Literature and Tuberculosis: La Traviata
Nowhere, perhaps, is death by tuberculosis more lyrically romanticized than in La Traviata . As the opera opens, Violetta Valery, a beautiful, young, and consumptive courtesan—La Traviata or The Fallen Woman of the title—is giving a nightlong party. A short while before, however, she was bedridden as a result of her disease. When asked if she can really enjoy herself now, Violetta says that she places her faith in "pleasure" because "with that medicine" (con tal farmaco ), she is used to soothing her "ills" (i mali sopir ).[8]
At her party, Violetta is introduced to Alfredo Germont, a young man who, she learns, came to inquire about her
every day when she was ill. Violetta at first makes light of this information. Later she will remember and be moved by it.
Violetta's illness soon makes its dramatic appearance. Just as she invites her guests to go into the next room to dance, she turns pale. Violetta tries to deny her illness when her friends ask her what is wrong, but she feels faint and must sit down. Admitting that she is trembling, she tells her guests to dance without her. All—except Alfredo—obey.
Thinking she is alone, Violetta looks in the mirror and confronts her illness. "Oh, what pallor!" she exclaims. Suddenly, she notices Alfredo. He asks if she is feeling better and then blurts out that her life-style is killing her, that if she were his, he would watch over her because he has loved her for a whole year. Not insensitive to Alfredo's protestations of love and his obvious anxiety about her health, Violetta tells him that he may return the next day.
At dawn Violetta's guests depart. When she is alone, she sings her splendid arias "Ah, fors'è lui . . ." and "Sempre libera. . . . "Here she begins to reveal the conflicts within herself, between the courtesan whose medicine for all her ills was pleasure and the soul within her which longs to be loved and loving. After asking herself if she can disdain love for what she condemns as the "sterile follies" of her courtesan's life-style, Violetta glides into a romantic reverie ("Ah, fors'è lui . . .") in which she thinks about Alfredo, her dreams, and her illness. Suddenly, in a strange metaphor, she links her tuberculosis with her images of Alfredo and love. Recalling how Alfredo came to inquire about her daily when she was ill, she transforms her memories of her tubercular fever into the metaphoric "new fever" of love.
Ah, perhaps he's the one my soul,
lonely amid these tumults,
took joy in painting frequently
with its hues of mystery.
He, who meek and vigilant
came by my sickroom door above,
and kindled a new fever
rousing me to love![9]
After dreaming like this for a while, Violetta stops herself short, and the counterpoint of the courtesan's claims begins. Rejecting her romantic reveries as "madness" and "delirium," the woman who must earn her living as a courtesan assesses her real situation in Paris.
What madness! A vain delirium in this!
Poor woman, lonely, abandoned
in this populous wilderness
people call Paris,
what hope have I?
What should I do?
To joy, fly!
To die in whirls of pleasure! Of pleasure I'll die!
To joy, fly![10]
It is striking here that even when Violetta says that she "should" pursue pleasure, images of death appear as if to remind her of her mortal illness: "To die in whirls of pleasure! Of pleasure I'll die!"
Continuing with the courtesan's claims but even more impassioned now, Violetta declares in her next aria ("Sempre libera . . .") that she "must" go "from joy to joy" and that "to ever new delights" her thoughts "must fly." The word "must," which is repeated, implies obligation, compulsion, or necessity. Violetta seems to be trying to convince herself that she has to continue her courtesan's life-style. Once more as in "Ah, fors'è lui . . .," an image of death ("let day die") insinuates itself into her apparently (but only apparently) joyful resolution to pursue pleasure at all costs.
I must frolic always free
from joy to joy;
I want my life to seek
the paths of pleasure.
Let dawn dawn, or let day die,
always happy at parties am I,
and to ever new delights
my thoughts must fly.[11]
With these words, Act I ends. Although Violetta appears to be saying that she will, because she must , continue her courtesan's life-style, her words actually reveal her longing for the opposite. In fact, we sense the conflict between the courtesan Violetta has been and the loving woman she will become, even while she seems to be voicing most strongly her courtesan's claims. Why must Violetta pursue her courtesan life-style? She is trying to force herself to flee from what she really craves: love.
