Lyndhurst, Ohio, United States
|Illustration by Jason Malmberg.|
“. . . phthisic beauty[’s] . . . most famous operatic embodiment was Violetta Valery . . .This physical type became not only fashionable but sexy . . . When a society does not understand—and cannot control—a disease, ground seems to open up for mythologizing . . . it.”1
Since antiquity, the perception of improper sexuality invited illness in the guise of divine punishment. Oedipus indeed killed his father, but he also was guilty of incest.1 The consequence—judgment directed at him and his people—was plague. Furthermore, for much of history—that is when medicine could neither explain nor cure disease—such illnesses would be enveloped by metaphors.2 In this regard, the arts provide a unique opportunity to metaphorically clothe illness and death in cultural costumes, freed from a purely medical context.3 Opera has taken full advantage of cultural stereotypes to provide metaphors connecting sexual mores and illness. Sex, disease, and doctors are prevalent throughout the operatic repertoire.3 Of nearly 500 operas spanning some 240 years, approximately 11% have included a patient or physician as characters.4
Giuseppe Verdi (1813-1901) composed nine operas with roles for physicians.5 One Verdi opera beloved since the nineteenth century has been La Traviata (1853). It explicitly depicts a nineteenth century sexual ethos through illness metaphors followed by their tragic consequences. In the opera, Violetta Valery succumbs to tuberculosis. There is, however, nuanced depth to metaphorical reflections on her demise. Verdi’s opera was based on a novel by Alexander Dumas—son of the author of Three Musketeers—titled La Dame aux Camelias (1848).6 The dame in the novel was likely Marie Duplessis.6 Called Marguerite in the book (Marie-Marguerite), she was a courtesan who died of tuberculosis at the age of twenty-three. It was presumed that Dumas had an affair with her. In La Traviata he would become the model for Alfredo, she for Violetta. Both women fell in love with bourgeois men, only temporarily escaping the darker side of their existence.
For Verdi’s and Dumas’ culture, fallen women were consumptive vectors whose unbridled sexuality degraded men and their families—physically and morally. Their era preceded the germ theory of disease and was therefore compelled to mythologize tuberculosis to understand it. A gendered illness metaphor was birthed. That metaphor was readily embraced by a male-dominated culture, inclusive of its physicians. An 1854 medical text observed, “Of all vices, however, none are so apt to lead to consumption as the . . . unrestrained indulgence of the sensual passions.”1 In 1861, Dr. James Copland observed that there were fourteen causes of consumption, “most of which were ‘moral inferences drawn from the belief that tubercular illnesses were culpable deviations from a moral healthy state.’”1 Among those predispositions was excessive sexual indulgence.1 How a culture persecuted “fallen women” as a mistaken source of contagion continues to be worthy of reflection today. As Susan Sontag observed, aware of AIDS’ more recent cultural framing as a “gay disease,” illness metaphors cause afflicted patients to suffer physically and also existentially: “Nothing is more punitive than to give a disease a meaning . . . invariably a moralistic one.”
Red, the color of desire and contagion
“Diseases . . . have always taken on meanings well beyond their medical significance . . . certain representations . . . are repeated . . . so often that they . . . create their own social reality. Think . . . of . . . leprosy . . . despite the unlikelihood of its casual transmission, people suffering from it have been seen . . . as dangerous to society . . . These moral judgments establish a hierarchy of . . . disease acceptability.”1
In the nineteenth century, consumptive metaphors were gendered, specifically targeting women. The culturally embraced metaphors were egregious misperceptions—with boundaries drawn by bourgeois morality. Consumption presumably manifested itself through outward signs of heightened sexual passion, placing women outside the pale of feminine virtue.2 The afflicted women would be contagious to the men who succumbed to their sexual magnetism. In La Traviata, Alfredo was hypnotized by Violetta after seeing her one time!1 The arts of the period told a story of “ . . . overtly tubercular women whose living, loving, and dying are inseparable not only from their disease but from their sexuality.”1 These fallen women could be identified. Their malady would be exposed by telltale physical signs. It would be reflected by the color red and by the passage of tainted fluids—especially blood. The significance of the color red is essential to exploring consumption as a gendered illness in both La Dame aux Camellias and La Traviata. In Dumas’ novel, Marie-Marguerite’s lips are “cherry red.” She publicly flaunts red camellias on her dresses, displays the ominous sign of hemoptysis, and finally, medicine intervenes with the archaic practice of bleeding her. “Ladies in red” would be stigmatized by the wounds of consumption and assumed guilty of being its vectors. The passion of the courtesan not only threatened society with a fatal infirmity, but with moral decay as well.
