Results and Discussion
Physical methods of treatment in the first half of the 19th
century
The semantic content of the terms physical treatment and physiotherapy in the
19th century and in our time are significantly different. There
was no generally accepted list of physical treatment methods at that time. The
only structured classification of the physical therapeutic means was provided by
a famous French psychiatrist Jean-Étienne Dominique Esquirol (1772–1840) in his
treatise Des Maladies Mentales, considerées sous les Rapports Medical,
Hygienique et Medico- Legal, & c. 1838 (from French: Mental
Diseases, Considered in a Medical, Hygienic, and Medico-Legal Point of
View). He noted: ‘The physical means are either hygienic or
pharmaceutical. a) Water as bath in every way, and of every degree of
temperature at all bearable; b) Emetics; c) Purgatives; d) Blood-letting; e)
Tonics and Antispasmodics; f) Narcotics; g) Counter-irritation: setons,
moxa, the actual cautery, dry cupping, friction with irritating and
mercurial preparations; h) Electricity and Animal Magnetism
[[11]. Phthisiatricians always added
the physical means to the above list: ‘The use of baths in a variety of forms
with dry or moist and stimulating frictions on the skin, are almost
invariably included in the treatment prescribed by different authors’
[[2], p. 318; [3], p. 134; [4], p. 64; [12], p. 148; [13], p. 370], ‘a milk and vegetable
diet’ [[2], p. 370; [3], p. 192; [4], p. 88; 10, p. 138; 11, p. 363],
‘muscular exercise, particularly in the open air’ [[2], p. 367; [3], p. 387; [4], p. 68; [12], p. 141; [13], p. 345], and of course ‘change
of climate’ [[2], p. 367; [3], p. 407; [4], p. 73; [12], p. 149; [12], p. 365].
Case history of Frederic Chopin
Frederic Chopin had poor health since childhood and his letters constantly
mentioned catarrhal affection, swelled glands, leeches on the throat, as well as
many physicians, who recommended walking as much as possible, emetic water,
Lau-Brunn water, Silesia for taking the waters, the spa Reinertz
(Duszniki-Zdrój), Sanniki resort spa [[14], p. 21, p. 27, p. 28, p. 32, p. 37]. Furthermore pills for
appetite, goat’s milk prescribed at the time for lung ailments, inhalations of
vapor, baths in oak bark, infusions of acorns, wine diluted in water in a beer
mug to build up blood [[15], p. 38].
Some of the above prescriptions in the 19th century were considered
purely anti-tuberculosis, others had a dual purpose. Chopin patiently and even
humorously followed all physicians’ orders, but his perception of tuberculosis
and related treatment changed dramatically after the death of his younger sister
Emily.
In a letter dated March 14, 1827, Frederic informed his close friend Jan
Bialobocki (1806–1828): ‘We have illness in the house. Emily has been in bed
for 4 weeks; she has got a cough and has begun to spit blood and Mamma is
frightened. Malcz [physician] ordered bloodletting. They bled her
once, twice; leeches without end, vesicators, setons, wolfsbane; all sorts
of nonsense! – All this time she has been eating nothing; she has grown so
thin that you wouldn’t know her, and is only now beginning to come to
herself a little – You can imagine what it has been like in the house.
You’ll have to imagine it, because I can’t describe it for you!’ [[16], p. 12]. Emily died of
phthisis at the age of 14 after three years of illness. One year
after death of his sister, his friend Bialobocki died, who was also treated with
‘bloodletting, setons and vesicators’.
Chopin’s letter indicated that he already in 1827 did not trust ‘bloodletting,
setons and vesicators’ (‘All sorts of nonsense’). Obviously, the
death of loved ones forever instilled fear of tuberculosis in Chopin’s heart. He
had repeatedly seen the physicians’ helplessness in the treatment of
phthisis throughout all his life. Chopin’s uncontrollable fear of the
diagnosis of tuberculosis is indicated by the fact that not one of the Polish or
French physicians ever voiced a diagnosis that was completely obvious to
everyone around him, even just before Chopin’s death. Many biographers
independently concluded that all attending physicians prescribed
anti-tuberculosis treatment without voicing a diagnosis of consumption: Adam
Zamoyski [[17], p. 192] Franz Hermann
Franken [[18], р. 176], Anton Neumayr
[[19], р. 67], Bernard Gavoty
[[10], p. 320]. Gavoty expressed
the general opinion: ‘What was Chopin’s treatment like? In the fashion of the
times. If we look at one of Laennec’s prescriptions written in 1823 for a
consumptive, we see that Chopin followed it to the letter. Laennec’s advice
was to “change air, go to the South of France, wear flannel next to your
skin, rub yourself with a hot wool cloth saturated with benzoin, go for
carriage rides, take soft drinks, gum water, chicken bouillon and lichen
jelly”. As the role of germs in the illness was unknown, it could not be
treated seriously. Doctors Louis and Clarke, well-known lung specialists,
scrupulously followed Laennec’s prescriptions. Matuszyñski had previously
‘treated’ Chopin in the same manner. Before Laennec, Broussais had advocated
vesicatory and anti-inflammatory medication: cauteries, bloodletting,
ipecac, kermes, opium, quinquina, sulphur water, creosote, arsenicals and,
on top of that, diet’ [[10], p.
320].
Many biographers believe that Chopin was not yet sick with tuberculosis as a
teenager. However, if we consider the fact that he lived in the same room with
his sister Emily until the last stage of her illness, and then his constant
malaise, coupled with the prescription of anti-tuberculosis drugs, makes us
think otherwise. Chopin’s appearance at the age of 20 caused everyone around him
think of consumption. The Hungarian composer Stephen Heller (1813–1888),
Chopin’s friend, recalled that Frederic ‘was then in delicate health, thin
and with sunken cheeks, and that the people of Warsaw said that he could not
live long, but would, like so many geniuses, die young’ [[20], p. 64]. By the mid-1830s, Chopin’s
health was relatively stable, probably thanks to medical supervision, regimen,
and systematic preventative treatment. However, after moving to Paris, Chopin’s
lifestyle changed dramatically.
