuttgart, to Paris. One of his Viennese encounters, a professor of music, Václav Würfel (1790 – 1832) suffered from tuberculosis. Chopin’s nose swelled embarrassingly with a prolonged cold and at times even forced him to cancel concerts³⁰. However, Wilfred (2010) argued that there is no evidence that Chopin, aged twenty-one, was in “poor health or affected by the illness that would plague him in later life”³¹.

In Paris (1831) Chopin had an episode of hemoptysis and fever but recovered very quickly³². On Christmas Day, 1831, he wrote to his friend of many years (and once a love interest) Titus Woyciechowski, « [O] utwardly I am cheerful but inside me I am tortured with all sorts of forebodings.” Chopin does not associate his premonitions with any particular physical ailment, but subsequent letters speak of ill health with increasing frequency³³. No known medical records dated 1832 through 1835 shed further light on Chopin’s health³⁴. He seems to have has a quiet phase for nearly five years and this is probably the happiest period of his life. Various sources show that between autumn of 1835 (following a resort stay in Karlsbad) and autumn of 1838, Chopin has had bouts of bronchitis and suppurative laryngitis. Though those bouts always resolved, they recurred again after some time³⁵.

According to those sources, in autumn of 1835, Chopin suffered of cough, fever and hemoptysis³⁶. Most likely, his condition was unusually serious at that time and Chopin may have suffered from depression. This was the time when he composed his famous “Funeral March” from his “Sonata in B Flat Minor” and prepared his testament.

In February 1837, Chopin caught an “acute grippe” with high fever and hemoptysis. At the same time he also experienced hallucinations, hearing “knocking on his door and seeing death standing there”³⁷. Around that time Chopin met Amantine-Lucile-Aurore Dupin (better known under her artistic name George Sand), a famous French novelist. This acquaintance has evolved into an intimate relationship.

The November 1838 trip to Mallorca together with George Sand and her children became a disaster. This journey was described by Sand in a book “Un hiver à Majorque” (A Winter in Mallorca). According to her, Chopin had all signs of pneumonia and the island inhabitants grew suspicious and distant to the couple, as they believed that Chopin has had a contagious disease. The fact that Sand and Chopin were not married did not help their popularity among Mallorcans either. That is why it was all but impossible to obtain a better dwelling than the one where Chopin and Sand have stayed. Both two-story chambers they occupied at the monastery Sa Cartoixa de Jesús Natzarè in Valldemossa were barely heated and damp. Sand wrote that Chopin coughed up sputum “by the bowlful”. That winter Chopin was seen by at least three Mallorcan doctors. As George Sand recollected, the recommended treatment included application of plasters at various intervals during the day and consumption of milk. However, no milk was available there³⁸ – likely due to the resentment of local inhabitants who did not want to have a potentially contagious patient to be around. In addition of all those hardships and his health continuing to deteriorate, Chopin’s piano has got stuck with the Spanish customs, so he did not compose much till the end of December 1838: “Meanwhile my manuscripts are sleeping whereas I cannot sleep”³⁹

But already by mid-January 1839, Chopin sends the Preludes op. 28 to Fontana with an instruction to pass them to Mr. Pleyel, a music publisher⁴⁰. A very productive phase followed and Chopin wrote, corrected or finalized during his stay on Mallorca following works, to name a few: Polonaise in C-minor, op. 40, Mazurka in E-minor, op. 41 no. 2, Scherzo in C-sharp minor, op. 39 (drafts), Nocturne in G-minor, op. 37, no., Tarantella op. 43 (draft), and Sonata in B flat minor, op. 35⁴¹. Most of those pieces were done by Chopin which has not yet fully recovered from the disease on “a poor Mallorcan piano…”⁴²

Later in 1838 he experienced pulmonary problems again⁴³. After three months on the island, Chopin and Sand with her children left Mallorca on the 13^th of February 1839. On their way back to Paris, in Marcel, Chopin recovered, at least for a while. His strength was back, there were no more hemoptysis and he started to gain weight again⁴⁴. Nevertheless the very same author, referring to G. Sand, says that for the next few years, Chopin continued to have cough bouts with dyspnea and intermittent fevers. Sand’s recollections show that he was then never absolutely well and experienced a slow progressive decline in his health.

Chopin was successfully treated with ‘oats and honey’ and often “courses of belladonna. which he continued to take through most of his life”⁴⁵. Belladonna has centuries-long history of use as a medicine⁴⁶, however it is not clear who, when, and for what purpose exactly prescribed or recommended it to the pianist. Kuzemko (1994) argues that a diet may have had a positive influence on the course of Chopin’s disease, citing the composer’s letter to his parents from Berlin, written on September, 27, 1828⁴⁷: “I am quite well… as long as I avoid meats, sauces, soups”⁴⁸. However, this very same letter is quoted differently by another source (text in bald – VW):

“I am quite well, and have seen all that [was] to be seen. I shall soon be with you again. In a week, from the day after tomorrow, we shall embrace […] I count among the great events of my visit here the second dinner with the scientists, which took place the day before the conclusion of the Congress, and was really very lively and entertaining. Several very fair convivial songs were sung, in which all the company joined more or less heartily. Zelter conducted, and a large golden cup, standing on a red pedestal, in front of him, as a sign of his exalted musical merits, appeared to give him much satisfaction. The dishes were better that day than usual, they say, “because the scientists have been principally occupied during their sittings with the improvement of meats, sauces, soups, etc…”⁴⁹

It is beyond of scope of this study to assess the biographic precision of both sources and to define which translation conveys a better sense of Chopin’s letters (they were originally written in French). Both sources do not specify whether that “quite well” description referred to Chopin’s digestive or respiratory issues. However, according to the authors in favor of the cystic fibrosis version, those gastrointestinal symptoms were not new for Chopin. Yet during his early adolescence he developed intolerance to ‘fatty foods’ which resulted in recurrent prolonged episodes of diarrhea and weight loss⁵⁰.

The slow decline of Chopin’s health continued for the next four years until (in winter 1843/44) he become severely cachectic and so weak, that he could no longer go upstairs by himself and had to be carried up⁵¹. 22 June 1849 Chopin had two episodes of hemoptysis in one night⁵² (according to Chopin’s letter to his friend Grzymala, as cited by Ganche, p.78). At that point he had less than four months to live.