—  HISTORY OF PATHOLOGY SOCIETY   —

Of Man, Mycobacteria, and Music


Anthony Gal
Emory University
Atlanta, GA


At the beginning of the third millennium, tuberculosis (TB) remains one of the most important, potentially lethal infections world-wide. It is currently estimated that one third of the world is infected, particularly in third-world countries where it is a significant direct and indirect cause of infectious-related death. It has been estimated that, on an annual basis, TB sickens 8 million people each year and kills 2 million. Active infection is on the increase due to various reasons including the increased prevalence of HIV-related disease, drug resistance, malnutrition, and other socioeconomic factors.

Since the dawn of civilization, TB has plagued mankind in its many clinical presentations and terminologies (Table 1).

Table 1: Other Terms for Tuberculosis

Consumption
Phthisis
Scrofula
The King's Evil
Pernicious Air
Tabes

Many myths and half truths about the disease persisted from Antiquity for thousands years until new lines of thinking during the Renaissance gave rise to the possibility of contagion. From a political and geographic standpoint it is interesting to note that this was favored by southern European countries (Italy and Spain), whereas an inherited predisposition or undetermined factors was advocated in the northern European countries (Germany, England, and France).

With the arrival of the Industrial Revolution, TB was rampant in Europe. The shift in population led to crowding, poor sanitation, and urban squalor. At the turn of the nineteenth century some form of TB was present in approximately 80-90% of urban dwellers. Tuberculosis was responsible for greater than 50% of deaths in patients under 25 years of age and for approximately a third of all deaths in patients in the ages of 25-45 years old.

Tuberculosis touched and struck the lives of many famous writers, poets, composers, and musicians in the 18th through early 20th century; it became a central theme in many of their creative works and artistic endeavors. Tuberculosis was the ultimate romantic disease in 18-19th C, as the good and bad, the young and old, the saint and sinner was dying from TB:
"It was the fashion to suffer from the lungs; everybody was consumptive, poets especially; it was good form to spit blood after each emotion that was at all sensational and to die before the age of thirty." Alexander Dumas (père), 1823

Tuberculosis in Composers
Several well known composers and musicians suffered from TB (Table 2).

Table 2: Composers with Tuberculosis

Henry Purcell
Giovanni Battista Pergolesi
Luigi Boccherini
Carl Maria von Weber
Frédéric Chopin
Niccolo Paganini
Edward Grieg
Igor Stravinski

Perhaps the best documented example is that of the pianist and composer Frédéric Chopin (1810-1849). It is believed that Chopin contracted TB from his sister Emilia when he was in his late teens, who herself died from the disease. By his early 20's he developed the first of many episodes of hemoptysis, breathlessness, and fatigue. In 1838 Chopin met the celebrated author Georges Sand and began a nearly decade-long affair. During that summer when his health deteriorated, Chopin, Sand, and her children sought refuge in the Spanish island of Mallorca. Shortly after arriving on the island, Chopin was declared consumptive and became the object of horror and terror by the local inhabitants. Ostracized by society, they were banished to an abandoned monastery known as Valldemosa. During that fall, as the weather turned cold, Chopin's health further deteriorated and he sought various medical opinions:

"The three most celebrated doctors have seen me. One sniffed at what I spat, the second tapped where I spat, the third sounded me and listened as I spat. The first said I was dead, the second that I am dying and the third that I am going to die". Chopin, 1838
Upon returning to the mainland, Chopin took refuge in Barcelona and Marseilles, but had exacerbations of pulmonary symptoms. In the ensuing decade, Chopin's health continued to deteriorate with many bouts of hemoptysis, productive cough, and weaknesses. This was particularly evident in situations where there was change in environment or temperature. In 1848, the cold weather in England and Scotland and exacerbated his symptoms and nearly totally incapacitated him. Terminally, Chopin developed intractable diarrhea, ankle edema leading to anasarca, and deteriorating pulmonary status. In 1849 Chopin died; his autopsy, performed by the eminent Parisian anatomist and physician Jean Cruveilhier, revealed that "the lungs were less affected than the heart".

Chopin's main symptoms were:
  1. Recurrent respiratory complaints (coughing, breathlessness, hemoptysis, and cyanosis)

  2. Systemic complaints (poor exercise tolerance, tiredness, emaciation, failure to gain weight, pallor, pigmentation, peripheral edema, muscle wasting, and icterus)

  3. GI symptoms (diarrhea, fatty food intolerance, hematemesis)

  4. Absence of clubbing
Some contemporary scholars have suggested that Chopin suffered from diseases other than TB, such as cystic fibrosis or emphysema due to alpha-1-antitrypsin deficiency. However, the consensus is that Chopin's disease was most likely chronic TB involving lungs, larynx, and intestines.