Chopin’s first physician in Paris was Aleksander Julian Hoffmann (1805–1867), who
shared Chopin’s apartment in 1833–1834. Chopin found apartment in the Chaussée
d’Antin flat in June 1833, when he decided to give lessons at his home. The
music lessons were his main source of income. The flat was so spacious and
costly that Chopin decided to share it with Alexander Hoffman, his childhood
playmate [[21], p. 186]. Hoffmann had
appointed himself Chopin’s personal physician, watched over his health, saw to
it that he observed his dietary regimen and prescribed rest hours. He made his
friend go on a vacation, which Chopin badly needed, having spent the previous
summer in town [[21], p. 187]. Hoffman
was a music lover, a caring physician, but at the same time, he was an
inveterate cigarette smoker and was frequently found at Chopin’s rooms smoking.
Chopin hated cigarette smoke, so he convinced Hoffman to move, emphasizing the
dangers of tobacco smoke to his health [[22], p. 56].
Next attending physician of Chopin was Jan Matuszyński (1808–1842), his closest
friends since the training in Warsaw Lyceum. In April 1834 Matuszyński arrived
in Paris where was appointed professor at the Ecole de Medicine. Apparently, Dr
Matuszynski had certain concerns for Chopin’s health, since he prescribed
balneological treatment for his friend. In June 1835, Chopin took the baths at
the popular Spa Resort Enghien-les-Bains [[21], p. 199]. New Paris Guide or, Stranger’s Companion Through the
French Metropolis 1827 reported: ‘The village of Enghien, four
leagues north of Paris, is situated upon the banks of the lake of St.
Gratien, between the heights of Montmorency and the wood of St. Gratien. The
sulphuric spring, to which it owes its celebrity as a bathing place, was
discovered, in 1766, by Pere Cotte, the learned rector of Montmorency. The
magnificent establishment of baths on the border of the lake is remarkable
for its cleanliness and elegance and affords accommodation equal to the
principal baths of the capital. The chief spring, called Source du Roi,
rises in the garden. Near it has been built a square tower of a sufficient
height to raise the water into the bath-rooms. On the summit is a terrace
that commands a fine and extensive prospect’ [[23], р. 737–739]. Matuszyński chose
Enghien-les-Bains because sulfur mineral waters were considered effective in the
treatment and prevention of phthisis. James Clark, (1788–1870) a famous British
physician, а prominent phthisiatrician, author of A Treatise on Tubercular
Phthisis, or Pulmonary Consumption 1834, wrote in his treatise: ‘We
consider the sulphureous waters are best form of administering for
tubercular phthisis; bathing should generally be combined with their
internal use; and when the water does not act on the bowels, they should be
kept open by laxatives’ [[4],
p. 71]. Pierre-Charles-Alexandre Louis (1787–1872), a friend and colleague of
Rene Laennec, author of Pathological researches on phthisis 1835 also
recognized the benefits of sulfur baths for tubercular phthisis: ‘To
be effectual, baths must be persevered in, and much care taken by the use of
diluents, friction, and exercise, to avoid their injurious effects. The
temperature should be regulated, and the stimulating nature of the bath
adapted to the peculiarities of the patient's constitution. In
scrophulous and chronic cases, much benefit may be expected from this mode
of treatment, and in opposite circumstances their judicious employment will
at least prove a valuable palliative remedy’ [[13], р. 370]. Laennec also prescribed
for phthisis pulmonalis ‘the natural and artificial sulphureous
waters, internally or externally’ [[2], p. 364].
However, despite preventive balneotherapy, in November 1835 Chopin fell ill; he
was coughing up blood, weak and irritable. Chopin was forced to spend several
weeks in bed and was sure that he was dying. Therefore, he wrote a will and a
‘mournful mass, as if for his death’, according to his most
authoritative Polish biographer Ferdynand Hoesick (1867–1941), who believed that
‘Chopin heard the sound of church bells sounding at his funeral’
[[22], p. 176]. The news of
Chopin’s illness soon spread in Paris and reached Warsaw in the form of a rumor
that Chopin had died [[21], p. 212].
Fearing for the life of a friend, Jan Matuszyński invited his more eminent
colleague Adam Raciborski (1809–1871) to see Chopin. Raciborski was the same age
as Matuszyński, but he was already very successful in his professional careerIn
1834, Raciborsky earned his Doctor of Philosophy in Medicine and became the head
of the clinic at Charité Hospital. Adam Raciborski published his treatise New
and complete manual of auscultation and percussion, applied to the diagnosis
of diseases in English in 1835 [[24], p. IV]. Despite the undeniable signs of pulmonary tuberculosis
in Chopin, Raciborski was diagnosed ‘high fever flu’, and ‘simple
severe chronic bronchitis with haemoptysis’. He prescribed the patient
bed rest, expectorant herbs, and during episodes of bleeding – apply ice to the
chest and swallow pieces of ice. In addition, Chopin’s apartment contained vats
of herbal scents and red-hot charcoal, which emitted, among other things,
creosote, known as a cough suppressant and sedative [[19], p. 57]. The healing properties of
creosote were known back in Ancient Egypt; in the 1820–30s in Britain and
France, creosote became very widely used as an antiseptic, anti-inflammatory and
wound healing agent in the form of inhalations and local applications [[25], р. 96–152]. Alexandre Louis (a
colleague of Adam Raciborski at the Charité Hospital and at the École
de Médecine in Paris) recommended for reduce the intensity of
hemoptysis ‘cold water and small pieces of ice taken internally are
valuable adjuncts in acute and incipient cases’ [13, p. 383].
Since 1835, Chopin was sick every winter, often the illness lasted until spring.
During the winter 1837 Chopin was again ill with ‘influenza’. In February
1838 he fell ill with high fever, hemoptysis, and hematemesis. He
was exhausted and listless, and was confined to his bed for several weeks. Franz
Hermann Franken noted that he was treated for this ailment with ‘vesicle
producing plasters and cupping’ by Dr. Jan Matuszynski [[18], p. 175]. Vesicators or
blisters were remedies with irritant or blistering effect. The main
active ingredient of such plasters was cantharidic acid in the form of an
alcoholic extract, the so-called ‘the Spanish fly’ (Lytta
vesicatori). The Spanish fly is an emerald-green beetle in the blister
beetle family, but not a fly [26]
.
