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Open Features: Composition And Decomposition

Peter Wintersgill tells of some of the ailments suffered by great composers.

As we were taught as medical students, common things occur most frequently; as with lesser mortals, so with composers.

Seven composers are considered here, ranging from Handel, born at the end of the 17th century, to Liszt, who died in the middle of the 19th century. In the first four cases the major illnesses during life were relevant to the cause of death; in the remainder the terminal illnesses were quite different.

George Frederick Handel (1685 -1759)

Apart from obesity, which was largely the result of an excessive intake of food and drink, Handel was fairly healthy up to the age of 50. He then suffered the first of three episodes of "rheumatism" associated with depression. It seems quite likely that the "rheumatism" was in fact a mild stroke.

During the next few months he had several bouts of depression, associated with financial worry, alternating with periods of mania. He then went to Tunbridge Wells to take the waters, a practice common among the nobility and gentry of that period. On his return to London five weeks later he was much improved.

Two years later he had a similar episode, this time associated with loss of use of his right arm. This meant that he was unable to play the organ or to conduct. He again visited Tunbridge Wells before travelling on to Aix-la-Chappelle (Aachen) in Germany. On his return to London a month later he was again much improved, so much so that some nuns, passing a cathedral, were amazed by his playing.

Six years later Handel was affected by another episode of stroke and depression. In a letter Horace Walpole wrote, "Handel has a palsy and cannot compose". This time there was loss of speech and "disorder of the senses" as well. He was evidently in pain and had a fever. Thus, in this case, he may have been affected by a rheumatic complaint as well, possibly gout, in view of his customary diet.

When Handel was 66 years of age, he started to develop cataracts, for which he had three operations during the next seven years. After the last operation he went completely blind.

His last illness lasted only a week. He was carried home from a performance of Messiah following a stroke. He died on Good Friday, 13th April, 1759, at his home in Brook Street, London, after lying semi-conscious for a week.


Wolfgang Amadeus Mozart (1756 -1791)

When he was six years old, Mozart had the first of several attacks of rheumatic fever, followed by what appears to have been erythema nodosum, judging by his father's description. Leopold found "a few spots as large as a kreutzer (a coin about one inch in diameter), very red and slightly raised, and painful to the touch" on Mozart's shins and elbows.

As an 11-year-old child, Mozart caught smallpox during an epidemic in Vienna. However he recovered completely.

Later in life Mozart had periodic attacks of fever accompanied by joint pains; presumably these were further episodes of rheumatic fever. It is now known that the streptococci causing rheumatic fever can also cause erythema nodosum and nephritis, but the physicians of the 18th century knew nothing of such matters. It is likely, therefore, that each time Mozart had rheumatic fever, he sustained kidney damage.

This would explain his death at the early age of 35, from kidney failure, with its symptoms of peripheral oedema, fever and vomiting. His decline was gradual, lasting approximately six months, until his death on 5th December, 1791.

There was no post-mortem and no evidence of poisonings, as has been suggested. Henoch-Schonlein purpura had been suggested as a cause of death, but it seems unnecessary to suggest a rare condition when a common one fits the bill.


Frederick Chopin (1810 -1849)

During childhood and adolescence Chopin was noticed by his family and friends to be thin, frail and easily exhausted. On one occasion at the age of 18 he had to be carried to his carriage after exerting himself on the piano. His sister had died at the age of 14 of a chest illness, which until recently was thought to be tuberculosis. However, in view of the length of the illness, this is unlikely.

Chopin himself suffered from a chronic cough from the age of 15 years. He was also intolerant of fatty foods, which gave him abdominal pain and diarrhoea. In addition, he never, so far as is known, fathered a child.

He had repeated chest infections, especially in the winter, when his cough became worse, and productive of sputuun. In addition he had periodic sinusitis and laryngitis. All this points to some form of bronchitis or bronchietasis, rather than tuberculosis, as was once thought.

On a visit to Majorca at the age of 28, he had a particularly bad chest infection, the winter being cold and wet. In the long term his cough got gradually worse and his breathing more difficult; he became weaker and more dependent on others.
From February 1849 until his death the same year he became weaker still and his face and legs started to swell. At the post-mortem no definite conclusion was reached, except that there was no sign of the tuberculosis that had been expected.

