Welcome to The Plague Pit.

For this issue, number 28, I’m delighted to present this excellent article from Dr Craig Goldsack. A fellow anaesthetist, his knowledge of operations is exceeded only by his operatic insights.

After thirty-five years as a hospital doctor I realise now that I have lived through the end of what has been termed, without irony, the “Golden Age” of medicine. This epoch, beginning in the middle third of the twentieth century, has been a period of marked scientific and medical advancement, with increasing affluence and life expectancy, and a pervasive feeling that effective treatments would soon be found for all diseases, and doctors able to cure all the ills of humanity.

The hubris behind this philosophy has become apparent over the past few years and has been brought sharply into focus during the current Covid-19 pandemic. We have taken it for granted that humankind would continue to advance materially, each generation would be more developed than the one before, and that we would all enjoy long lives throughout which bad things happen to other people.

In truth, society has always had to cope with disease, pestilence and death, but through the “Golden Age” we have lost sight of this harsh fact. Even the Covid-19 crisis is nothing like the illnesses our ancestors will have faced. It is not, for example, the Black Death (bubonic plague, case fatality 60%), or smallpox (40%), or measles (25% mortality – get vaccinated!). It is not even as bad as tuberculosis, which kills two million people a year, every year, worldwide, although these are “other people”, not “us”.

Perhaps, in society at large, we have lost our ability, or willingness, to discuss death. Yet, until recently, death was seen as a part of everyday life: sickness and disease were everywhere; the dying were nursed at home; elderly relatives would come to live with the extended family rather than be consigned to care homes; and we forget how many people died young. For the first time in two generations doctors are having to revert to their atavistic role: managing illness but unable to cure it; adopting a caring, humane approach to death; manifesting an holistic approach to the relief of suffering; and placing a greater priority on the prevention of disease and the containment of contagion.

Fortunately for the wellbeing of civilisation, dark times have often been a major stimulus for artistic expression: some of the finest music, literature and art have been created in the face of great adversity, providing enormous solace for contemporary society and for future generations. One of the most powerful art forms in this regard is opera, where passion, love, disease and death are frequently entwined to profound emotional effect.

Opera as we would recognise it today began in about 1600. One of the earliest surviving operas is La Favola d’Orfeo, dating from 1607, by Claudio Monteverdi, already well known for his polyphony, here experimenting in a new genre.

This early opera tells the myth of Orpheus and Eurydice, young lovers whose joyous wedding is soon followed the sudden death of Eurydice. A distraught Orpheus, adored by the gods for his singing prowess, was permitted by them to descend into the Underworld and rescue Eurydice on the condition he did not look back on their return journey to the land of the living. Orpheus, his joy tinged with anxiety, could not resist glancing behind him to check his beloved bride was still following, whereupon Eurydice is returned forever to Hades and Orpheus laments his fate.

In the seventeenth century the loss of a loved one, perhaps a spouse or a child, was all too common and this allegorical tale will have resonated with audiences, the moral being that we must grieve and move on, look forward and don’t look back.

Health concerns during subsequent centuries, from the seventeenth to the middle of the twentieth, were dominated by the ubiquitous blight of tuberculosis (TB). In the England of 1800, one in three of the population were killed by TB, and the disease remained a major killer until the 1950s, when improvements in public health and housing, then latterly the development of antibiotics and a vaccine, helped to reduce the incidence in the western world. Globally, TB remains a significant problem, and in the UK we face a worrying increase in antibiotic-resistant TB.

During the eighteenth and nineteenth centuries, TB gained a certain romantic allure and, indeed, became associated with the Romantics in general. The poet John Keats, who had studied medicine at Guy’s Hospital in London, is known for writing some of the most sensuous poetry in the English language, but was dead from tuberculosis at the age of twenty-five. The disease is also a major theme in two of the greatest operas ever written: La Traviata and La Bohème.

Giuseppe Verdi wrote La Traviata (“The Fallen Woman”) in 1853, based upon the life of the French courtesan Marie Duplessis, known as “The Lady of the Camelias”. In mid-nineteenth century high society a beautiful hostess was held in high regard, achieving celebrity renown and near-aristocratic status. They would often become extremely wealthy and were famed for hosting brilliant salons and glittering soirées, yet most had come from humble origins and began their professional careers as prostitutes or “escort ladies”. Many of these ladies had developed tuberculosis during their impoverished early years and were frequently to die from the disease at a tragically young age.

