ial report_ The Long Suffering of Frederic Chopin

Adam K. Kubba, MD; and Madeleine

Young, MA
had three sisters. Isabella (1811-1881) led a healthy life and died at age 70 (cause of death unknown). Ludwika (1807-1855), who suffered recurrent respi ratory tract infections throughout her life, died at age 47 of a respiratory condition. Finally, Emilia (18131827).she was a frail, thin child who suffered
recurrent

(CHEST 1998; 113:210-16) the half-Polish, half-French Chopin, composer and virtuoso pianist, used the piano to express his thoughts and feelings as perhaps no other composer has done before or since.the piano was his means of communication, his other self. His frailty and ill health from a very early age, together with his conviction that he would not live to an old age, meant that he was denied many of the usual outlets for his emotions. These factors, however, combined with his extraordinary gifts, probably re sulted in a legacy of music for the pianoforte (as the instrument was then known) which has been and will continue to be a source of delight to countless music lovers throughout the world. Despite his ill health and short life, the legacy of music he left the world included 27 piano etudes, 25 preludes, 19 nocturnes, 52 mazurkas, 4 impromptus, 2 concertos, 3 sonatas, and a barcarolle.

Frederic

pneumonia, "asthma,"

recurrent hematemesis from the age of 11 years. She died of a massive upper GI hemorrhage at age 14. To our knowledge, the only unusual family medi cal history is the illness and early death of Emilia.

coughing, breathlessness, weight loss, and

Family History
Many dates have been given as the exact date of birth of Frederic Francois Chopin. March 1st, March 5th (St. Frederic's day), and February 22nd are possible dates; the latter has the greatest histor ical support.1 Chopin was born in the village of Zelazowa-Wola, near Warsaw, in the year 1810. The course of his boyhood was not particularly marked by anything extraordinary, except that he was "sickly and delicate"2 and that the attention of his family was concentrated on his health. He studied music under Fredrik Ziwna, a passionate disciple of Johann Se bastian Bach. His father, Nicolas Chopin (a Frenchman by birth, who worked as a bookkeeper and teacher), suffered from a recurrent respiratory disease but survived until the age of 73 (1770-1844). He died on May 3rd, 1844 of "lung disease and weakened heart."3

Chopin's mother, Justyna (Polish by birth), enjoyed good health and died at age 77 (1784-1861). Chopin
*From the Gastro-Intestinal Unit, Western General Edinburgh, and The University of Glasgow Library,
UK.

Hospital, Glasgow,

Manuscript received August 6, 1997; accepted August 7.

210

Chronic 111 Health In his teens, Chopin suffered from respiratory complaints, recurrent diarrhea, and weight loss.4 The onset of his illness was reported by George Sand (a female friend and lover) and Franz Liszt (a friend and famous composer) to have started well before In 1826 (at age 16), he had an illness lasting puberty. 6 months, in which respiratory complaints, severe headaches, and cervical adenopathy were prominent symptoms.5 He suffered similar complaints while in Vienna in 1830 (at age 20). Chopin lived in Poland and developed his musical genius there, but the desire to become famous and to learn more music, coupled with political instability in Poland, made him leave for France. He left for Paris on November 2nd, 1830. This was a highly emotional journey for Chopin who, at that stage, expected to be in Paris for a year or so. In 1831 (at age 21), he complained of chest pain, hemoptysis, fever, and headaches. In 1835, he had bronchitis and laryngitis. It was noted when he was as young as the age of 20 that he lacked the growth of facial hair, such that he wrote in 1832, "I have one side-whisker.the other won't simply grow."6 Chopin never fathered any children that we know of, despite his 11-year rela with George Sand. tionship in Early 1837, an epidemic of influenza broke out in Paris. In February, Chopin fell ill with high fever; he had hemoptysis and hematemesis. He was ex hausted and listless, and was confined to his bed for
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have TB or because it was expedient to deny the presence of an infectious disease such as TB, which carried with it social and economic disadvantages. Chopin was chronically breathless and easily ex hausted; he often had to be carried off after playing the piano for any length of time. He was compelled to travel southward to avoid the rigors of winter. He chose to live in the mild climate of the island of Majorca. He continued to be ill for weeks after his arrival on Majorca. On December 3rd, 1837, he wrote: "These two weeks, I was sick as a dog, I got a chill despite the temperature of 70, amidst roses, oranges, palms and fig trees. Of the three most famous doctors on the island, one sniffed at what I up, the other tapped at the place from where spewed I spewed it, the third poked and listened while I The first said that I was dead, the second spewed. that I was dying and the third that I would die."7 The natives on the island regarded all pulmonary diseases as incurable and infectious, and the landlord demanded that Chopin and George Sand should leave the house (in writing, because he was afraid to come near his tenant). He insisted that their furni ture be burned and the house disinfected at their expense. Chopin and Sand left for Valdemosa, but he did not recover and was troubled with fever, weak ness, and nightmares. This went on till the middle of January 1839. While they were isolated in Majorca, Sand reported difficulties in finding the right food for Chopin, because fatty food gave him indigestion and severe diarrhea. In February 1839, he left Majorca for Marseilles. By September 1842, he was back in Paris. Chopin's health, already affected by many declined from the year 1840 onward changes, visibly 1). He exhibited gross weight loss (weighing (Fig 97 A only pounds) and had a parchment-like pallor. caricature done by his friend Pauline Viardot in 1844 clearly demonstrated that Chopin was barrel chested and had extremely thin limbs (Fig 2). A married sister of Gutmann (a close friend) remembered that in 1843 Chopin already had to be carried upstairs when he visited her mother. When left the carriage and stayed shopping, he never in his blue mantle.57 closely wrapped In the winter of 1843 he was very ill again, in pain and very pale. This condition continued until the spring of 1844. Later that year, his lover George Sand wrote to his sister Ludwika: "His illness has not been greatly different over the last 6 years. In the morning he has a fairly severe coughing spell. During