Cupping therapy is a form of treatment in which a therapist puts special
cups on patient’s skin for a few minutes to create suction. Physicians in the
19th century regarded cupping as a local form of bleeding.
Alexandre Louis in the treatment of phthisis, prescribed cupping
‘against the intercurrent inflammatory complications’ [[13], р. 374]. Laennec, who was not
enthusiastic about bleeding, noted in his treatise: ‘Cupping is in general
more useful’ [[2], p. 69]. He
clarified: ‘I have just stated that the detraction of blood is useless;
derivatives, such as dry cupping, particularly if the glasses are left long
enough to cause vesication, blisters, emetics and even purgatives, afford
some slight but very temporary relief. Nevertheless, one is occasionally
under the necessity of having recourse to some applications of this kind;
and that which I prefer is a pitch plaster powdered with tartar emetic,
applied between the shoulders’ [[2], p. 92]. James Clark believed that local remedies like the
‘vesicle producing plasters and cupping’ are all useful in different
cases. Nevertheless, the practice of relying on any local remedy as a principal
means of curing a disease, which originates in and depends upon a morbid
condition of the whole system, is decidedly condemned by Dr. Clark [[4], p. 81–82]. Samuel George Morton
(1799–1851), who studied under Rene Laennec and Alexandre Louis in Paris, in his
Illustrations of Pulmonary Consumption, Its Anatomical Characters,
Causes, Symptoms and Treatment 1834 recommended for pulmonary
tuberculosis ‘bleeding from the arm and cupping over the seat of pain’
[[12], p. 80].
Chopin could not recover from the illness for a long time; he lost a lot of
weight and coughed constantly. A debilitating illness, as well as the breaking
of the engagement to Maria Wodzińska (1819–1896) had an extremely negative
impact on Chopin’s psychological state. It was during this period that George
Sand appeared in his life (pen name of Aurore Dupin, a famous French novelist,
1804–1876). Chopin’s biographer Moritz Karasowski (1823–1892) believed that by
the beginning of 1838 the figure of George Sand was assuming a role of the first
importance. He wrote: ‘he (Chopin) learned that his bride had elected to
marry a count instead of an artist. The consequences to Chopin were very
serious: finding that his hopes of an ideal union were shattered, to wipe
out and forget the insult he had received, he threw himself into the arms of
a woman who exercised a very pernicious influence over him’ [[27], p. 258]. In the spring of 1838,
Chopin still looked seriously ill and George Sand wrote in her Histoire de ma
Vie 1854 (from French: Story of My Life): ‛As I was making my
plans and preparations for departure, Chopin, whom I saw every day and whose
genius and character I tenderly loved, said to me that if he were in
Maurice’s place he would soon recover. I believed it, and I was mistaken. I
did not put him in the place of Maurice on the journey, but beside Maurice.
His friends had long urged him to spend some time in the south of Europe.
They thought he was consumptive’ [[28], p. 1089]. Sand insisted on Chopin consulting with her ‘usual
doctor’ and ‘great friend’ Pierre Marcel Gaubert (1796-1839).
Dr. Pierre Gaubert until the mid-1830s served as professor position at the
Faculty of Medicine at the University of France. Gaubert was a student and
associate of François Broussais. Sand then reported: ‘Gaubert examined him
and swore that he was not (consumptive): You will in fact save him if you
give him fresh air, exercise, and rest' [[28], p. 1089]. As noted by the modern
German physician Franz Hermann Franken, an author of book Diseases of Famous
Composers: Twenty-two Pathographies from Bach to Bartok (1996), on the
one hand, Dr. Gaubert’s comments were confusing, as he convinced Sand that
Chopin was not suffering from tuberculosis, while, on the other hand, still
pushed for his departure for the south. Franken stated: ‘The suggestion of a
move to the south for the betterment of respiratory ailments such as
pulmonary tuberculosis was quite common, and it seems almost contradictory
that he suggests a cure for a disease or ailment that Chopin supposedly did
not have. One might venture to guess that perhaps Dr. Gaubert was trying to
hide the fatal truth from Chopin and Sand while still guiding them according
to the proper 19th-century treatment plan’ [[18], р. 176]. Another Chopin’s medical
biographer Anton Neumayr also believed that the apparent contradiction between
the diagnosis and recommendations showed that Dr. Gaubert was aware of Chopin’s
family anamnesis and his fear of tuberculosis [[19], р. 67].
George Sand’s papers contain a recipe signed by Dr. Gaubert in the name of
Frederic Chopin dated 22 April 1838, it indicated the tincture of opium and
belladonna. It is also known that Gaubert prescribed Chopin ‘soothing’
chest plasters [[19], р. 67]. Opium and
belladonna extract were applied to the base of the plaster (Emplastrum
Diachylon). Opium and belladonna at that time were the most powerful
antispasmodic, analgesic and antitussive drugs. Alexandre Louis claimed in his
treatise: ‘When the cough was very troublesome during the night, we
prescribed at first an ounce or half an ounce of syrup of poppies in the
evening, and if this did not succeed, we ordered a mucilaginous mixture with
gradually increasing doses of opium; from one to three grains. In some
obstinate cases the acetate of morphia and extract of belladonna were
successively tried without any additional success’ [[13], p. 352]. Laennec considered the
combination of opium and belladonna an effective remedy for severe shortness of
breath, even during an attack of ‘spasmodic asthma’ (bronchial
asthma): ‘When the dyspnoea becomes extreme, narcotics, particularly
the recently prepared powder of belladonna or stramonium, in doses of half a
grain to a grain, afford most relief. Their administration is frequently
followed by the speedy but temporary cessation of the dyspnoea
shoulders’ [[2], p. 77, p.
416]. Dr. Clark referred to ‘soothing medicines’: ‘ipecacuan in
combination with some mild narcotic, or with the compound ipecacuan
powder’ [[4], p. 87].
Ipecacuanha, opium and belladonna were also favorite antispasmodics and
analgesics of François Broussais [[3],
p. 85, p. 432] and Samuel Morton [[12],
p. 127, p. 134].