Violetta, the heroine in La Traviata, epitomises the genre: a glamorous and rich courtesan, renowned for her fabulous parties, is courted by a young nobleman, Alfredo. They fall in love but their marriage is forbidden by Alfredo’s father, a baron. After much beautiful singing, expressing loss and longing, retribution and reconciliation, Violetta dies in Alfredo’s arms.

The characteristic appearance of the tubercular courtesan was to influence for a century the perceived ideal of feminine beauty: weight loss and anaemia would lead to a slim, delicate figure, with a generally pale skin; commonly, a chronic low-grade fever imparted rosy cheeks, a shining face and gently sparkling eyes. All of these features came to represent the apogee of female allure.

During this time the cause of tuberculosis was unknown. It was widely believed in Victorian times that diseases, including TB, were spread through mysterious vapours in the air, the so-called “miasma theory” of infection. Many Victorian men grew enormous bushy beards and moustaches in the belief that these hairy appendages would be a sort of filter or net, providing some protection from inhaling the “miasma” and, therefore, disease. Hence the, to our eyes, terrifying and forbidding appearance of the eminent Victorian male whom we see portrayed in pictures from that era.

In 1882 the German physician and proto-microbiologist Robert Koch discovered that tuberculosis was caused by a bacillus, Mycobacterium tuberculosis, and that the disease was spread via droplets originating from the infected individual coughing, sneezing or singing. By the time La Bohème was premiered in 1896 the public perception of TB had changed completely. It was now regarded as a disease of poverty and of those in over-populated poor housing.

La Bohème tells the story of a group of impoverished young artists and writers living in a shared garret. One of the circle, the writer Rodolfo, falls in love with a poor seamstress, Mimi, who lives in an adjacent room, working by candlelight. Rodolfo captures Mimi’s heart with one of the most famous of all arias, Che gelida manina (“Your tiny hand is frozen”). There is no money and Mimi is showing the early signs of progressive tuberculosis, yet they are happy.  Of course, being opera, things go wrong: the couple have their ups and downs (mostly downs), including Mimi becoming the mistress of a wealthy viscount; and the financial situation deteriorates even further. Ultimately, Mimi and Rodolfo are reunited but she is weak, pale and in the terminal stages of tuberculosis, dying in the final scene as an anguished Rodolfo cries out in despair and grief.

In society at large, it became known that tuberculosis was caused by a bacillus rather than mysterious “miasmic vapours”. This led to a radical change in fashion. Late Victorian and Edwardian gentlemen became clean-shaven and short-haired, and personal hygiene improved hugely, to the benefit of all.

During this period some rather darker, less romantic tales of tuberculosis were turned into operas. The year 1881 saw the premiere of Les Contes d’Hoffmann (“The Tales of Hoffmann”) by Jacques Offenbach of “can-can” fame. In one of the Tales an opera singer, Antonia, is depicted in a series of hallucinatory scenes, representing the febrile stages of advanced tuberculosis. She is goaded into singing herself to death by the Devil in disguise as a quack doctor, Dr Miracle.

Other infectious diseases, perhaps lacking the romantic and Romantic associations of TB or, indeed, being regarded as too unsavoury, are portrayed less frequently in opera. A relatively modern example is Benjamin Britten’s 1973 work, Death in Venice. Based upon Thomas Mann’s 1912 novella, the opera tells the story of a distinguished, solitary writer, Aschenbach, who becomes besotted with a divinely beautiful aristocratic adolescent boy, Tadzio.

The story is one of ageing, intimations of mortality, lost youth and unrequited love. It is set in Venice against the backdrop of the 1911 cholera epidemic. The city empties as people leave, or isolate themselves at home, in a striking parallel to today’s Covid quarantine policy. Meanwhile, Aschenbach’s obsession with Tadzio deepens until, with a self-destructive melancholy, Aschenbach dies, unfulfilled and alone on the beach, with a solitary Tadzio beckoning to him.

Cholera is a disease of poverty, overcrowding and poor sanitation. It is caused by the bacillus Vibrio cholerae, which is transmitted by the faecal contamination of food or water that is subsequently ingested by others. Seafood and shellfish from polluted water are common sources. The infected individual develops torrential diarrhoea, leading to profound dehydration and death if left untreated. V. cholerae is sensitive to antibiotics and readily curable if caught in time. However, the most successful approach to eradication is one of disease prevention in the first place. Improved sanitation and sewage disposal, less overcrowding and pure drinking water have made the disease rare in the developed world. Cholera is still a major problem in the developing world with two million cases and a hundred thousand deaths per year.

