Thursday, 21 September 2017

The debate over Robespierre's health


In 2013 the popular TV forensic anthropologist Philippe Charlier - unchastened by his debacle with Louis XVI and his DNA - caused yet more controversy  by  his collaboration with Philippe Froesch in the now-notorious  Robespierre "facial reconstruction". Not content with proving Robespierre was an ugly thug, he also pronounced him to have been victim to a hitherto little known disease called "sarcoidosis". Historical diagnoses are always highly speculative but Charlier meant to be taken seriously - he even managed to publish his findings in The Lancet.  Not surprisingly historians were quick to criticise;  Peter McPhee was particularly affronted, since he found his article on Robespierre's "medical crises" cited as Charlier's chief authority.

Sarcoidosis, we learn, is "an autoimmune disorder involving the abnormal collection of chronic inflammatory cells that form as nodules in multiple organs" (most usually the lungs and skin.)  The disease was not described until 1877, so naturally it would not have been recognised in Robespierre's time.  There are wide variations in presentation.  According to NHS Choices, the most common symptoms are tender red bumps on the skin, shortness of breath and a persistant cough, though some sufferers have no symptoms at all.  In some cases the condition clears spontanously, and there are both acute and chronic forms of the disease. All of which makes it hard to diagnose without x-ray and detailed medical examination.

Charlier, however, was not deterred:  Robespierre suffered from "diffuse sarcoidosis with ophthalmic, upper-respiratory-tract (nose or sinus mucosa), and liver or pancreas involvement."  He waded in with the medical jargon:

The following diagnoses could be proposed, but they do not fit exactly with the clinical presentation and evolution of the disease: diffuse tuberculosis (but no cough, fever, polyadenopathy, or pulmonary signs have been described); Wegener-type vasculitis (rhino-sinusal localisations are particularly frequent); leprosy (with skin lesions and rhino-sinusal necrosis); chronic adrenal insufficiency (when considering not jaundice but melanoderma, with its characteristic asthenia); haemochromatosis (melanoderma, again, and nose bleeds due to coagulation troubles after cirrhosis, but the patient was not from a high-risk population); and scleroderma (with the characteristics of pinched lips, dry eye syndrome causing eye complications, leg ulcers, and asthenia). 




What is the evidence?  Charlier rested his case on a number of "clinical signs" referred to in the sources:

Several clinical signs were described by contemporary witnesses: vision problems, nose bleeds (“he covered his pillow of fresh blood each night”), jaundice (“yellow coloured skin and eyes”), asthenia (“continuous tiredness”), recurrent leg ulcers, and frequent facial skin disease associated with scars of a previous smallpox infection. He also had permanent eye and mouth twitching. The symptoms worsened between 1790 and 1794.

Put like this, the catalogue of medical woes sounds quite impressive, but, as Peter McPhee emphasises, contemporary accounts cannot simply be taken at face value;  no writer on Robespierre was a neutral observer.  In fact, when taken individually, the symptoms do  amount to that much:

Robespierre's "vision problems". He certainly suffered from poor eyesight.  He is recorded as wearing two pairs of glasses, a pince-nez on top of a pair of tinted green spectacles.  The green "eye preservers" are well attested.  It seems probable that he was congenitally short-sighted and was already beginning to develop the long-sightedness of middle age - the price no doubt of long hours spent reading and writing by the light of oil lamps and candles.  According to an English visitor John Milligen, he found his eyes  "painful and impatient of light", complained of headaches and compressed his brow with a tightened handkerchief, all of which sounds like a classic migraine sufferer.  Barras, among others, was caught offguard by the dullness of his eyes.  

The nose bleeds.  The sole source here, is a single sentence in the memoirs of Pierre Villiers, who claimed to have been his secretary for seven months in 1790. Villiers stated that Robespierre had an "ardent temperament" and that almost every night, he "soaked his pillow in blood."  It is hard to know how much weight to give this observation, especially since Villiers is by no means an unbiased witness.
Pierre Villiers, Souvenirs d'un déporté (1802)
https://books.google.co.uk/books?id=zDhPAQAAMAAJ&printsec=frontcover#v=onepage&q&f=false

Jaundice.  Most observers testified simply that Robespierre's complexion was pale, though a few certainly described his skin or eye colour as "yellowish".  The most extreme version is that of Stanislas Fréron, who, having known him from schooldays, claimed that he had always been "bilious" and"morose", as his yellow complexion testified. Again it is hard to know how much weight to give this:  Fréron was surely more interested in inputing Robespierre's personality than questioning his health.  Likewise, it was Madame de Staël, who had met him only a few times and hated him, who originated the idea he had veins of a "greenish colour".