George Sand initially planned a trip to Italy for the fall, because she resolved
to take her son Maurice to a milder climate, hoping thus to prevent a return of
the rheumatism from which he had suffered so much in the preceding year [[20], p. 19]. In early October 1838 Sand
wrote to her friends: ‘My son’s health is better, but the doctors recommend a
cool climate for him in the summer and a warm one in the winter. We shall
soon therefore be in Geneva and afterwards in Naples’ [[29], p. 287]. However, a certain
circumstances forced Sand to immediately change her plans. Her carefully hidden
liaison with Chopin was revealed, and George Sand’s former lover Félicien
Mallefille (1813–1868) showed dangerous aggression because he could not come to
terms with the thought of ending their relationship [[16], p. 155, p. 162]. A British
musicologist, scholar, and biographer Arthur Hedley (1905–1969) commented on
this situation: ‘In the meantime the lover whom George Sand was about to
discard, Felicien Mallefile, a writer who had been acting as tutor to her
son, was quite unaware of what going on behind the scenes and wrote an
enthusiastic essay on Chopin for the Paris Gazette Musicale. By the time his
effusion appeared the liaison of Chopin and George Sand was a fact,
Mallefille was bound to discover the truth sooner or later, and when he did
his threats of violence and public scandal, put into effect on one occasion,
encouraged the lovers to avoid Paris’ [[16], p. 161]. Sand’s friend, Marie
d’Agoult (Marie Catherine Sophie, Comtesse d’Agoult; 1805–1876, a Franco-German
romantic author and historian, known also by her pen name, Daniel Stern) in one
of her letters outlined further events as follows: ‘Finally, prompted by what
devilish inspiration I do not know, he (Mallefille) began to get suspicious,
and hung about, watching the door of Chopin’s apartment where George was in
the habit of going every night. The dramatic author became a character of
drama. He shouted, he yelled, he was terribly fierce and all out for
blood’ [[30], p. 267].
Mallefill was well aware of Sand’s upcoming journey and could continue the
pursuit to Italy. Mallefille threatened Chopin with a pistol during the
scandalous scene, so Sand hastily and secretly changed her travel route. She
recalled in her Histoire de Ma Vie: ‘I had chosen Majorca on the advice of
persons who thought they knew the climate and resources of the country well,
but who did not know them at all’ [[28], p. 1090]. She was talking about the couple Manuel Marliani
(1795–1873) and Carlotta Marliani (1790–1850), her friends who mistakenly
believed that Mallorca in winter was the same as Italy, only cheaper.
Climate therapy in the first half of the 19th century was the
most important part of the complex treatment of pulmonary tuberculosis. A
Scottish physician John Forbes (1787–1861), translator and co-author Laennec’s
treatise, noted: ‘I consider consumption, with your distinguished author
(Rene Laennec), as a disease very generally consequent to a deranged or
cachectic state of the general system, originating in a series of functional
disorders, and often favored by an hereditary pre-disposition to tubercles.
When adopted for the removal of this state of the system, and previously to
the actual development of tubercles in the lungs, I look upon change to a
milder climate as a measure of the utmost importance’ [[2], p. 367].
George Sand's plan to spend fall and winter in Italy seemed medically sound.
The physicians recommended ‘a cool climate in summer and a warm one in
winter’, not only to prevent rheumatism but also to treat consumption
[[2], p. 367]. James Clarke in his
The Influence of Climate in the Prevention and Cure of Chronic
Diseases 1829 pointed out that the climate of Naples, Nice, and Madeira
has a huge advantage to certain invalids, since ‘it is warmer during the
winter and cooler during the summer’ [[29], p. 151]. François Broussais argued:
‘There is no exception to this rule: every individual having a soft
texture, slender form, and contracted chest, who apprehends pulmonary
phthisis, cannot pursue a better course to avoid it, than to fix his
residence in a country where there is no winter. Dry, elevated places,
exposed to fresh air, should be preferred, because humid and marshy lands
are extremely unhealthy in southern latitudes’ [[3], p. 426–427]. George Sand was well
acquainted not only with Broussais's physiological theory, but also with
him personally, since she had a consultation with him in 1830 [[28], p. 876].
From the above it is obvious that Italy, with its warm winters, was a good choice
for Chopin. It was Italy that Chopin’s friends had in mind, who thought he was
consumptive and therefore had long told him to spend some time in the south of
Europe. The opinion of Sand and Chopin's friends was quite reasonable.
James Clark after the publication of his Medical notes on climate, diseases,
hospitals, and medical schools. France, Italy and Switzerland 1820, and
A Treatise on Tubercular Phthisis, or Pulmonary Consumption 1834,
became a generally recognized authority in climatotherapy of pulmonary
tuberculosis. He stated in his treatise: ‘In Italy, Rome, Pisa, and Nice,
afford the best climates for consumptive patients during the winter’
[[4], p. 80]. James Clark’s 1829
book, The Influence of Climate in the Prevention and Cure of Chronic Diseases,
includes a favorable description of Nice's and Naples’ winter climate
[[31], p. 83–94; p. 105–107]. Italy
was indeed a favorite winter holiday destination for consumptive patients. John
Forbes stated: ‘the places usually resorted to by consumptive invalids, are
on the sea coast, or at no great distance from it. On the continent, the
places chiefly frequented, and which I have had an opportunity of observing,
are Hyeres in the south of France, Nice in Piedmont, Pisa, Rome and Naples
in Italy’ [[2], p. 362].
