Of Man, Mycobacteria, and Music
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
| The King's Evil|
| Pernicious Air|
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: 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
"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
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:
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
- Recurrent respiratory complaints (coughing, breathlessness, hemoptysis, and cyanosis)
- Systemic complaints (poor exercise tolerance, tiredness, emaciation, failure to gain weight, pallor, pigmentation, peripheral edema, muscle wasting, and icterus)
- GI symptoms (diarrhea, fatty food intolerance, hematemesis)
- Absence of clubbing
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:
- Chronic tuberculosis involving the lungs, larynx and lymph nodes
- Probable mercury toxicity
- Tertiary syphilis
- ?Ehlers-Danlos syndrome
- 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 
| Symptom || Musicial|
|Dyspnea || High divisi violins |
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
- The infectious causation of TB was verified by Robert Koch
- The sanitarium movement
- The implementation of many public health initiatives such as improvements in living, workplace, nutrition
- The prevention & isolation of disease
- 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.
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.
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