What is the role of tuberculosis in Violetta's development so far? It is probably accurate to say that Violetta was drawn to Alfredo just because of her illness. At her party he stayed with her, showed concern for her health, and declared his love for her when she was feeling ill, and in "Ah, fors'è lui . . ." she recalls how he had inquired about her every day. There is a link, therefore, between her nascent love for Alfredo and her tuberculosis. Her disease and the knowledge of her impending death are, along with her basic nature and character, some of the most important factors that help transform her from a pleasure-seeking courtesan into a romantic and spiritualized person—a person who will show herself capable of great love and tremendous personal sacrifice.
By the beginning of Act II, Violetta has already given up everything for love. She and Alfredo have been living together in the country for three months. Suddenly, however, Alfredo's joy is shattered when he learns from her servant that to meet their expenses Violetta is selling all her possessions in Paris. Stung with shame and remorse, Alfredo rushes off to try to amass the money needed.
When Alfredo leaves, Violetta enters. She is expecting a man on business and when he arrives, she tells her servant to show him in immediately. Instead of the businessman,
however, it is Giorgio Germont, Alfredo's father. The ensuing dialogue between Violetta and Germont is central to Violetta's further transformation from the romantic woman she has already become to a spiritualized one.
Germont, who has come from Provence to try to reclaim his son, angrily accuses Violetta of letting Alfredo squander all his money on her. He learns, however, that she is selling all her worldly possessions. Although puritanical and moralistic, Germont is not insensitive to this disclosure, nor to what Violetta reveals next: she has a spiritual side. For now she tells him that her past "no longer exists" because "God erased it" with her "repentance."
Germont immediately uses this information to his own advantage. Picking up on her spiritual theme, he tells Violetta he has come to ask a "sacrifice" of her. "Sacrifice" is probably the key word of the opera. Derived from the Latin sacer , "sacred," and facere , "to make," it means, literally "making sacred." It is essentially a religious concept: one gives up something valued for the sake of something with a higher claim, that is, for the sake of "making [something] sacred." The word "sacrifice" and the concept of it occur so often in the ensuing emotion-charged dialogue between Violetta and Germont as to be emblematic of it and, therefore, of the rest of the opera.
Without hesitation Germont tells Violetta of the sacrifice he wants. Drawing heavily on a religious vocabulary—with references to God, purity, an angel, and prayers—as well as on figures of family obligations and love, Germont says that God gave him a daughter who is "pure as an angel." But, he adds, the man betrothed to his daughter will not marry her unless Alfredo leaves Violetta and returns home.
Violetta says that she understands. She will leave Alfredo for some time so that the marriage may take place. But that is not enough for Germont; he demands that Violetta leave Alfredo forever. "Ah, no! Never! / No, never!" she exclaims and immediately tries to win him over with three arguments. First, she speaks of the "immense and living love" for Alfredo
that "burns" in her "breast." This figure recalls how in "Ah, fors'è lui . . ." she had transformed her tubercular fever into the "new fever" of love. Next, she says that she has neither friends nor family and that Alfredo has promised to be everything to her. As her final and, she hopes, most powerful argument, Violetta speaks of her "horrible malady" and impending death.
Don't you know that my life
is stamped with a horrible malady?
That I see the end is near already?
Were I to leave Alfredo,
ah, I would suffer so,—why
I would rather die,
yes, I would rather die![12]
Germont, however, remains insensitive both to Violetta's pleas and to her fears about dying. In response, he too uses three arugments. She is young, he says, and will find other men. When Violetta rejects that, he says that men are often fickle. Finally, he resorts once more to religion and moralizing. One day when she is no longer beautiful, he tells Violetta, boredom will set in for Alfredo and her because their "bonds" were not "blessed" by "heaven." It is striking—and of paramount importance to Violetta's character development—that she is shaken by this, for she responds, "It's true, it's true!"[13] From this moment on, her transformation into a martyr—for love, for her past, and for her tuberculosis—is sealed.