Dr. Clark in his treatise provided precise indications and contraindications for
climatotherapy of pulmonary tuberculosis depending on its stage [[4], p. 79–81]. In the preclinical stage,
when ‘the tuberculous diathesis is strongly manifested’, Clark
recommended climate change ‘as a preventive of the disease’ [[4], p. 79]. For patients with already
diagnosed pulmonary tuberculosis Dr. Clark considered climate change possible
only in the stage of stable remission: ‘during the incipient stage of
phthisis, that is, after tuberculous matter is deposited in the lungs, the
power of climate is much less, and much more caution is necessary in
prescribing it. If due precautions are not taken to improve the local
functional derangements before the patient leaves this country, the measure
may prove highly injurious’ [[4], p. 79–80]. Clark held a belief that ‘in the advanced stages of
phthisis, when tuberculous disease of the lungs exists to a considerable
extent, change of climate will be of little avail, and will probably be
prejudicial’ [[4], p. 80]. Rene
Laennec and John Forbes came to this conclusion much earlier than James Clark:
‘If the mischief has advanced a little further, and there are good
reasons for believing that tubercles are already formed in the lungs, more
especially if a disposition to inflammation of these organs or to
haemoptysis, has manifested itself; then, change of climate becomes a more
doubtful measure; and, unless adopted with judgment and with some
precaution, may accelerate rather than retard the progress of the disease.
In cases of this kind, it will be necessary, previously to undertaking the
journey to remove, or at least to moderate, the more evident and important
of the functional derangements, to subdue excitement, and diminish plethora.
Much evil has arisen from inattention to these precautions. Medical men in
general seem hardly sufficiently aware of the great excitement produced in
the system by travelling, and of the necessity, therefore, of removing those
morbid complications most likely to suffer aggravation from this’ [[2], p. 367–368].
According to the criteria of Dr. Clark, Chopin had the advanced stage of
phthisis: continuous cough, hemoptysis, weight loss. It is probable that
in April 1838, Pierre Gaubert intended ‘to subdue excitement, diminish
plethora, and remove or moderate functional derangements’ before
undertaking the journey. However, the treatment did not give the expected
result. Chopin's friend, a Hungarian composer and Franz Liszt (1811–1886)
wrote about Chopin's health on the eve of leaving for Majorca: ‘he was
so weak when he left Paris that we had no hope of his ever returning’
[[32], p. 170]. Biographer Adam
Zamoyski cites a letter from Astolphe de Custine (1790–1857), French aristocrat
and writer, who met Chopin the day before his departure from Paris: ‘He is
leaving for Valencia in Spain, that is to say for the other world. You
simply cannot imagine what Madame Sand has managed to do with him in the
space of one summer! Consumption has taken possession of that face, making
it a soul without a body. He played to us a farewell, with the expression
that you know. First a polonaise, which he had just written, magnificent by
its force and verve. It is a joyous riot. Then he played the Polish prayer.
Then, at the end, a funeral march, which made me burst into tears in spite
of myself. It was the procession taking him to his last resting place; and
when I reflected that perhaps I would never see him again on this earth, my
heart bled. The unfortunate creature cannot see that the woman has the love
of a vampire! He is following her to Spain, whither she is preceding him. He
will never leave that country. He did not dare tell me he was going; he only
spoke of his need for a good climate and for rest! Rest! — With a Ghoul (a
vampire) as traveling companion!’ [[17], p. 173].
It should be noted that the information available in the 1830s about the climate
of Majorca would not have caused concern to anyone. Scottish academic and author
James Playfair (1736–1819) in his A System of Geography Ancient and
Modern 1808 provided an alluring depiction of the climate of Majorca.:
‘The climate of Majorca is delicious; resulting from the varied surface
of the country, which rises from some beautiful plains to gentle slopes,
which, after many undulations of surface, terminate in mountains. In the
greatest heats of July and August, the hills preserve a temperature almost
vernal; nor are the heats in any part suffocating. The winters, except on
the most elevated parts of the hills, are so mild and pleasant, that almonds
blossom in December, and many are in all their beauty throughout the year.
In the depths of winter, ice formed during the night melts before the day is
far advanced. No piercing winds are ever felt, and a fog is scarcely
known’ [[33], p. 152–153].
German university teacher, writer and traveler Christian August Fischer
(1771–1829) in his A Geographical and Statistical Survey of Valencia, and of
the Balearic and Pityusian Islands 1811 gave a similar description:
‘The climate of Mallorca is exceedingly mild, salubrious, and agreeable.
In the winter months, the thermometer scarcely ever falls below 48°F (9°C)
and is often as high as from 60°F to 68°F (15–20°C). Cold and violent north
winds are very rare. In the summer months the thermometer stands almost
invariably between 84°F and 88°F (29–31°C); but the heat, owing to the
constant sea breezes, is never too oppressive’ [[34], p. 273]. A Scottish geographical
author James Bell (1769–1833) described Majorca's climate without delight:
‘Its (Majorca's) climate is in general temperate, the sea-breezes
moderating the heat of summer, and the high grounds affording shelter in
winter’ [[35], p. 291]. As a
result, Majorca seemed to Chopin and Sand to be a completely adequate
replacement for Italy. In addition to all this, the Spanish ambassador in Paris,
Manuel Marliani and his wife Carlotta, assured Sand that Majorca (where they had
never been) was very warm in winter. The real winter weather of Majorca caused a
shock to Chopin and Sand, who, even before winter set in, understood what James
Bell meant when he wrote: ‘the high grounds affording shelter in
winter’.
Majorcan episode. Chopin's climate therapy
Chopin, Sand and her children arrived at Majorca on the 7th of November, 1838.
Until mid-November, Majorca's weather pleased travelers. 15 November 1838
Chopin wrote to his close friend Julian Fontana: ‘Here I am at Palma, among
palms, cedars, cacti, olive-trees, oranges, lemons, aloes, figs,
pomegranates. … In a word, life is marvelous’ [[16], p. 163]. On the day after he wrote
his cheerful letter to Fontana, Chopin fell ill. One careless excursion, during
which he caught a cold, left him so weak that he had to remain in bed [[21], p. 260]. To make things worse, the
weather shifted to rain, and the rest was done by Son-Vent (the villa
where Chopin and Sand lived), which turned out to be a real house of winds. Sand
wrote in Un hiver à Majorque 1841 (from French: Winter in
Majorca): ‘The House of the Wind (Son Vent in Mallorquin), as
Senor Gomez called his villa, became uninhabitable; its walls being so thin
that the lime with which our rooms were whitewashed swelled up like a
sponge. Never have I suffered so much from the cold, though the temperature
was not really low: but people like us are used to keeping warm in winter,
and this house had no fireplace. The damp settled like a cloak of ice over
our shoulders, and reduced me to paralysis. We could not get used to the
suffocating smell of the charcoal braziers, and our invalid (Chopin) grew
seriously ill and began to cough’ [[36], p. 46]. The rains were interminable. The patient coughed more
and more, and began to spit blood. As it later turned out, strong winds, heavy
rains and continuous storms in the winter season are quite common in Majorca.