Sex and death are never far apart in opera. For those with louche and recherché tastes, Igor Stravinsky’s 1951 opera, The Rake’s Progress, may provide a salutary lesson on the benefits of clean living. During a visit to London, Stravinsky had seen Hogarth’s famous series of eight paintings, A Rake’s Progress, executed in 1732-34.

Hogarth’s pictures depict the decline and fall of Tom Rakewell, the wealthy but dissolute son of a rich merchant, who squanders his money on gambling, wild living and prostitutes, before being sentenced to a debtors’ prison and, ultimately, the Bethlem Hospital for the insane. Stravinsky was inspired to tell this cautionary story in operatic form, with W H Auden commissioned to write the libretto. The result is one of the great operas of the twentieth century, with several notable productions over the following decades, perhaps the most noteworthy being the 1975 Glyndebourne production designed by David Hockney and which is revived regularly to this day.

The tale describes Tom’s downfall in a series of scenes of increasing chaos and dissolution, including the depiction of the various stages of syphilis, a serious sexually transmitted disease, prevalent and difficult to cure until the advent of penicillins. Early treatments included various compounds of mercury from the fifteenth century onwards and, in the early twentieth century, arsenical derivatives. Both mercury and arsenic are highly toxic, with significant side effects, yet were considered appropriate to use in attempts to eradicate the scourge of syphilis.

 Following the story of The Rake’s Progress, we can see how Tom will have caught syphilis from infected prostitutes in brothels, scenes depicted also by Hogarth in his paintings. Thankfully, we do not see the primary lesion, a sore or “chancre” on the genitals or in the mouth. Later stages of the disease can be observed, depicted as sores on the skin of various infected characters in the debauched scenes of Stravinsky’s opera and of Hogarth’s images. These lesions look like black spots or patches, having been covered with a mercury paste as a treatment.

Subsequent stages of the illness are marked by facial and skeletal deformities. Progressive syphilis will lead to neurological damage and serious psychiatric problems, previously labelled “general paralysis of the insane”, or GPI. The Bethlem Hospital would have been full of such cases and we can barely imagine the chaotic and distressing conditions there. Indeed, the word ‘bedlam’, meaning ‘uproar, confusion’, is a corruption of ‘Bethlem’, reflecting how awful life must have been for the inmates. Poor Tom Rakewell.

What of the depiction of doctors in opera? By and large, doctors are portrayed as kindly characters, moving between various social classes, never quite aristocratic but often on informal terms with the upper classes, as well as with their servants and the poorer strata of society, all of which is unsurprising given the intimate nature of the doctor-patient relationship. Often doctors are not really part of the plot as medical practitioners but more as devices to facilitate plot development or add humour. Dr Bartolo in The Marriage of Figaro is depicted more as a buffoon than as a man of learning, but he does help the opera come to an happy ending.

In Gaetano Donizetti’s 1832 opera, L’Elisir d’Amore (“The Elixir of Love”), Dr Dulcamara is a charlatan, a quack doctor, whose “elixir” is no more than a bottle of cheap wine. The “medicine” does, however, succeed in drawing together the shy but already interested parties. In vino veritas for young the lovers. To redress the balance, Donizetti, in Don Pasquale (1843), depicts Dr Malatesta (tr. “headache”) as a kind and good man, a true friend to Don Pasquale. This is more reflective of the general status as doctors in society: humane, educated, non-judgemental and devoid of the self-interested agendas of lawyers or priests.

In La Bohème, Dr Grenvil is a minor role but is seen as a kind and honourable physician in what would now be called general practice. He is unable to cure Violetta but is a noble and decent presence towards the end of the opera.

When doctors lose sight of their fundamental obligation to relieve suffering, and become motivated by the desire for scientific advancement rather than patient care, they are portrayed as rather more cynical and inhumane. This is epitomised by the character of The Doctor, unnamed, in Alban Berg’s 1925 work Wozzeck. I would not recommend this as an introduction to opera but it is interesting to see how the then new concept of “doctor as scientist” was regarded as selfish and unemotional, even unkind, in contrast to the “doctor as carer”, who could not cure much but was seen as a supportive, holistic, non-religiously pastoral figure.

Berg wrote Wozzeck at the very beginning of the “Golden Age” of medicine. The current Covid-19 pandemic has highlighted that modern medicine cannot cure all human disease. In truth, this has been increasingly apparent for some time but has been brought into sharp focus during recent events. The medical profession has a responsibility to adapt to this new reality, and the next few years provide an opportunity for those starting out as medical students and doctors to bring about a new “Golden Age” of medicine, focused on the prevention of disease from first priciples, on better public health and the containment of contagion. Exciting times!

Dr Craig Goldsack