1.5 Social history

Living arrangements

Chopin’s living arrangements varied greatly. Reportedly, he had never owned a house himself and lived in rented accommodations, at times sharing them with friends. It is likely that many of his dwellings have helped to an exacerbation of Chopin’s pulmonary symptoms and progression of disease:

– Fireplaces and cooking stoves – are all known sources of irritants of the upper airways

– Cold damp dwellings (for example, the one on Mallorca).

– Mold and fungae are regularly present in damp settings and may have contributed to Chopin’s cough bouts, too (Szpilczynski) discussed Chopin’s allergic predisposition in 1961⁷⁶).

Marital status / Children

While known for having had numerous sexual relationships – some of them lasted for years – Chopin was never married and no biological children are known.

Drug use

Though the composer did not like wine, he occasionally got drunk, likely on social grounds or as an effort of self-medication for his bouts of melancholy⁷⁷. Chopin detested tobacco smoke which made him cough. However, chronic passive smoking was an important factor influencing his lung disease. Throughout the most of his life he was surrounded by many cigar and pipe smokers such as George Sand, Liszt and his father Nicolas, to name a few⁷⁸.. Fair to note, the adverse effects of tobacco smoking on health were not widely known at that time. A century after Chopin’s time, in the 1920s, a German internist F. Lickint has published the results of his scientific investigations of health issues related to alcohol and tobacco, describing lung cancer and stomach ulcer associated with prolonged smoking⁷⁹..

As brief Chopin’s recreational drugs list is, as ample was his usage of medications. He frequently took opiates⁸⁰. One such remedy, laudanum, is known to contain [битая ссылка] morphine, codeine, [битая ссылка] morphinan, thebaine, papaverine, and noscapine (narcotine). Laudanum is a [битая ссылка] tincture of [битая ссылка] opium containing approximately 10% powdered opium [битая ссылка] by weight (the equivalent of 1% [битая ссылка] morphine). In the nineteenth century laudanum was widely used “against many ailments”⁸¹. Opium was used not only as laudanum tincture and not only as a single medication. It was a part of numerous prescriptions and well as home remedies. It was mixed with virtually anything available: sugar, alcohol, mercury, hashish, cayenne pepper, ether, chloroform, belladonna and so on⁸². Chopin’s attending physicians have most likely recommended laudanum – and not another tincture – not only due to analgesic and antitussive effects of this medication, or to control Chopin’s frequent diarrhea, or to alleviate his sleep problems, but also because laudanum was a strong emetic. Emetics were popular, (as one can see on the example of Emilia’s treatment) since medieval times they were deemed important as “body cleansers”⁸³. The emetic treatment is further discussed in Chapter. As Chopin had a pre-existing pulmonary condition, the use of opium tincture was especially dangerous due to the risk of a respiratory depression, even at therapeutic doses⁸⁴. Opium is also known for releasing histamine from skin and muscle. Histamine, in turn, plays a primary role in the respiratory system as a bronchoconstrictor⁸⁵.

The composer’s dependence on opium⁸⁶ may explain its frequent use. A number of Chopin’s symptoms can be found on the vast list of opium side effects: drowsiness, headache, malaise, CNS depression, insomnia, mental depression, nausea, vomiting, anorexia, stomach cramps, neuromuscular and skeletal weakness.

Ganche (1935) lists other medications and remedies prescribed to Chopin: foxglove (digitalis), monkshood (aconite), creosote, protioduret <of mercury>, jelly lichen (collema), gum water (diluted acacia sap that was a popular prescription for phthisis⁸⁷). Most of those remedies are known for their toxicity, but little is known on how Chopin’s treatment may have influenced his symptoms. Caruncho and Fernandez (2011) discussed opium toxicity as a possible reason for Chopin’s mental problems, only to dismiss it on the grounds that the symptoms (particularly hallucinations) were present before Chopin began receiving the treatment on a regular basis and that the hallucination pattern differed from that of toxicity. The authors point out that the exact treatment chronology remains unknown. Chances are, the symptoms’ onset might, in fact, have preceded or coincided with Chopin’s treatment. Certainly, a simultaneous occurrence does not equal to causality, but it is possible that at least some of Chopin’s pathology might be explained with toxic effects of the remedies he was treated with⁸⁸.

Foreign travel

At various periods of his life Chopin has visited geographic areas that today are known as Germany, Poland, France, Austria, United Kingdom, and Spain⁸⁹. Following diseases were present in those parts of Europe in the 19th century and/or caused outbreaks of a significant importance:

– typhus

– scarlatina

– measles

– smallpox

– cholera

– smallpox

– tuberculosis

– influenza

However, the course of Chopin’s disease does not match the spread and the magnitude of those epidemics. For instance, neither his gastrointestinal symptoms nor his pulmonary problems were aggravated or first present at the times of cholera or influenza outbreaks, respectively.