Often storms prevented any ships from entering the port of Palma from December
to February. Chopin already realized in December 1838 that, due to winter rains,
he would not receive the piano ordered in Marseille until February of the
following year, and he himself would not be able to leave the island. He wrote
Juljan Fontana: ‘I suppose the piano will spend the winter in port or at
anchor (for everything conies to a standstill as soon as it rains) and I
shall receive it when I am ready to leave’ [[16], p. 165].
3 December 1838 Chopin wrote to Juljan Fontana: ‘I have been as sick as a dog
these last two weeks; I caught cold in spite of 18 degrees of heat, roses,
oranges, palms, figs and three most famous doctors of the island. One
sniffed at what I spat up, the second tapped where I spat it from, the third
poked about and listened how I spat it. One said I had died, 1 the second
that I am dying, the 3rd that I shall die. … I could scarcely keep them from
bleeding me, and they put no setons or vesicators’ [[16], p. 164]. Majorcan physicians
immediately diagnosed Chopin with pulmonary tuberculosis and did not hide the
diagnosis from him, since they did not have such an opportunity. The southern
medical school, which included Spain and Italy, believed, rightly as it
happened, in the contagiousness of phthisis. In 1751 King of Spain Fernando VI
(1713–1759), called the Learned (el Prudente) and the Just (el
Justo) proclaimed The Obligatory Declaration of Consumption. The
following are the terms of the famous ordinance: 'Every physician shall
notify the magistrate of his district of the sick and dead from consumption
and contagious disease, or shall incur for the first violation of this law a
fine of two hundred ducats; for a second offense a fine of four hundred
ducats, and a penalty of exile for four years’
[37]]. The Obligatory Declaration of
Consumption 1751 also stated: ‘The magistrates must cause all linen
and other stuff, as well as the clothing and furniture of rooms used by such
sick persons personally, to be burned. The chamber formerly occupied by such
persons, and in which they died, must be replastered and whitewashed’
[[37]]. Chopin and Sand were forced
to pay the villa’s owner for repairs and furniture, and also move to located in
the mountains ‘a huge deserted Carthusian monastery where in a cell with
doors larger than any carriage-gateway in Paris’ [[16], p. 165].
A serious illness and a poor prognosis from Majorcan doctors convinced Chopin of
his imminent death. Sand noted in her Histoire de Ma Vie: ‘He (Chopin)
allowed himself to become completely demoralized’ [[28], p. 1091]. Majorcan physicians
‘prescribed a regime suitable for consumptives: namely bleeding,
starvation and a milk diet’ [[36], p. 149]. They also prescribed setons and
vesicators (сantharidin plasters), a milk and vegetable diet,
decoctions of field violet and thymus vulgaris. James Clark wrote
in his treatise on the treatment of active phase phthisis: ‘In this critical
and dangerous situation accompanied with change of air and occasional
bleedings, the patient will find his greatest security in a drain from a
large scapulary issue (seton) assisted by a diet of asses milk and
vegetables’ [[4], p. 82].
‘Setons or vesicators’: so called ‘сounter-irritants’ –
routine physiotherapeutic remedies of the XIX century. A seton was a cord
or number of threads laid together, and drawn through the skin by the help of a
needle of a proper shape. An eminent Irish surgeon and physician Robert James
Graves (1796–1853) looked on setons as ‘one of the most important
means in the prevention, if not in the treatment of phthisis’
[38]. Setons were advised for
phthisis from the earliest periods of medical history.
Physicians' orders were adjusted due to a number of circumstances.
Bloodletting Sand rejected immediately: ’when I saw our patient getting
worse, I became the pray of great anxiety, as anyone can well understand. “A
blood-letting will save him”. They told me, “and if you don’t agree that we
do it, he will die”. Yet there was a voice inside me said, “A bleeding must
kill him, and if you save him from it, he will live” I am persuaded that
that voice was the voice of God. And now that our friend, the terror of
Majorcans, has been declared to be about as tubercular as I am, I thank
Heaven for not losing the confidence that saved us’ [[36]], p. 149]. Chopin had a prejudice
towards ‘bloodletting, setons and vesicators’ after the death of his
sister Emily and close friend Jan Bialobocki. Professor Thomas M. Daniel, an
author of book Captain of Death: The Story of Tuberculosis 1999, believes
that ‘Chopin's reluctance to accept bloodletting and blistering from his
physicians may have resulted from his memories of his sister's illness
and demise and the treatment she received’ [[39], p. 61]. Chopin felt instinctively
that prescribed treatment would be injurious to him, that bleeding would even be
fatal. Про starvation Sand написала: ‘Starvation did not suit him (Chopin) at
all. When we saw its ill effects, we complied with it as little as possible;
but alas, there was no middle course to follow between the scorching local
spiced meats and the most meager diet’ [[36], p. 149]. The milk diet did not suit
Chopin at all either. The milk from Majorcan cows gave Chopin indigestion,
significantly when messenger boys diluted it with raw water. Sand wrote:
‘Milk and milk products, the harmful effects of which we came to
appreciate later, were fortunately scarce enough in Majorca not to do him
any harm’ [[36], p. 149].
Indeed, there were no cows in the mountains of Majorca, so Sand had to buy a
goat and milk it herself. Violets and thymus Sand also had to be
collected by her own hand [[36], p.
151]. Medicines and dietary products that could be purchased in Majorca were
decidedly not suitable for Chopin. Sand noted: ‘There was hardly anything
else we could use. All the drugs obtainable in Palma were insufferably
dirty. The badly refined sugar imported there from Spain is dark and oily,
with a strong purgative effect on those who are unaccustomed to it’
[[36], p. 151].
