Climate in the Treatment of Pulmonary Tuberculosis in the First Half 19^th Century: The Case of Frederic Chopin

Abstract

Background The famous Polish composer Frederic Chopin (1810–1849) suffered almost all his short life from pulmonary tuberculosis. Physical treatment and climate therapy are the only aspect of Chopin’s disease history that has not yet been thoroughly studied. The etiology of tuberculosis in Chopin’s time was not yet known, so physical means and changes in climate in the first half of the 19^th century were the most important part of the physicians’ therapeutic arsenal in the treatment of pulmonary tuberculosis. Objectives are to study the use of physical methods and climate therapy in the treatment of Frederic Chopin.

Methods Scopus, WoS, MedLine, and PubMed data-bases, electronic archives were searched without time restriction for information on the use of physical methods and climate therapy in the treatment of pulmonary tuberculosis in the first half of the 19^th century in Europe. The analysis was also made of Chopin’s letters and the work of his most respected biographers in order to identify information about physical therapy in his treatment.

Results Chopin’s disease had been actively progressing since 1835. According to the proper 19^th-century tuberculosis treatment plan which was set out in the treatises of prominent European physicians, Chopin was treated with physical means: blister plasters, cupping, creosote inhalations, sulfur baths, opium and belladonna plasters. Changing the climate in winter (southern France or Italy) was also a standard recommendation. In October 1838, Chopin, who was still recovering from another seasonal exacerbation of pulmonary tuberculosis, took a trip to Mallorca, where he spent the winter.

Conclusions Chopin had the advanced stage of consumption, which was already regarded at that time as a contraindication to climate change. The destination was also unsuitable for patients with pulmonary tuberculosis: winter climate of Majorca, characterized by high humidity and strong winds, negatively affected Chopin’s health. The disease was manifested by fever, hemoptysis, shortness of breath and exhaustion, which indicated tuberculosis intoxication and destruction of lung tissue. Chopin’s trip to Majorca 1838/1839 will forever go down in the history of climate therapy as an example of the negative consequences of ignoring contraindications to climate change.

Zusammenfassung

Der Hintergrund Der berühmte polnische Komponist Frédéric Chopin (1810–1849) litt fast sein ganzes kurzes Leben lang an Lungentuberkulose. Physikalische Behandlung und Klimatherapie sind der einzige Aspekt der Krankheitsgeschichte von Chopin, der noch nicht gründlich untersucht wurde. Die Ätiologie der Tuberkulose war zu Chopins Zeiten noch nicht bekannt, daher waren physikalische Maßnahmen und Klimaveränderungen in der ersten Hälfte des 19. Jahrhunderts der wichtigste Teil des therapeutischen Arsenals der Ärzte bei der Behandlung von Lungentuberkulose.Das Ziel dieser Arbeit ist es, den Einsatz physikalischer Methoden und Klimatherapie bei der Behandlung von Frédéric Chopin zu untersuchen.

Die Methoden Die Datenbanken Scopus, WoS, MedLine und PubMed sowie elektronische Archive wurden zeitlich unbegrenzt nach Informationen zum Einsatz physikalischer Methoden und Klimatherapie bei der Behandlung von Lungentuberkulose in der ersten Hälfte des 19. Jahrhunderts in Europa durchsucht. Die Analyse erfolgte auch an Chopins Briefen und der Arbeit seiner angesehensten Biographen, um Informationen über die Physiotherapie in seiner Behandlung zu ermitteln.

Die Ergebnisse Seit 1835, schritt Chopins Krankheit voran. Gemäß dem richtigen Behandlungsplan für Tuberkulose aus dem 19. Jahrhundert, der in den Abhandlungen prominenter europäischer Ärzte dargelegt wurde, wurde Chopin mit physikalischen Mitteln behandelt: Blasenpflaster, Schröpfen, Kreosot-Inhalationen, Schwefelbäder, Opium und Belladonna Pflaster. Auch ein Klimawechsel im Winter (Südfrankreich oder Italien) war eine Standardempfehlung. Im Oktober 1838 unternahm Chopin, der sich immer noch von einer weiteren saisonalen Verschlimmerung seiner Lungentuberkulose erholte, eine Reise nach Mallorca, wo er den Winter verbrachte.

