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– other relevant publications by medical professionals (such as biographic, demographic or historical documents);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