several weeks. Dr. Gaubert, Chopin's physician, was adamant that Chopin was not suffering from tuber culosis (TB) and felt that a warmer climate might report arose either Chopin's condition. This that help because the physician believed Chopin did not

life.

Figure 1. A photograph of Chopin taken in the last months of his

the winter he has 2-3 more serious crises lasting 2-3 days each suffering from neuralgia but he has no lesion of his chest."7 The Last Years The winter of 1847 brought short improvements and long relapses, and his relationship with George Sand came to an end, which appeared to be a turning point in the decline of his health.7 Although Chopin was described in 1848 as "puny, thin and pale,"5 he was determined to visit London. The trip to Britain appears to have been a mistake. The purpose of this journey was to give concerts. This, combined with the political unrest in France, the encouragement of his friends, and his desire to recover from the pains of his separation from George Sand, were sufficient motives for him to leave Paris. Some believe that he wanted a new life in London, and that this was the reason he carried letters of introduction to Englishmen and Poles living in En as though his name alone was not sufficient gland, introduction. Others deny that he ever intended to
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Figure 2. A caricature done in 1844 shows

barrel-chested

Chopin with thin limbs (courtesy of Madam M. Maurvois).

leave Paris for good, as he retained his apartment and had no farewell party prior to his departure. In London, he was confined to bed frequently, but in felt well enough to visit Edinburgh. It was in April Scotland that he formed a new relationship, with Jane Stirling (a Scottish heiress). On his return to London (November 17th, 1848), he wrote, "I have been ill for the last 18 days. Ever since I reached London, I have not left the house at all. I have had such a cold and such headaches, short breath and all the bad symptoms (my head is very painful apart from the cough and suffocation). The doctors visit me every day."5 Chopin left London for Paris on November 19th. On the way to Paris, he wrote to his friend Solange: "Tomorrow I go to Paris, scarcely dragging myself and weaker than you have ever seen me. I am swollen up with neuralgia, can neither breathe nor sleep."5
212

