As brief Chopins 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 ailments81. 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. Chopins 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 Chopins 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 Emilias treatment) since medieval times they were deemed important as body cleansers83. 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 composers dependence on opium86 may explain its frequent use. A number of Chopins 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 Chopins treatment may have influenced his symptoms. Caruncho and Fernandez (2011) discussed opium toxicity as a possible reason for Chopins 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 Chopins treatment. Certainly, a simultaneous occurrence does not equal to causality, but it is possible that at least some of Chopins 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 Chopins 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 Chopins 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). Chopins 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 Chopins poor exercise tolerance and failure to gain weight93.
Musculoskeletal system
What reliable evidence might help to assess Chopins 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 OShea (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 Chopins 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 OShea (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 Chopins 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
Chopins lung problems are dated back to his adolescence with prolonged episodes of cough and lymphadenopathy. There are reports of Chopins 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. OShea (1987) and Kuzemko (1994) citing G. Sand argue that a cavitating lesion was not found during an auscultation of Chopins 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 bronchitis111