Thus, contrary to popular belief, tuberculosis is unlikely to have been the cause of Chopin's death. In view of his lifelong cough and physical weakness, together with his intolerance of fats, the most likely diagnosis is cystic fibrosis, which was unknown to medical science at that time.


Franz Liszt (1811-1886)

Immediately after his birth Liszt was a weakly infant, who seemed unlikely to survive. Later he was subject to convulsions, which were usually associated with fever, so were probably not epileptic fits. Following vaccination against smallpox at the age of six years, he was very ill. Liszt collapsed during a concert at the age of 24 years. This may have been a simple vaso-vagal attack, or possible tetany caused by over-breathing; he is known to have been an intense, highly strung individual. It had also been suggested, rather uncharitably, that the attack was psychogenic, designed to attract attention. This seems unlikely.

He developed jaundice during a visit to Bonn, which was probably due to infective hepatitis.

The swellings on his fingers were probably Heberden's nodes, associated with osteo-arthritis of the finger joints.

Liszt's main disability, however, was chronic bronchitis with emphysema, doubtlessaggravated by the strong cigars he frequently smoked. This disability caused increasing breathlessness as he got older, as did the resultant cor pulmonale.

Later in life he developed left ventricular failure, with still more breathlessness. During his last year of life Liszt became weak and breathless after the slightest exertion. During his concerts, however, mind triumphed over matter, enabling him to display his mastery of the keyboard in his accustomed way.

At this time he also developed cataracts, on which it was planned to operate, but death intervened.

Liszt's terminal illness lasted only ten days. He became rapidly thinner and more breathless as his abdomen swelled, no doubt from ascites. As a result of all this he became severely depressed.

He had chest pains on 31st July, 1881, the day he died. Death was due therefore
to congestive heart failure, due to cor pulmonale, with possible terminal coronary
thrombosis.


Ludwig van Beethoven (1770 -1827)

Apart from a possible attack of smallpox in childhood, and several attacks of asthma in his teenage years, Beethoven's only illness was a chronic bowel disease This consisted of recurrent abdominal pains with anorexia and diarrhoea. This could be what we now call the irritable bowel syndrome, or, more probably, pancreatitis, due in turn to excessive intake of alcohol.

Beethoven, like his father, was fond of wine, though not to quite the same extent. In middle age he used to take more wine in a attempt to relieve the pain, but it may have well have made it worse.

A more familiar ailment is his deafness. This began at the age of 30, gradually increasing in degree until it was complete when he reached the age of 45. The deafness was accompanied by tinnitus, which gradually decreased as the deafness increased. This points to otosclerosis as the most likely cause.

He tried various treatments, usually prescribed by his doctors, which he applied to his ears, in a vain attempt to control his deafness. The only effect of these was to cause otitis externa. One suggested cause of his deafness was syphilis, but there was no sign of this elsewhere in the body, either during life or post-mortem.

Beethoven's final illness was cirrhosis of the liver, which became evident about four months before his death. He developed ascites, for which his abdomen was tapped three times, a total of 20 litres being withdrawn. Other symptoms at this time included jaundice and peripheral oedema. He died on 26th March, 1827. The diagnosis was confirmed at the autopsy by the state of the liver and enlargement of the spleen.


Franz Peter Schubert (1797 -1828)

Like many other young men of his time, Schubert caught syphilis, probably from a prostitute, at the age of 25. A few weeks later came the signs and symptoms of the secondary stage: headaches, dizziness, pains in the bones, skin rashes, iritis, and loss of voice and hair.

It is known that he felt shame soon afterwards, followed later by a depressive phase. It can be deduced therefore, that he recognised the diagnosis. The secondary stage lasted about six months and included a period spent in the Vienna General Hospital. He composed one of his songs - Die schone muller - in hospital at the age of 26.

His treatment included copious fluids but little or no food, cold baths, plenty of exercise, and the administration of mercury, then a popular treatment for syphilis. It is also known that he lost some hair during this period, for he had his head shaved and wore a wig.