power precision of ideas remained his of intact, perception intentions clear. When cholera broke out in Paris around the summer of 1849, his friends decided to move him to the outskirts of Paris. By now, Chopin was being treated by a Dr. Fraenkel, who satisfied him no better than all his other previous physicians. Chopin said of him: "There is no way of finding out from him whether I should go to some spa or to the south. He has once again taken back his infusion and given me another medicine and once again I don't want it.and when I ask him concerning my regimen, he says that I do not need to lead a regular life. In short, he is crazy."5-8 On the night of June 21st, he had two hemor rhages (though not clarified, the implication was that these were hemoptysis). The following day he had a hematemesis, edema ofthe ankles and legs, lethargy, and increased tiredness. At the end of June, he wrote, "I have no fever, thank God. .Which baffles and angers all run of the mill doctors."9 On July 2nd he wrote: "I have not spat blood since the day before yesterday, my legs are swollen, I am weak and lazy, I can't go upstairs, I suffocate."910 On July 10th, he consulted Dr. Jean Cruveilhier (1791-1874). Dr. Cruveilhier was one of France's most accomplished doctors. He held the Professor at Montpellier from 1823 to 1825, ship of Surgery of Professorship Anatomy at Paris from 1825 to 1836, Chair of Pathological Anatomy at Paris from 1836 to 1850, and wrote several books on TB, surgery, anatomy, and pathology. He was considered the father of the clinical and pathological science of peptic ulcer disease. His most famous publication was his Anatomie Pathologique du Corps Humain, published in Paris between 1830 and 1842. To this is considered the most magnificent patho day, this atlas ever published. logical said Chopin of his encounter with his new doctor: "I have some sort of diarrhea, he [meaning Dr. Cruveilhier] also regards me as consumptive and ordered a tea spoonful of something with Lichen in it, he ordered me to rest."3 Early in September, Chopin's physicians held a
.

Dr. Molin, had died. This was very upset physician, ting to him, because he credited this doctor with him out of several relapses, and with saving helping his life in the winter of 1847. After Dr. Molin's death, he had no confidence in any other physician. In early 1849, Chopin's disease progressed rapidly, and his friends' fears turned to despair. Chopin's condition was such that he hardly spoke or left his bed. He also suffered from pains of the wrists, hands, and ankles. On hearing this, his sister left Warsaw for Paris. the suffering grew more and more terrible, Although his of will and

On his return to Paris, he found that his trusted

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consultation; Drs. Cruveilhier and Louis (another of Chopin's physicians) had invited Dr. Blacke, a fa
wrote

pediatrician, to confer with them. Chopin of the pediatrician's presence: "He will help me most, for there is in me something of a child."69 The only output we know of this consultation is that it was decided that the patient was too ill to travel out of Paris. By mid September, Mr. Norwid (a close friend) came to visit Chopin in Chaillot and described his visit: "I found him dressed but reclining on his bed with swollen legs, then in voice broken by his me for coughing and choking, he began to reproach he had not having come to him for such a long time; fits of coughing. .he said farewell to me and he pressing my hand, threw his hair back from his forehead and said: T am going. .' and began to cough. Upon hearing this, I kissed him on the arm and knowing that he was pleased when sharply contradicted, I said, Tou have been going in this way every year, and yet, thank God, we still see you alive.' To this Chopin finishing the sentence that was interrupted by the coughing said, T am saying I am going to leave this apartment and move to the place Vendome.'"13 Late in September, Chopin moved to his last apartment at 12 Place Vendome.
mous
.

back to the room. Princess Marcelina began to recite the litany for the dying, which others repeated after her.1'3'11 Chopin's tears ran down his cheeks and he asked for some music. Princess Marcelina (one of many wealthy lady friends) and Mr. Franchomme began to play the Sonata in G minor, but after the first few measures, the music had to defer to a coughing fit. This dying agony went on for 4 days, during which Chopin remained conscious most of the time. On the evening of October 15th, 1849, Chopin felt worse; in the night he could not speak because of sudden hoarseness, and he lost consciousness at times. The following day, he made some last instruc tions regarding his manuscripts and personal papers. He told his sister Ludwika that he wished his heart to be taken to Warsaw and expressed a wish that Mozart's Requiem should be sung at his funeral
mass.

The Last Days The accounts of Chopin's last days, even if we confine ourselves to those given by eye witnesses, are a mesh of contradictions that is not wholly possible to
In the first days of October 1849, Chopin's condi tion was such that when unsupported, he could not sit upright and was very breathless. He lived in this apartment for no more than three weeks. Liszt said

from Dr. Cruveilhier's and would not let him take his pulse, saying, "It is not worth the trouble Doctor .soon I'll rid you of me."11 Then he fell asleep until and choked with midnight; when he awakenedstill. The doctor bent his face was dark and coughing, over him with a candle and asked him whether he
was

(the nature and etiology of which are not clear) and severe pain. At eleven o'clock he withdrew his hand

During the night he was troubled with convulsions

disentangle.