Exposure to environmental pathogens

With an exception of a regular exposure to biomass (wood) home heating and passive smoking (as many of Chopin’s friends and family were heavy smokers), no particular environmental exposures are known.

1.6 Review of systems

According to ample verbal and visual evidence Chopin had asthenic habitus. In his travel passport, used for the journey to England in 1837, his height is stated as 170 cm⁹⁰, weight – 50 kg⁹¹ at some points – in 1835, and, probably, in 1838, too – dropping below 45 kg⁹². Both parameters substantially deviate from population averages (see Appendix). Chopin’s body mass index (BMI) varied between 16 and 17, which is considered underweight (normal range BMI ranges between 18.5 and 24.9). A number of sources depict Chopin’s poor exercise tolerance and failure to gain weight⁹³.

Musculoskeletal system

What reliable evidence might help to assess Chopin’s appearance from a clinical viewpoint? Obviously, various verbal and graphic depictions are always to some extent subjective and may sometimes be rather a telltale of their creator, not so their object. Various portraits, inclusive photographs are consistent in portraying of asthenic, thin-faced man. The written sources convey an image of a man who is ‘whiskerless, beardless, fair of hair, and pale and thin of face … <and has> a prominent aquiline nose⁹⁴. But it is barely possible to draw a clinically relevant conclusion based on something as trivial as a caricature⁹⁵. For example, based on a sketch by P. Vairdot, Kuzemko (1994) suggests that Chopin has probably had emphysema, since he become apparently barrel-chested in his early thirties. However, that very sketch – as fairly pointed out by other researchers – shows Chopin with a disproportionally giant head, too.

The other authors describe Chopin as having “thin, long and barely muscular limbs, very slender, delicate hands⁹⁶. Those extraordinary thin limbs might probably be interpreted as an early sign of emaciation⁹⁷. Almost all observers noted the extreme thinness of his limbs. Here is one fact that let us think that Chopin may, indeed, have had a distorted musculoskeletal development that goes beyond a mere asthenic habitus. While travelling in horse-drawn carriages, Chopin feared he may fracture his frail limbs⁹⁸. Both Erlinger (2010) and O’Shea (1987) hypothesize that this could be due to his pulmonary hypertrophic osteoarthropathy, that manifested itself by painful swelling of distal joints and soft tissue⁹⁹,¹⁰⁰. Quite evidently (see Appendix 10.7,“Postmortem hand cast”), Chopin did not have digital clubbing (finger clubbing). Though finger clubbing is most commonly seen in patients with bronchiectasis (as well as in those with cystic fibrosis and bronchial carcinoma) and not commonly seen in patients with pulmonary tuberculosis¹⁰¹, this sign is neither specific nor particularly sensitive for lung pathology¹⁰² and cannot be reliably used for a differential diagnosis in Chopin’s case.

Throughout most of his adult life, Chopin frequently suffered of pain in the ankles, feet and hands¹⁰³. During the terminal phase of his illness, he also developed severe pain in his wrists and ankles, which was relieved partially by massage and sometimes worsened at cold and wet weather. The hot weather was also poorly tolerated: according to O’Shea (1987), Chopin had frequently experienced prostration and hyperhidrosis in summer¹⁰⁴. As mentioned above, at least once in his life – namely in winter of 1826 – Chopin had nodal swelling that Kubba and Young, referring to Chopin’s letter dated February 12, 1826 to his friend, physician Jan Bialoblocki¹⁰⁵, regarded as a cervical lymphadenopathy. Cervical lymphadenitis is a common (about 15%) manifestation of extrapulmonary tuberculosis, especially in patients with compromised immune system¹⁰⁶. A nodal regression is possible indeed, but only under chemotherapy¹⁰⁷. Other infections or neoplasia, and rarely, drug reactions may also cause a nodal enlargement that in some cases can resolve untreated¹⁰⁸.

Respiratory system

Chopin’s lung problems are dated back to his adolescence with prolonged episodes of cough and lymphadenopathy. There are reports of Chopin’s repeated exacerbations of nasal infection with substantial blockage of air passage (i.e. a possibility of polyps), pulmonary infections with productive cough, hemoptysis and recurrent fevers, later chronic dyspnea¹⁰⁹. O’Shea (1987) and Kuzemko (1994) citing G. Sand argue that a cavitating lesion was not found during an auscultation of Chopin’s chest (by Dr. Papet)¹¹⁰.

The bouts of cough and dyspnea accompanied Chopin throughout most of his adult life. Long (1956) describes the episodes of hemoptysis consisted of blood streaking purulent sputum as “a picture of bronchiectasis or chronic bronchitis”¹¹¹