Encouraged by Violetta's concession, Germont presses on, now offering Violetta a kind of forgiveness as well as a promise of spiritual reward. He tells her that "God . . . inspires" him to ask her to be the "guardian angel" of his family.[14] Suddenly, Germont's victory is complete. With the awareness of her fallen state as a woman, the knowledge of her impending death, her feelings of guilt over her past, and her spiritual longings all mingling in her mind, in great sadness Violetta assesses her situation.
Thus, for the poor woman
who fell one day,
all hope of rising is taken away.
Even if God to her is merciful,
man to her will be implacable.[15]
And so, craving love and forgiveness—from God and from man—Violetta, weeping, asks Germont to tell his "pure" daughter that she, a "victim" of misfortune, will "sacrifice" for her the one ray of good she has left in life and "then die." Twice in these few lines Violetta evokes the notion of sacrifice: she calls herself a "victim" (comparing herself, therefore, to something sacrificed in a religious rite) and she uses the verb itself.
Tell the young girl so pretty and pure
that there is a victim of adversity
who has only
one ray of good that she
will sacrifice for her, and then die,
and then die, and then die![16]
No longer living for a love in life, Violetta now turns to a love in renunciation, death, and spiritual consolation.
So that she will have the courage to leave Alfredo, Violetta asks Germont to embrace her as a daughter—perhaps as the pure daughter for whom she is sacrificing her love and her life. Germont, not unmoved by Violetta's sacrifice, embraces her, calls her "generous," and asks what he can do for her. Filled with thoughts of her imminent death, Violetta asks him to tell Alfredo of her "sacrifice" so that he will not curse her memory. The exchange between Germont and Violetta which follows is a lyrical outpouring of death thoughts, images of sacrifice, and promises of heavenly reward.
VIOLETTA
I'll die!
So that he
won't curse my memory,
let someone tell him at least
how I suffered horribly.
GWEMONT
No, generous girl, live,
and happy you should be;
one day for these tears you'll have
heaven's mercy.
VIOLETTA
Tell him the sacrifice
1 made in love, for I
shall love him until
my heart's final sigh.
GERMONT
Recompense there will be
for your love's sacrifice;
of such a noble deed,
you'll be proud, you'll see,
yes, yes, yes![17]
Violetta's sacrifice suggests, above all, her spiritual longings, which are inseparable from her feelings of guilt for her past, as well as her knowledge of her illness and approaching death. Further, acceding to Germont's wishes establishes a sacrificial bond between Germont and Violetta—a bond that binds both of them, each to the other. Violetta's sacrifice thus suggests her acceptance of many of Germont's social and religious values (purity, love and marriage, God, heaven, and spiritual reward). It also implies her craving for Germont's forgiveness and paternal affection, for Violetta asks him to "embrace" her "as a daughter," and he does so. On the other side of the bond, Germont's embracing Violetta suggests that he is not uninvolved in her sacrifice. In the opera's final act, in fact, it becomes clear just how strong the sacrificial bond between Germont and Violetta really is; there Germont's words and acts reveal how much Violetta has been able to teach this puritanical and moralistic—but
not uncaring—man about the true meanings of charity, forgiveness, sacrifice, and love.
After Germont exits, Alfredo returns. Distressed because he has received a stem letter from his father saying that he is coming to see him, Alfredo fails to understand how distraught Violetta is. Weeping, she exclaims in a burst of self-renouncing passion, "Love me, Alfredo, / Love me as much as 1 love you! / Good-bye!"[18] She then rushes away.
Alfredo is left alone. Moments later a man brings a note from Violetta saying that she has left him. Gennont enters and tries to convince his son to return home, but Alfredo barely listens. Consumed with anger, he exclaims that Violetta has gone to a party (given by Flora, one of her courtesan friends) and rushes out, vowing "retaliation."