He replied, "no more" in a barely voice.11 perceptible A convulsive sleep came over him and lasted until October 17th. At 2 am, a cold sweat ran profusely
in

pain.

actually arrived on the day wrote a few days before his death: "As this Chopin earth will suffocate me, I implore you to have my body open so that I may not be buried alive." When Chopin's death approached, he took on severe cramps. On the night of October 12th, it seemed that his death was imminent. Dr. Cruveilhier sent for Father Alexander (Abbe Alexander Jelowicki, a Pol ish priest), who came at once. The following day, St. Edward's day, the priest came back and was sur with prised to be invited by Chopin to have breakfast him; the patient's condition seemed to have im proved. Accounts of this encounter were later recalled by Father Alexander. The priest handed him a crucifix and knelt beside him; Chopin made his confession, asked for the and called his friends
later that he died.3
new

furniture

sacrament,

then

from his brow, and after a brief loss of consciousness, he asked who was near him and kissed the hand of Gutmann after receiving his answer. Chopin died at two o'clock in the morning on October 17th, 1849. Dr. Cruveilhier confirmed the death. The cause of death was given in his death certificate as "tubercu losis of the lungs and larynx." Mr. Gavard reported that "Chopin's face, which was blackened in the last returned to its normal color soon after death."11 days, Later that day, a man from the art gallery named Mr. came and took casts of the dead man's face Clesinge and hands. Chopin's closest friends reported that the condition of Chopin was not the outcome of physical a newly contracted disease but only an acuter phase of that old disease from which he had suffered for over 12 years and which he probably inherited from his father,1 who died of a chest and heart complaint. His funeral was reported in Paris's Daily News on November 2nd, 1849: "The doors of the Church of Madeleine were opened at eleven o'clock on Tues and at noon, the vast area was filled by an day 30th of ofwhom assembly nearly four thousand people, all was burreceived special invitation." Chopin's body
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ied in the cemetery of Pere Lachaise; his heart was sent back to Poland and placed in the church of
Sainte Croix at Warsaw. Post Mortem

This analysis was carried out by Dr. Cruveilhier, but this document was never found. Speculation suggests that it might have been destroyed in the great fires of Paris in 1871 or during the two world
wars.

Jane Stirling, response letter from Liszt, quoted Dr. Cruveilhier as saying that "the autopsy did nothing to disclose the cause of death, but it that the lungs were affected less than the appeared It is a disease that I have never encountered heart. before." Ludwika Chopin later reported Dr. Cru veilhier as saying that "the autopsy did nothing to disclose the cause of death. .nevertheless he could not have survived. .diverse pathology. .enlarged heart. .did not disclose pulmonary consumption .lung changes of many year duration. .a disease was not previously encountered."9
in
a

to

Differential Diagnoses Summary of Chopin s symptoms. (1) Recurrent respiratory complaints (coughing, breathlessness, he

etiology). Emphysema. (Dilation of air spaces distal to the terminal bronchioles with destruction of their walls.) The two common causes of this disease are smoking, which is not applicable in Chopin's case because he developed his condition early in life and as far as we know did not smoke, and a1-antitrypsin (cqAT) this is a genetic metabolic deficiency deficiency: caused by the lack of the protease inhibitor c^AT. The g^AT gene has been mapped to the distal portion of the long arm of chromosome 14.12 It is associated with degenerative lung disease (panacinar bronchiectasis, chronic bronchitis, and emphysema, recurrent bronchopulmonary infections), liver cir rhosis, neonatal hepatitis, failure to thrive, and pan creatic insufficiency. The common deficiency is as sociated with the ZZ phenotype,13 but only 70 to
GI

ponent

moptysis, cyanosis), which seem to have started in patient's teens; (2) Systemic complaints (poor exercise tolerance, tiredness, emaciation, failure to gain weight, pallor, pigmentation, peripheral edema, muscle wasting, and icterus); (3) GI symptoms (di arrhea, fatty food intolerance, hematemesis); and (4) no finger clubbing (Fig 3). The most prominent feature of Chopin's illness was the respiratory com of his
the condition (adjunct to that is a possible This could be caused by the following

conditions:

Figure 3. Cast of Chopin's 214

hand, taken after his death, shows no finger clubbing.