Die Schlussfolgerung Chopin hatte ein fortgeschrittenes Stadium der Schwindsucht, die bereits damals als Kontraindikation für den Klimawandel galt. Auch für Patienten mit Lungentuberkulose war das Reiseziel ungeeignet: das winterliche Klima Mallorcas, das durch hohe Luftfeuchtigkeit und starke Winde gekennzeichnet ist, wirkte sich negativ auf Chopins Gesundheit aus. Die Krankheit äußerte sich durch Fieber, Hämoptyse, Kurzatmigkeit und Erschöpfung, was auf eine Vergiftung und Zerstörung des Lungengewebes hindeutete. Chopins Reise nach Mallorca 1838/1839 wird als Beispiel für die negativen Folgen des Ignorierens von Kontraindikationen für den Klimawandel in die Geschichte der Klimatherapie eingehen.

Keywords

balneology - physical therapies - physiotherapy - physiotherapy prescription - spa resorts

Schlüsselwörter

physikalische Therapien - Balneologie - Spa-Resorts - Physiotherapie-Rezept - Physiotherapie

Introduction

Tuberculosis was endemic in 19^th century Europe, especially in Britain and France, whose medical schools denied its contagiousness. According to statistics from the first half of the 19^th century, every fifth death in Parisian hospitals was caused by consumption [[1]. Leading physicians in Britain and France sincerely believed that tuberculosis was associated with congenital and acquired predisposition [[2], p. 330; [3], p. 265; [4], p. 52]. European medical schools accepted the challenge; in the first half of the 19^th century, a large number of treatises based on a huge number of empirical observations were devoted to the diagnosis and treatment of tuberculosis. Physical methods, such as climatotherapy, were used to treat and prevent pulmonary tuberculosis. James Clark, a prominent British physician and author of multiple books on medical climatology and pulmonary tuberculosis in his A Treatise on Tubercular Phthisis, or Pulmonary Consumption 1834 noted: ‘Since the nature of phthisis has been more fully understood, the expectations from climate as a means of cure have greatly abated, and hence it is much more justly considered at the present time simply as a preventive of the disease. When adopted with this view, climate is certainly one of the most powerful remedies we possess for improving the tuberculous constitution, and enabling us to correct the predisposition to the disease’ [[1], p. 79]. In other words, in the 19^th century, physicians used climate change to treat risk factors for pulmonary tuberculosis through pathogenetic and symptomatic therapy. This approach remains relevant today.

The most valuable source for studying the climate in the treatment of pulmonary tuberculosis in the first half of the 19^th century are clinical cases of that time, which give an objective idea of ​​the real practical application of a particular treatment method, the attitude of the physicians and their patients towards it. Our choice fell on the medical history of the famous Polish composer Frederic Chopin (1810–1849). He suffered almost all his short life from a lung disease, which was manifested by shortness of breath, cough, hemoptysis, fever, and weight loss. Although the causes of Frederic Chopin’s death are still debated, most of his medical biographers are inclined towards the diagnosis of pulmonary tuberculosis [[5]. The manifestations of Chopin’s disease were considered pathognomonic of pulmonary tuberculosis and therefore could not cause his physicians to doubt the diagnosis. René-Théophile-Hyacinthe Laënnec (1781–1826), the inventor of the stethoscope and the founder of the mediate auscultation indicated in his treatise De l’Auscultation médiate, ou Traité du diagnostic des maladies des poumons et du coeur, fondé principalement sur ce nouveau moyen d’exploration (from French: A Treatise on the Diseases of the Chest and on Mediate Auscultation) the typical signs of phthisis (pulmonary tuberculosis): ‘Cough, dyspnoea, puriform sputa, hectic fever, haemoptysis, emaciation, — the complete reunion of symptoms of which the frightful picture has been so faithfully delineated by Aretaeus’ [[6], p. 303]. The symptoms of phthisis, described by Aretaeus Cappadocian in the second half of the 2^nd century AD and Rene Laennec in the first half of the 19^th century, are still relevant today. European Union Standards for Tuberculosis Care contains the following instructions: ‘The most common symptoms of pulmonary TB are persistent cough with or without sputum production for more than 2–3 weeks, while haemoptysis (blood in mucus) is more rare. Respiratory symptoms can be accompanied by fever, night sweats and weight loss’ [[7]. According to biographers, Chopin had over thirty-three physicians who attended to him during his relatively short lifespan [[8], [9], p. 19; [10], p. 49, p. 156, p. 241]. All Chopin’s physicians were quite respectable, some of them were luminaries of European or national repute, so information about their professional activities has survived to this day. In addition, information about Chopin’s treatment is contained in his correspondence as well as in the memoirs of his contemporaries and the works of his biographers.