Niccolo Paganini (1782–1840) is the renowned violinist and composer who allegedly suffered from TB. His extraordinary physical capacities, namely, the hyperflexibility of his fingers, elbows, and shoulder contributed to his virtuosity and superhuman talents. His bizarre physical appearance and technical wizardry led to the speculation that he "was in a pact with the Devil".

Paganini was a child protégé who achieved rapid fame and fortune, but led a life of womanizing, debauchery, and excesses. During the period of 1828 to 1832, he performed 100 concerts in 40 European cities and became a truly international musical "superstar". However, the stresses of his travels and salacious lifestyle also ruined his health. From a medical prospective it is quite difficult to separate real disease from hypochondriasis. The latter is evidenced by his frequent seeking of refuge and treatment from various physicians, quacks, and charlatans. He received emetics, laxatives, and medications that most likely contained mercury and opiates. Once diagnosed as consumptive, he was refused of lodging in Naples. It is also likely that he suffered from syphilis. In 1839 his health deteriorated and he developed loss of voice, pulmonary hemorrhage, painful tabes dorsalis, and urinary retention. Terminally, Paganini's illnesses led to a slow and agonizing death and many critics thought that this was just compensation for his sinful life. He died in 1840 at the age of 58, but was not properly buried for decades due to a variety of peculiar circumstances.

Unlike Chopin, where TB would be the most likely disorder, the evidence to implicate it in Paganini is less convincing. Several of his biographers have difficulty in separating his real diseases from hypochondriasis. Nonetheless, the tentative diagnoses of Paganini are:
  1. Chronic tuberculosis involving the lungs, larynx and lymph nodes

  2. Probable mercury toxicity

  3. Tertiary syphilis

  4. ?Ehlers-Danlos syndrome

  5. Masochistic personality disorder

Tuberculosis and Opera
Consumption was the subject of several important operas written in the 19th century. Haunted feminine beauty, romantic passion, and fevered sexuality were common themes in literary works and in their operatic adaptations. Thus, the fragile, consumptive "Femme Febrile" became the principal operatic character afflicted with TB.

Principal Opera Composer Year
Violetta La Traviata Verdi 1853
Antonio Contes d' Hoffman Offenbach 1881
Mimi La Bohème Puccini 1896

Giuseppe Verdi's La Traviata exemplifies operatic death by tuberculosis. As an adaptation of Alexander Dumas' novel La Dame aux Camellias, La Traviata is loosely based on the life and death of Dumas' the courtesan lover Marie Duplessis who succumbed to tuberculosis. La Traviata, is the first operatic work in which a disease, namely TB, was depicted in the libretto and musical scoring (Table 3).

Table 3 - TB in La Traviata: Muscial Manifestations [3]

Symptom Musicial
Dyspnea High divisi violins
Halting oboe
Off beat accents
Gasping Repeated notes & rests
Vocal instability Chromatism
Collapse Jumping octaves

Moreover, La Traviata is a tragic, complex psychological work that intertwines morality with the morbidity and mortality of TB.

Giacomo Puccini's La Bohème is a realistic and more contemporary portrayal of tuberculosis in opera. Unlike La Traviata, this is a social commentary on human suffering, poverty, and the lives of ordinary people. In the 40 year interval between these two operatic works, there were many scientific, public health, and societal differences:
  1. The infectious causation of TB was verified by Robert Koch

  2. The sanitarium movement

  3. The implementation of many public health initiatives such as improvements in living, workplace, nutrition

  4. The prevention & isolation of disease

  5. Disease surveillance and regulations

Like La Traviata, La Bohème was largely based real people afflicted with TB. Henri Murger was the venerated Parisian Bohemian author whose lover, Lucille Louvret, died of TB. His play and novel Scènes de la Vie De Bohème became the inspiration for Puccini's opera. In La Bohème, the street artists, as opposed to the bourgeoisie, are the principal operatic characters. The portrayal of disease is more realistic and contemporary without being excessively dramatic or outlandish. Table 4 depicts some of the key differences between these two operatic works:

Table 4: Comparison of Operatic Works

La Traviata La Bohème
1853 1896
Romanticism Realism
TB is inherited TB is infectious
Wealth Poverty
Courtesan Seamstress
Redemption Pity

Tuberculosis in Vocal Ensembles
The transmission of TB primarily occurs during air-borne acquisition of the organisms via aerosolisation of infectious organisms and subsequent development of disease. However, talking, shouting, or singing can potentially lead to TB, as there have been well-documented instances of TB occurring in school and church choirs and in a rock concert. The evidence suggests the direct acquisition of disease through singing, rather than through random inhalation or reactivation. In one particular study, restriction fragment length polymorphism (DNA fingerprinting) demonstrated a common subtype or strain of the tuberculous organism.