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tory disease.14 The incidence ofthe presence of this phenotype is around 1:1,000 in Western Europe, while the number of heterozygous carriers is around 4% ofthe population; both are at an increased risk of

80% of homozygotes

develop symptomatic respira

developing respiratory problems. This, we believe, is a very credible diagnosis. It would explain Emilia's death at the age of 14 from massive upper GI hemorrhage secondary to portal caused by liver cirrhosis. It would also hypertension account for Chopin's recurrent chest infection, and GI symptoms, all of which were weight loss, chronic and early in onset. However, it is worthy of note that a history of chronic diarrhea associated with axAT deficiencyinduced pancreatic insufficiency was not obvious. Furthermore, should oqAT deficiency be the cause of Chopin and Emilia's deaths, it is surprising that portal hypertension giving rise to variceal bleeding was not associated with jaundice or ascites. However, the absence of these signs does not exclude the possibility of this diagnosis. Rronchiectasis. This is a pathological dilatation of the airways associated with respiratory infections in childhood, especially whooping cough, measles, and TB. The following are causes of bronchiectasis: 1. axAT deficiency (see above). 2. Cystic fibrosis (CF): this is a multi-system disorder associated with bronchial obstruction due to inspissated mucus. It is one of the most common autosomal
recessive diseases

(incidence of 1:2,000, with 1:22 of the general population being carriers).16 This condition commonly is associated with recurrent pneumonia. Death from overwhelming infection and cor pulmonale (right heart failure) occurs in the first decade of the child's life. This was especially true in the pre-antibiotic era. The exocrine gland dysfunction leads to pancreatic (steatorrhea). Liver cir insufficiency, causing diarrhea rhosis, polyarthropathy, and infertility are uncommon It is possible to explain most of complications of CF. and Chopin's symptoms signs by CF, but it seems unlikely that Chopin had CF, since survival of patients with this disorder beyond a very early age was very rare in the pre-antibiotic era. It is worthy of note, however, that CF is a disease of variable severity, and therefore it is possible that Chopin had a milder form of this disease. 3. Hypogammaglobulinemia (congenital and ac quired), the primary form of which is an X-linked autosomal recessive disease, characterized by selective deficiency of B lymphocytes, resulting in immunoglob ulin deficiency. The patient tends to be susceptible to recurrent bacterial infections, which may explain Chopin's recurrent chest infections, but not his GI symptoms. Furthermore, one would expect patients with this disease to develop other infections involving

the skin, the soft tissues, the throat, and other areas susceptible to bacterial colonization. We do not believe that Chopin had this disease, because his disease was limited to the chest and the GI tract. invariably 4. Pulmonary TB: it could be argued that Emilia (Chopin's sister) suffered from TB, though that would not explain her death from massive GI hem orrhage. This may have resulted in transmission to her brother. However, it seems unlikely that with no treatment, someone would have over 24 years of recurrent tubercular infection. Chopin's hemoptysis could have been caused by TB, but the lack of finger clubbing and recurrent hematemesis tend to suggest a different diagnosis. Chopin's doctors, including Dr. Cruveilhier, seemed to be convinced that he suffered from consumption, but it is worthy of note that although Dr. Cruveilhier's post mortem report was never found, the second hand reports of its contents seem to suggest that he was persuaded that his patient did not have TB. If this was the case, his belief must be taken seriously because he was an in pathological anatomy and TB. authority 5. Allergic bronchopulmonary aspergillosis, a disease that occurs due to sensitivity to the fungus Aspergillus this organism thrives in warm, wet condi fumigatus: tions, and therefore its symptoms tend to occur in Autumn. This disease may occur as simple, asthmatic like attacks, but eventually it leads to eosinophilic infiltrates with consolidation. Mucus impaction can lead to proximal bronchiectasis and upper zone fibrosis. It often occurs early in a patient's adult life as worsen ing asthma associated with production of rubbery brown or green sputum plugs and is treated in modern medicine by prednisolone. This disease would explain Chopin's respiratory symptoms well, but may not ex his other disorders or easily explain his early plain demise. Moreover, wheezing appeared not to have been prominent in Chopin's complaints and would have been in a patient with allergic aspergillosis. There are other, less common causes of bronchiectasis (Kartagener's syndrome and pulmonary fibrosis) that we do not believe Chopin had.