Continual tiredness.  Hum -  Hands-up who thinks Robespierre led a relaxing life!

Recurrent leg ulcers. We know that the doctor Joseph Souberbielle regularly visited the Duplay house and tended at least one varicose ulcer on Robespierre's leg. He was even summoned to change the dressing on the morning of 9 Thermidor.
Here is a detail about Robespierre, that I haven't found written down anywhere, and which I got from old Souberbielle, his friend and doctor.  Robespierre had a chronic ulcer on one of his legs which Souberbielle dressed every morning, but in great secrecy and taking infinite care that nothing was heard about this infirmity.  We know that Robespierre, a gentleman of the old school, was very careful about his appearance, always freshly shaved, always powdered, wearing breeches, putting the ragbag Montagnards and Jacobins to shame.  The morning of 9 Thermidor, Robespierre did not neglect his ulcer but sent for Souberbielle, who dressed it in a room in the  Hôtel de Ville.
https://archive.org/details/cu31924028168064
The "ulcer" may have been an infection, or it may have been the a symptom of some circulatory problem, but at this distance it is impossible to say.  Peter McPhee dismisses it as a relatively minor ailment.

Facial skin disease.   Many observers noted Robespierre's pockmarked skin, the result of childhood smallpox.  The lumps and bumps on the deathmask looks as though he might have had additional skin problems but there is not much to go on (and the authenticity of the mask is itself disputed.)

Twitching.  There was certainly a "tic" but it sounds more nervous in origin.  If John Millingen is to be believed, by the end, when threatened or enraged, Robespierre's whole frame would shake; his speech became inarticulate and he sometimes appeared close to suffocation.


Treatments?

As Charlier himself pointed out, the disease sarcoidosis was not recognised until 83 years after Robespierre’s death, so the treatment options available to his personal physician, Joseph Souberbielle, would have been limited.  Charlier believed they may have included a diet of fruit (Robespierre consumed a lot of oranges), as well as baths and bloodletting.

There is an element of wilful misreading here. Oranges were considered good for both the digestion and circulation, and Robespierre was fond of them, but that hardly makes them a "treatment". The allied idea that his disease created an insatiable craving for citrus fruit comes only from the malicious pen of Fréron:

Robespierre was choked with bile.  His eyes and his yellow complexion showed it.  At Duplay's care was taken to always have on offer for him at desert, a pyramid of oranges, which Robespierre devoured avidly.  He was insatiable;  no-one dared to touch the sacred fruit.  No doubt the acidity countered his bilious humour and helped his circulation. One could always see where he had been seated at table by the orange rinds..... 
Stanislas-Louis-Marie Fréron "Notes sur Robespierre", Papiers inédits trouvés chez Robespierre.... vol. 1 (1828), p.157
https://books.google.co.uk/books?id=K7pBAAAAcAAJ&pg=PA154#v=onepage&q&f=false)  



....And what Peter McPhee really said

Peter McPhee's original article set out the evidence chronologically, based mainly on Robespierre's own statements in his correspondence. The article freely available on the internet in English. so there is little real point in summarising his findings in detail.  His general conclusion is that Robespierre's poor state of health was the result of physical and emotional exhaustion, and the constant psychological stress he was under. Whilst the exact nature of his increasingly debilitating bouts of illness is unclear, they corresponded closely with periods of political crisis and confrontation.


References


Philippe Charlier and Philippe Froesch, "Robespierre: the oldest case of sarcoidosis?
The Lancet, Vol 382 December 21/28, 2013

Peter McPhee, "'My Strength and My Health Are not Great Enough': Political Crises and Medical Crises in the Life of Maximilien Robespierre, 1790-1794", 
Annales historiques de la Révolution française, 371 | 2013, 137-152
http://www.cairn-int.info/article-E_AHRF_371_0137--my-strength-and-my-health-are-not-great.htm

______, "What if your research is used to draw conclusions you never intended?"  Guardian HE Network Blog 11.02.2014

______,  "Robespierre: the oldest case of sarcoidosis?"

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