Regarding the winter climate of Majorca, we can conclude: extremely high humidity
and strong winds made the island unsuitable for consumptive patients, even
during the period of stabilization of the disease. Chopin wrote in December 1838
to Julian Fontana: ‘I have come here many times from Palma, always with the
same coachman but always by a different route. Roads are made by the
torrents and repaired by landslides. You can't drive through this way
today because it's ploughed up, tomorrow only mules can pass, and what
vehicles they have!’ [[16], p.
166]. The heavy rains on also made a strong impression on Sand. She said in her
letter: 'winter not cold, but rainy to a degree to frighten us. It is a
deluge! The rain uproots the mountains; all the waters of the mountain rush
into the plain; the roads become torrents. We found ourselves caught in
them, Maurice and I. We had been at Palma in superb weather. When we
returned in the evening, there were no fields, no roads, but only trees to
indicate approximately the way which we had to go. I was really very
frightened, especially as the horse refused to proceed, and we were obliged
to traverse the mountain on foot in the night, with torrents across our
legs’ [[20], p. 32].
James Clark, in his A Treatise on Tubercular Phthisis, or Pulmonary
Consumption published in 1834, cited Dr. Renton's report on the
influence of the climate of Madeira on the patients who spent the winter of
1833/1834 on the island. This report sheds light on the effectiveness of
climatotherapy in treating pulmonary tuberculosis: ‘The total number of
pulmonary invalids who arrived there during the season of 1833/34 was 66. Of
this number 15 died; 43 returned to their homes, and 8 still remain on the
island [[4], p. 80]. Dr. Renton
believed that almost all the patients who died on Madeira were contraindicated
for climate change, since they had the advanced stage of phthisis: ‘of the 15
fatal cases, 13 ought not to have left their homes; of the 43 who left the
island for England, or other parts of the world, 36 were very much improved;
indeed I may say a large majority of them went away well’ [[4], p. 80]. James Clark praised
Madeira's healthy climate: ‘I think, to show that where climate is
likely to be useful in consumption that of Madeira is preferable to any in
the South of Europe’ [[31], p.
163]. Clark provided reasoning to support his viewpoint: ‘The rain
at Madeira falls at particular seasons, chiefly in the October, leaving the
atmosphere, in general, dry and clear during the remainder of the year. … In
November the weather clears up, and generally continues fine and mild till
the end of December. The weather continues more or less damp through January
and February; but fog is never seen, and even during this, their winter, the
thermometer at sun-rise rarely ever falls below 50°F
(10
o
C) [[31], p. 152–153]. Obviously, even in Madeira, Chopin would have been
in danger in the winter, since he had the advanced stage of phthisis. By Dr.
Renton's words, Chopin ought not to have left his home. Dr. Renton, who has
long resided on Madeira, stated: ‘when it (consumption) has proceeded to any
considerable extent, I should consider it the duty of a medical attendant
not only not to advise the adoption of such a measure, but most earnestly to
dissuade from it those, who, from hearsay evidence of the recovery of others
in circumstances similar to their own, may feel disposed to fly to it as a
last resource’ [[31], p.
157].
The winter climate of Majorca had a detrimental effect on both Chopin's
physical and psychological state, Sand reported: ‘There are rains here of
which one has elsewhere no idea: it is a frightful deluge! The air is on
account of it so relaxing, so soft, that one (Chopin) cannot drag one's
self along; one is really ill. But the little Chopin is very depressed and
always coughs much. For his sake, I await with impatience the return of fine
weather’ [[20], p. 31].
Unfortunately, Sand's hopes were not realized and Chopin's condition
worsened. François Broussais seems to have written about Majorca: ‘humid and
marshy lands are extremely unhealthy (for consumptive patient) in southern
latitudes, and because the night dews, which are often very cold, would
expose him to catarrhs, which he should always avoid’ [[3], p. 426–427]. George Sand recalled in
her Un Hiver à Majorque: ‘As the winter advanced, sadness more and more
paralyzed my efforts at gaiety and cheerfulness. The state of our invalid
grew always worse; the wind wailed in the ravines, the rain beat against our
windows, and the voice of the thunder penetrated through our thick walls and
mingled its mournful sounds with the laughter and sports of the children.
... Death seemed to hover over our heads to seize one of us, and we were
alone in contending with him for his prey’ [[20], p. [40]]. At the beginning of February 1839,
Chopin's situation became desperate. George Sand noted: ‘The climate at
Majorca was becoming more and more deadly to Chopin and I hastened to get
away’ [[16], p. 169]. And
further: ‘Our invalid did not seem to be in a state to stand the passage, but
he seemed equally incapable of enduring another week in Majorca. The
situation was frightful; there were days when I lost hope and courage’
[[20], p. 46]. Chopin's most
ardent wish was to get away from Majorca and back to France. But for some time
he was too weak to travel, and when he had got a little stronger, contrary winds
prevented the steamer from leaving the port of Palma [[20], p. 39]. As soon as fair weather set
in and the steamer resumed its weekly courses to Barcelona, George Sand and her
party hastened to leave the island. She recalled in her Un hiver à
Majorque: ‘Chopin got worse and worse, and in spite of all offers of
service which were made to us in the Spanish manner, we should not have
found a hospitable house in all the island. At last we resolved to depart at
any price, although Chopin had not the strength to drag himself along’
[[20], p. 47].
The return journey was very difficult for Chopin, Sand wrote: ‘Chopin arrived
at Barcelona still spitting blood by basins-full, and crawling along like
ghost' [[20], p. 39]. It
was only after receiving three weeks of treatment from Marseille physician Andre
Francois Cauviere (1780–1858) that Chopin was able to put aside his troubling
thoughts about death: he asked Julian Fontana to burn his testament
'without reading it’ [[16], p. 171; 9, p. 377]. Dr. Cauviere said that Chopin needs
‘extensive care and rest’ [[26], p. 1094], and prescribed cantharidin plasters, milk and
vegetable diet, tincture of opium and belladonna [[16], p. 170, p. 173]. Physician Gustave
Papet (1799–1850) examined Chopin in George Sand’s house at Nohant in June 1839.
He recommended 'steady diet, fresh air, and a regular, restful
life' [[28], p. 1095].