That night, at Flora's party, we observe Violetta's further spiritual transformation. The gathering, the type of affair Violetta once delighted in, is replete with dancers, fortune-tellers, drinking, dining, and gambling. Alfredo enters. Soon after, Violetta enters with one of her former lovers, the Baron. When she notices Alfredo, Violetta calls on God, as she will do increasingly in this scene, for pity and help: "Have pity, dear God, have pity, / dear God, on me!"[19]
When the others go in to dinner, Violetta meets alone with Alfredo and begs him to leave. Alfredo says he will leave only if she will follow him. "Ah! no, never!" Violetta exclaims. She tells him she has made a "sacred vow" to flee from him. The word "sacred" is not lost on Alfredo, who demands to know who could have forced her to make such a vow. Violetta answers, "One who had every right." Because she does not explain herself, Alfredo assumes that it was the Baron and asks her if she loves him. Lying now to consummate her sacrifice, Violetta forces herself to say "Yes." Enraged, Alfredo calls everyone in to witness a terrible scene. When all are assembled, he tells them that Violetta has spent all her money on him and now he is paying her back. Contemptuously and contemptibly, he throws his winnings from the gaming table at her. Violetta faints.
Germont arrives and denounces his son for treating a woman so shamefully. At the same time, Germont admits to himself Violetta's virtue and fidelity to Alfredo. Alfredo, humiliated, says he despises himself for what he has done. As this powerful act closes, we hear the spiritually transformed Violetta, who has revived, saying how much love there is in her heart for Alfredo. Violetta's words here, like her music, are sublime, focusing on love, renunciation, death, and heaven.
Alfredo, Alfredo, you cannot understand
all the love my heart contains.
You do not know that I have proved it even at
the price of your disdain.
The time will come, though, when you will know
how much I loved you; you'll admit it, too. . . .
May God then save you from remorse!
Ah! when I am dead I will still love you.[20]
With Violetta's words filtering through Alfredo's and Germont's, this act ends.
As Act III opens, Violetta is dying. At 7:00 A.M., Dr. Grenvil comes to see her. Violetta tries to rise but cannot and must be helped by the doctor and her faithful servant, Annina.
The brief scene between Violetta and Dr. Grenvil is touching in its simplicity and in its disclosure about what nineteenth-century medicine could—or could not do—for tuberculosis. Dr. Grenvil takes Violetta's pulse and asks how she is feeling and if she slept well that night. When Violetta responds that she did sleep well, the doctor says, "Have courage, then, / convalescence is not far off." Violetta appreciates his encouraging words, which she calls the "white lie that doctors are permitted to use."[21] Dr. Grenvil does not deny this. He leaves, promising to return later. But Dr. Grenvil gives his true medical opinion to Annina, who has asked how Violetta really is. Because of her "phthisis," Violetta has only a few hours to live. Thus, this doctor who knows his medical limitations supports his tuberculitic patient in the
only way he can—with kindness, kind words, and a "white lie" that offers hope. He also takes her pulse, thereby giving the impression that he is performing some kind of medical act (he is, although by that act he cannot help his patient here), and promises to return later. This doctor can do nothing medically but he does all he can humanly.
Violetta's thoughts are concentrated now on death and religion. She has told Dr. Grenvil that although her body is suffering, her soul is at peace. The night before she was comforted by a "pious priest," as "religion is a relief to those who suffer."
When she is alone, Violetta rereads a letter she received some time before from Germont, In it, he says that he has told Alfredo of her "sacrifice" and that Alfredo, who was abroad, is coming to ask her forgiveness. Germont, too, is on his way. But Violetta has almost given up hope. In a gesture that recalls how, during her party in Act I, when she felt ill and thought herself alone, she had looked in the mirror and was startled by her "pallor," Violetta, who is now really alone, looks in the mirror and finds herself horribly changed.