It has been said that by Marie-Marguerite’s “sporting of red camellias . . . those days of the month when she is menstruating . . . not only does she defy gender norms governing women’s modesty . . . but it symbolically denaturalizes and desacralizes the most valued female biological function, that of reproduction . . . subordinating it to economic interests.”6 Red is symbolic of the social improprieties flaunted by courtesans. The color red, presumably an emblem for wayward sexuality, has been prominent throughout history. Hester Prynn’s Scarlet Letter serves as one example. In the movie Pretty Woman, Julia Roberts’ character Vivian wears a red dress to the opera, also La Traviata. In 2013, a scientific article demonstrated that women were more likely to wear red at times of peak fertility.7
The color red also symbolizes bodily fluids, especially blood: “Bodily fluids are crucial . . . [Marie-]Marguerite’s bronchial blood (hemoptysis) . . . [transferred by] a blood-stained kiss . . . [the] mingling of saliva . . . his (the author Dumas himself) sporting a red camellia signals his symbolic assimilation into the tainted economy . . . of the consumptive, blood-spitting courtesan.”6,8
In Verdi’s time, it was also believed that children conceived by prostitutes inherited tainted blood.1,6 This bad blood supposedly robbed the demimonde and her children of moral consciousness. A connection was perceived between “morally bad ways and physiologically bad blood.”6 The complicity of the medical establishment in fostering gendered illness metaphors—in this instance, bad blood—provided a cultural rationale for bleeding as therapy. “[As] bad blood is expelled in repeated . . . fits of coughing as well as under doctor’s knives, we see . . . the implacable gendered medical logic of bleeding . . .”6 Bloodletting was a medical means to remove tainted blood.6
Both Marie-Marguerite and Violetta Valery suffer the same fate at the hands of their lovers and culture. Their passing was perceived as a means to their forgiveness.1,3 The men are redeemed by their deaths, otherwise blameless throughout. The women are perfect examples of a punitive illness metaphor and the contingent existential suffering for those with that illness.
Are illness metaphors vestiges of the past?
“It has been claimed that the way any society responds to disease reveals ‘its deepest cultural, social, and moral values’; patterns of judgment about what is good or bad shape and guide human perception and action.”1
Today it seems easy to judge Verdi’s and Dumas’ culture for a naive perception of consumption. Contemporary physicians might even snicker at the poor quality of medicine practiced by physicians hindered by a pre-scientific and gendered medical logic. However, the copyright on Susan Sontag’s book Illness as Metaphor was 1977, and AIDS and Its Metaphors 1989. Other than those attached to HIV-AIDS, what other punitive illness metaphors may haunt the present?
Illness metaphors continue to be applied to groups of people such as immigrants. Cassandra White observed that “leprosy is popularly imagined to be a disease of the past, to be highly contagious, and to cause flesh to rot and limbs to fall off. Leprosy can be a powerful metaphor, carrying with it all the ills assumed to be caused by foreign populations entering the U.S.”9 Dr. William Lewis of the U.S. Public Health Service has furnished some dubious statistics regarding contemporary leprosy in the United States. Although the number of new cases annually peaked at 456 in 1983 and since 1988 has remained stable, Dr. Lerner has said, “Leprosy is emerging—burgeoning, even as a modern problem.”9 He then proceeded to say that more than 7,000 people have leprosy in the United States although the inflated number includes a majority of people who have successfully completed therapy and are no longer infectious.9 His next step was to observe that people afflicted in the U.S. “are immigrants from global leprosy.” Dennis Daumiere of the World Health Organization countered Lewis’ statistics and said in regard to leprosy, there is absolutely no risk posed by immigrants coming to the U.S.9 It has been said in response,
“. . . how claims to protect the [U.S.] public’s health frequently have served as proxies for bias, discrimination, and nativism.”10
The arts—even those from the nineteenth century—serve as a reminder of the negative impact of illness metaphors. La Traviata provides a lesson that continues to resonate today.
- Hutcheon L. and Hutcheon M. Opera, Desire, Disease, and Death. University of Nebraska Press, Lincoln, Nebraska, 1996. Pages 38-39, 14, 2, 41, 45, 3.
- Sontag S. Illness as Metaphor and AIDS and its Metaphors. Picador, New York, 1978 and 1989. Pages 58,13.
- Mason B.M. Seeing Medicine through Opera Glasses. Can. Med. Assoc. J.1996; 154:921-923.
- Willich S.N. Physicians in opera—reflection of medical history and public perception, BMJ. 2006;333:1333-1335.
- Soriano J.B. On Doctors and Their Operas: A Critical (and Lyrical) Analysis of Medicine in Opera. Chest 2018;154:409-415.
- Lintz B.C. Concocting La Dame aux camellias: Blood, Tears, and Other Fluids. Nineteenth Century French Studies 2005; 33:287-307.
- Beall A. And Tracy J.L. Women likely to wear red or pink at peak fertility. Psychological Science 2013; 24:1837-1841.
- Moreau T. Sang sur: Michelet et le sang feminine. (article in French) Accessed at https://www.persee.fr/doc/roman_0048-8593_1981_num_11_31_4478.
- White C. Déjà vu: Leprosy and Immigration Discourse in the Twenty-First Century United States. Lepr. Rev. 2010; 81:17-26.
- Steelfisher G.K, Blendon R.J, Lsasala-Blanco N. Ebola in the United States—Public Reactions and Implications. N. Engl. J. Med. 2015; 373:789-791.
MILAD MATTA, MD, is an Internal Medicine Resident (PGY-1) at the Cleveland Clinic. He is a native of Lebanon and is trilingual—French, Arabic, and English. He wants to pursue a career in Cardiology.
GREGORY W. RUTECKI, MD, received his medical degree cum laude from the University of Illinois, Chicago (1974). He completed internal medicine training at the Ohio State University Medical Center in 1977 and a fellowship in nephrology at the University of Minnesota in 1980. After 12 years of private nephrology practice, he re-entered Academic Medicine at The Northeastern Ohio Universities College of Medicine (awarded “Master Teacher” designation) and became the E. Stephen Kurtides Chair of Medical Education at Evanston Northwestern Healthcare and Professor of Medicine at the Feinberg School of Medicine, Northwestern University. He now practices medicine at the Cleveland Clinic.