Chopin had only partially recovered from his trip to Majorca by the autumn of
1839. One of Chopin's favorite students Friederike Muller (1816–1895)
recalled that on the 30th of October, 1839 ‘Chopin was from home and very
ill. He suffered greatly. Feeble, pale, coughing much, he often took opium
drops on sugar and gum-water, rubbed his forehead with eau de Cologne’
[[20], p. 336]. Chopin said,
smiling: ‘For a year I have not studied a quarter of an hour at a time. I
have no strength, no energy. I am always waiting for a little health to take
all that up again, but I am still waiting’ [[40], p. 196].
In reality, Chopin never recovered from his trip to Majorca. Although he lived
another 10 years, his consumption progressed steadily from year to year. Some
physicians replaced others, but the recommendations were the same: rest, fresh
air, feasible physical exercise (walking), moving to the south of France for the
winter. Physician's prescriptions were not varied: cantharidin or
mustard plasters, milk and vegetable diet, opium and belladonna. During
these 10 years, Chopin never managed to visit a single climatic resort, even in
the south of France. However, Chopin did not lose faith in the healing power of
climate until almost the end of his life. Moreover, almost until the end of his
life, he hoped to take advantage of physicians’ advice about climate change. On
June 18, 1949, just four months before he passed, Chopin persistently bothered
another attending physician with questions about his trip to the resort: ‘My
Dr Fraenkel I can't get out of him whether I should go to some spa or
to the south of France has once more stopped prescribing his herbal infusion
and has given me a fresh medicine which I once more refuse to take’
[[16], p. 359]. Even a month before
his death on September 12, 1849, Chopin still had the dream of traveling to the
south. Sadly, he informed his close friend Tytus Wojciechowski (1808–1879):
‘the doctors won't allow me to leave Paris. They won't even let
me go to a warmer climate for the winter’ [[16], p. 371]. After another 5 days,
Chopin informs Wojciechowski of the most important result from consulting three
physicians: ‘Messrs Cruveilhier (Jean-Baptiste Cruveilhier)
,Louis (Pierre-Charles-Alexandre Louis), and Blache (Gaston Marie Blache)
decided in consultation that I ought not to undertake any journey just now,
but that I should find rooms facing south and stay in Paris’ [[16], p. 372].
Over the next century, physicians maintained their faith in the benefits of
climate therapy for tuberculosis. After Robert Koch (1843–1910) discovered
Mycobacterium tuberculosis, interest in the use of climate therapy in
phthisiology did not decrease. However, in the mid-1950s, after the success of
isoniazid, the effectiveness of climatic therapy for pulmonary tuberculosis was
reconsidered. An American chest physician Edmund Anthony Spriggs (1918–1988) in
1960 reviewed 60 scientific papers on the use of climatic factors in the
treatment of pulmonary tuberculosis from ancient times to the 1950s. Spriggs
noted that throughout this period, physicians reduced the effect of climatic
factors to 'rest and exercise'
[41]. Spriggs' findings are
strongly supported by the case of Frédéric Chopin. Suffice it to recall the
recommendations of Chopin’s physicians: Pierre Gaubert, Francois Cauviere,
Gustave Papet, Jean-Baptiste Cruveilhier, Alexandre Louis, Gaston Marie Blache.
Spriggs also noted: ‘It is now, fortunately, becoming the practice to base
treatment in pulmonary tuberculosis on factual evidence, statistically
analyzed’
[41]. Spriggs concluded that climate
therapy is ineffective for tuberculosis: ‘what statistical evidence there was
for the value of rest treatment (climate therapy) does not nowadays
convince’
[41]. Another famous American physician
Frank Bradway Rogers (1914–1987) spoke more harshly: ‘By the time of World
War II climatotherapy in the United States was a dead issue, ridiculed by
the medical community as a pseudo-science’
[42].
As we can see, Rene Laennec, François Broussais, Alexandre Louis, James Clark and
Samuel Morton in their time were very restrained in assessing the potential of
climatic factors in the prevention and treatment of pulmonary tuberculosis. They
believe in ‘the necessity of adopting a change of climate as a means of
preventing, rather than curing consumption’ [[31], p. 154–155]. However, in the first
half of the 19th century, physicians could not offer a more effective
treatment than climate, calm and rest. Chopin, half a year before his death,
commented with bitter irony on the recommendations of Alexandre Louis (who
became his attending physician) and his colleagues: ‘I have had Mr Louis
(Pierre-Charles-Alexandre Louis), Dr Roth for two months and now Mr Simon,
who has a great reputation as a homoeopathic doctor. But they try their
different methods without bringing me relief. They all agree on the need for
a good climate, calm and rest. I shall have the rest one day without their
help’ [[16], p. 355]. Edmund
Spriggs, in his landmark review, noted: ‘The best reason for reading the
history of medicine is the fun of it. But it also puts into perspective the
fashions of today’
[41]. Indeed, in the 19th
century climate was considered as one of the risk factors for tuberculosis
[[2], p. 323–326; [3], p. 285; [4], p. 49; [12], p. 108; [13], p. 346–348], and as a means of
correcting ‘hereditary and acquired predisposition’ or, in the words of
James Clark, ‘tuberculous diathesis’ [[2], p. 367–369; [3], p. 426;
[4], p. 61, p. 79–80; [12], p. 149–160; [13], p. 365–367].
Nowadays, the interest of researchers in risk factors for tuberculosis has not
only remained but also intensified due to global climate change. The researchers
noted: ‘Climate change affects tuberculosis through diverse pathways: changes
in climatic factors like temperature, humidity, and precipitation influence
host response through alterations in vitamin D distribution, ultraviolet
radiation, malnutrition, and other risk factors’
[43]. Systematic reviews on climate
change and tuberculosis 2021–22 found evidence supporting a positive association
between climate change and each of the discussed risk factors for tuberculosis
[43]; [44]. Researchers believe that
‘further studies and novel methodologies are required to address such a
complex relationship and better understand the occurrence of tuberculosis
attributable to climate change’
[43]. Perhaps further studies and novel
methodologies will allow us to find means of correcting risk factors that will
be more effective than rest and exercise.