Final Musings
Contemporary arts, either in written, visual, or musicological forms continues to show the reflection of man and society with disease. The popular Broadway musical Rent, largely based on La Bohème, depicts AIDS, rather than TB. In the film, Moulin Rouge, the plot is a loose adaptation of La Traviata and shows convincing evidence of TB.

References

  1. Dubos, RJ, Dubos, J. The White Plague: Tuberculosis, Man and Society. Boston: Little Brown, 1952.

  2. Dutt AK, Mehta JB, Whitaker BJ, et al. Outbreak of tuberculosis in a church. Chest 1995; 107:447-52.

  3. Gross A. "TB sheets': love and disease in La Traviata. Cambridge Opera J 1995; 7: 233-60.

  4. Haas F, Haas SS. The origins of mycobacterium tuberculosis and the notion of its contagiousness. In: Tuberculosis. Rom, WN, Garay SM, eds. Little Brown & Co, 1996; 3-19.

  5. Ho NC, Park SS, Maragh KD, et al. Famous people and genetic disorders: from monarchs to geniuses--a portrait of their genetic illnesses. Am J Med Genet 2003;118A:187-96.

  6. Hutcheon L, Hutcheon,M. Opera: Desire, Disease, Death. Univeristy of Nebraska Press, Lincoln, 1996.

  7. Kubba AK, Young M. The long suffering of Frederic Chopin. Chest 1998;113:210-6.

  8. Kuzemko JA. Chopin's illnesses. J R Soc Med 1994;87:769-72.

  9. Long ER. A History of the Therapy of Tuberculosis, and the Case of Frederic Chopin. U Kansas Press, 1956.

  10. Loudon RG, Roberts RM. Singing and the dissemination of tuberculosis. Am Rev Respir Dis 1968;98:297-300.

  11. Mangura BT, Napolitano EC, Passannante MR, et al. Mycobacterium tuberculosis miniepidemic in a church gospel choir. Chest 1998;113:234-7.

  12. Moorman, LJ. Tuberculosis and Genius, Chicago: University of Chicago Press, 1945.

  13. Morens DM. At the deathbed of consumptive art. Emerg Infect Dis 2002;8:1353-8.

  14. Mullan F. The sickness of Frederic Chopin: a study of disease and society. Rocky Mt Med J 1973;70:29-34.

  15. Neumayr A. Music and Medicine, vol 3. Medi-Ed Press, Bloomington, IL, 1997.

  16. O'Shea J. Music and Medicine: Medical Profiles of Great Composers. J.M. Dent & Sons, London, 1990.

  17. Raffalli J, Sepkowitz KA, Armstrong D. Community-based outbreaks of tuberculosis. Arch Intern Med 1996;156:1053-60

  18. Reibman J. Phthisis and the arts. In Tuberculosis. Rom, WN, Garay SM, eds. Little Brown & Co, 1996; 21-34.

  19. Rubin SA. Tuberculosis: captain of all these men of death. Radiol Clin North Am 1995;33:619-39.

  20. Sacks JJ, Brenner ER, Breeden DC, et al. Epidemiology of a tuberculosis outbreak in a South Carolina junior high school. Am J Public Health 1985;75:361-5.

  21. Sakula A. Robert Koch: centenary of the discovery of the tubercle bacillus, 1882. Thorax 1982;37:246-5.

  22. Sandblom P. Creativity and Disease: How Illness Affects Literature, Art and Music. G.B. Lippincott, Philadelphia, 1989, 131-144.

  23. Sontag S. Illness as a Metaphor. Farrar, Straus & Giroux, New York, 1978.

  24. Waksman S. The Conquest of Tuberculosis. Berkeley: University of California Press, 1964, pp 29-47.

  25. Washko R, Robinson E, Fehrs LJ, et al. Tuberculosis transmission in a high school choir.J Sch Health. 1998;68:256-9.