Long-term complications of chronic lung disease

Pulmonary hypertrophic osteoarthropathy: this of the of distal clubbing fingers, painful swelling and soft tissue It be caused joints, swelling. may by bronchial cancer, emphysema, or bronchiectasis. This condition may explain Chopin's pains in his hands, ankles, and feet, but it is worth noting that was not evident in the casts made of finger clubbing hands. Chopin's 2. Infertility: despite Chopin's several sexual en counters and a relationship with George Sand lasting 11 years, Chopin never fathered a child.
1.
is
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3. Poor exercise tolerance, failure to gain weight. All of the above signs and symptoms were present in Chopin's illness, but it is fair to note that such complaints are also commonly associated with chronic states of ill health of different etiologies and are not necessarily specific to respiratory disorders.

occurs as early a patient's unlikely thatItthis disease also is difficult to believe that one years. would survive 22 years of pulmonary hemorrhage secondary to mitral stenosis. It is also difficult to account for Chopin's GI complaints if he only had mitral stenosis. Tricuspid valve incompetence. This often presents with distended pulsatile tender liver, portal hyper tension (which Chopin could have had and which would account for his hematemesis) secondary to esophageal varices, gastric varices, or portal hyper tensive gastropathy and with fatigue, peripheral edema, abdominal pain, and jaundice. We do not believe that Chopin had tricuspid valve incompetence because the natural history of this disease is not compatible with his case presentation, and the lack of jaundice or ascites adds more doubt to this diagnosis. Churg-Strauss syndrome, chronic lung abscess formation, pulmonary hemosiderosis, and pulmonary arteriovenous malformation are all rare but possible diagnoses.

breathlessness, orthopnea, palpitations, weight loss, and cachexia. We cannot conclude that Chopin had mitral stenosis from the evidence we have; it is
teen

Other explanations of Chopin s symptoms Mitral stenosis. This is almost always the conse quence of rheumatic fever (which Chopin could have had during childhood, though we have no evidence to that effect). This disease may result in poor exercise tolerance, recurrent chest infections,

deficiency because these two conditions could ex plain his chronic ill health and early death. They may also explain his sister's death at the age of 14. The argument for the latter disease is a little more persuasive than the former. Ultimately, readers will have to make up their own minds about the real causes of Chopin's illnesses and early death, but we hope that this review will shed more light on the matter. The name of Chopin conjures up an image of a sentimental artist, one of the giants of the musical Romantic Period. His music became a symbol of his personal tragedy and sometimes a protestation
inflicted upon him.
References
1 Niecks F. Frederick Chopin: as a man and a musician. 2nd ed. London: Novello, Ewer, & Co., 1890; (vol 2) 277-328 2 Liszt F (translated by John Broadhouse). Life of Chopin. London: William Reevers Publisher, 1877; 28-66 3 Murdoch W. Chopin: his life. New York: McMillan, 1934 4 Marek G. Chopin. New York: Harper and Row, 1979 5 Karasowski M. Life and letters of Chopin. London: William Reevers Publisher, 1879 6 Bone A. Sir James Hedderick. Glasgow: John Smith Publish ers, 1848 7 Wierzynski C (translated by Nortbert Guterman). The life and death of Chopin. New York: Simon and Schuster, 1949 8 O'Shea J. Music and medicine. London: JM Dent, 1993;

against the

restraints that his chronic ill health

140-55

Heinemann, 1962; 73-74

Heldey

A. Selected

correspondence

of

Chopin.

London:

Conclusions We believe that Chopin's diagnosis could be nar rowed down to either a mild form of CF or axAT

10 Kuzemko JA. Chopin illnesses. J Roy Soc Med 1994; 87: 769-72 11 Zamoyski A. Chopin: a biography. London: Granada, 1979 12 Shin MS, Ho JK. Bronchiectasis in patients with alpha 1antitrypsin deficiency: a rare occurrence? Chest 1993; 104: 1384-86 13 Fagerhol MK, Cox DW. The pi polymorphism: genetic biochemical and clinical aspects of alpha 1 antitrypsin. Adv Hum Genetics 1981; 11:1-62 14 Morse JO. Alpha 1 antitrypsin deficiency. N Engl J Med 1978; 299:1045-48, 1099-1105

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