The following year he felt "newly rejuvenated" and his hair had grown again. The secondary stage had passed and his various treatments received the credit. In early September 1828 he complained of headaches and "rushes of blood to the head", which may well have been the result of syphilitic meningitis.

Schubert's terminal illness barely lasted a month. He was on holiday and, after tasting some fish, he pushed it away, saying that it was poisoned. When he returned from his holiday, he took to his bed, taking no food or drink until his death some three weeks later, on 19th November, 1828. During this time he had been feverish, delirious at times, and increasingly weak.

The cause of death stated on the death certificate was "typhus abdominalis", a blanket term used at that time on the continent to cover a variety of illnesses, but notably typhoid fever. It has been considered in the past that Schubert died of syphilis, but as only about five years elapsed between his primary infection and his death, there was probably insufficient time for tertiary syphilis to develop. It seems more likely therefore that Schubert died of typhoid fever.


Robert Schumann (1810 - 1856)

There was strong family history of depression in Schumann's family, involving his sister, who committed suicide at the age of 19, and his father, who was mentally unstable, and died soon after his daughter.

Robert himself was sensitive and subject to bouts of depression, notably after the deaths of his sister and father. As a young man he indulged in drinking bouts, as well as being somewhat promiscuous. There was however no definite history of venereal disease.

He injured his right hand when aged 22 years, which ended any hopes he might have had of becoming a concert pianist. The exact nature of the injury is not known, but it was apparently caused by a gadget he was using to strengthen his hand muscles. The injury may well have been some form of tenosynovitis. It has even been suggested that it was functional in nature, but this seems unlikely. At all events it was followed by one of his episodes of depression.

During his adult life Schumann was physically healthy, but began in his forties to have hallucinations. These made him fear he was becoming insane, especially as they became more frequent and prolonged. Finally he attempted suicide by throwing himself into the River Rhine, from which he was rapidly rescued. He was then admitted, at his own request, to an asylum where he stayed until his death some two years later.

The cause of Schumann's death, on 29th July, 1856, is still open to debate. One school of thought favours general paralysis of the insane (GPI)1 a form of tertiary syphilis of the nervous system; this would explain his hallucinations.

The other school favours multiple physical causes, such as malnutrition, hypertension and heart failure. In either event the terminal cause was bronchopneumonia, the only definite finding at autopsy.


Conclusion

Two groups of composers have been considered here. In four the major illness during life was relevant to the cause of death; in the other three it wasn't. Handel had three strokes between the ages of 50 and 58 years old, finally dying of one at 74.

Mozart had several attacks of rheumatic fever associated with nephritis, finally dying of kidney failure at 35.

With Chopin there is still some doubt about the cause of death, although a diagnosis of cystic fibrosis would account for all the facts.

Liszt had a long history of bronchitis and emphysema, from the effects of which he died.

In the remaining three composers the terminal illnesses had not been experienced before. Beethoven had abdominal pain and deafness, but died of cirrhosis of the liver. Schubert had a prolonged bout of secondary syphilis, but died of typhoid fever. Finally Schumann died of bronchopneumonia, following no major illness.

It can be concluded therefore that common things occur most frequently.

References
1. Keynes M. Handel's illnesses. Lancet 1980 21354.
2. Fluker J.L. Mozart's health and death. Practitioner 1972 209 841.
3. Davies P.J. Mozart's illness and death. J.R. Soc Med 1983 76 776.
4. Carp L. Mozart, his tragic life and controversial death. Bull N.Y. Acad
Med 1970 46 267.
5. O'Shea J.G. Was Frederick Chopin's illness actually cystic fibrosis'?
Med J Aust 1987147 586.
6. O' Shea J.G. Medical history of Liszt. Med J. Aust 1986145 625.
7. Landsberger M. Beethoven's medical history. N.Y. State J. Med. 1978 78 676.
8. Harrison P. Effects of deafness on musical composition. J.R. Soc Med
1988 81 598.
9. Newman E. The unconscious Beethoven. Vol. I New York. Alfred A. Knoff. 1970.
10. Deutsch O.E. Schubert: a documentary biography. London. Cassel 1946.
11. Sams E. Schubert's illnesses re-examined. Musical Times. 1980 121 15.
12. O'Shea J.G. Music and Medicine. London. Dent 1990.

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