The Aim

The purpose of this research is to explore the medical treatment received by Frederic Chopin using physical therapy and climate. The study is based on the analysis of Chopin’s letters, accounts of his contemporaries, works of his most authoritative biographers, and advanced treatises on the treatment of pulmonary tuberculosis during the first half of the 19^th century.

Materials and Methods

In order to achieve the study’s objective, various databases and electronic archives were searched using keyword combinations such as Chopin’s illness, physical treatment, and climate therapy in Europe during the first half of the 19^th century. Additionally, Chopin’s letters were examined to gather information on the use of physical treatment. The information gathered from the letters was analyzed using the works of Chopin’s most prominent biographers and medical treatises on phthisis treatment during the first half of the 19^th century.

Results and Discussion

Physical methods of treatment in the first half of the 19^th century

The semantic content of the terms physical treatment and physiotherapy in the 19^th 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 19^th 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 19^th 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 19^th-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 19^th 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 19^th 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 19^th 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.

Conclusion

Leading European physicians in the first half of the 19^th century were realizing that a change in climate is a means of preventing, rather than curing pulmonary tuberculosis [[31], p. 154–155]. Indications and contraindications for climatic therapy of pulmonary tuberculosis in the time of Chopin had already been determined. Majorcan episode in Frederic Chopin's life serves as a notable example of an unregulated climate change that disregarded the fundamental principles of tuberculosis climate therapy outlined by James Clark in his work, A Treatise on Tubercular Phthisis, or Pulmonary Disease, 1834 [[4], p. 79–81]. During the later stages of his illness, Chopin's condition significantly worsened when he went on a trip without being fully in remission. The winter climate in Majorca, with its very high humidity, played a large role in making his illness more severe. Profuse and repeated pulmonary hemorrhages, fever, severe shortness of breath, and exhaustion indicate destruction of the lungs and severe tuberculosis intoxication. Chopin avoided a fatal outcome only thanks to a timely return to more favorable climatic conditions.

The case of Frederic Chopin is valuable not only for the history of medicine (climatology, pulmonology, phthisiology, physical therapy), but it deserves a place in modern textbooks as an example of the unfavorable influence of climatic factors on the course of pulmonary tuberculosis, and also as an example of adverse consequences due to errors in determining indications and contraindications to climate therapy. In addition, one cannot ignore the fact that Chopin lived after the Majorcan episode for another 10 years without etiotropic therapy, which simply did not exist in his time. Then what treatment made this possible? We can’t help but recall biographer Bernard Gavoty’s words: ‘What was Chopin’s treatment like? In the fashion of the times’ [[10], p. 320]. Diet, rest, feasible physical exercise, and physical therapy (mustard plasters, opium and belladonna plasters) significantly slowed down the destruction of lung tissue. To paraphrase Edmund Spriggs: The best reason for reading the case of Frederic Chopin is the fun of it, but it also puts into perspective the fashions of today.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 15 October 2023

Accepted: 05 March 2024

Article published online:
28 March 2024