Oh, how I am changed!
But I should still hope, the Doctor said!
Ah! with this illness
all hope is dead.
Smiling dreams of the past, adieu;
the roses of my cheeks are already pale in hue;
and I miss Alfredo's love for me,
the comfort and help of a soul that's weary. . . .
Smile on . . . the yearning of. . . th fallen woman, do;
forgive her, and receive her, 0 God, with you!
Ah! All is through!
Now all is through.[22]
In this plaintive song, Violetta voices her contradictory longings for earthly love and heavenly love. Although she craves heaven, she regrets the "smiling dreams" of her past and
laments that "all is through." But this "fallen woman" also wants to translate the "smiling dreams" of her past into God's smiling on her.
Suddenly, Alfredo returns. He and Violetta, joyously embracing, sing a lyrical and spiritualized love song in which they envision a reward for the pain they have suffered and speak of a future when Violetta's health will "bloom anew" In addition, they promise that they will be for each other both breath and light: body and vision, the physical and the spiritual. Once again, as in Violetta's song, the image of a smile recurs, suggesting a longed-for reception that is gentle, warm, and loving.
ALFREDO
We'll leave Paris, oh dearest one,
through life we'll go in unison;
you'll be rewarded for the pain you've gone through;
your health will bloom anew
Breath and light you will be to me.
All the future will treat us smilingly
VIOLETTA
You'll be rewarded for the pain you've gone through;
my health will bloom anew.
Breath and light you will be to me.
All the future will treat us smilingly.[23]
As they end this dreamy duet. Violetta's spiritual concerns become most important. She suddenly wants to go to church and give thanks for Alfredo's return. Instantly, however, she turns pale and falters. She tries to deny her tuberculosis but then has to admit the truth: it is the "weakness" that comes from her "illness." Although Violetta hurriedly sends Annina for the doctor, she realizes that if Alfredo has not saved her by returning to her, then no one on earth can. In agony, she voices a reproach to God.
Ah! Dear God!
to die so young!
I, whom such pain wrung!
To die when I could dry erelong
the tears I wept so long!
Ah! then it was delirium,
my hopeful credulity!
In vain I armed my heart,
In vain with constancy![24]
Alfredo begs her not to despair, but Violetta knows the end is coming.
At the same time, both Alfredo's father and Dr. Grenvil arrive. Germont says he has come to embrace Violetta "as a daughter," but seeing her state, he is suddenly struck with "remorse" and exclaims, "Rash old man! I see only / now the evil / caused by me!"[25]
By this time, Violetta's thoughts have turned wholly to heaven and to spiritual concerns. Calling Alfredo to her bedside, she gives him a locket containing her picture and tells him that if a pure young virgin falls in love with him, he should marry her. She herself, she says, will be "among the angels" praying for her and for him. It is significant that Violetta does not want Alfredo to marry the kind of girl she was but the kind of girl she now wishes she could have been. It is also noteworthy that Violetta believes she has earned her heavenly reward.
If a pure virgin
in the flower of her youth
gives her heart to you, . . .
I want you to make her your wife . . . I do.
Give her this portrait;
tell her it's a gift from someone who
among the angels
is praying for her, for you.[26]
After Violetta voices her sublime renunciation, the final consummation of her sacrifice, Germont, Dr. Grenvil, and Annina say that as long as they have tears, they will weep for her. We see here how fully the sacrificial bond between
Germont and Violetta has transformed not only Violetta but also Germont. For now, in addition to feeling great remorse for the harm he did, Germont believes that Violetta will become a heavenly creature, one of the "blessèd spirits."
Germont, Doctor, Annina
As long as my eyes have tears
I shall weep for you.
Fly to the blessed spirits,
God is calling you.[27]
As though released by their words, Violetta says she no longer feels pain and, in fact, feels herself reviving.
It's strange!
The painful spasms have ceased!
I feel born in me,
stirring me, unusual strength!
Ah! why I'm coming back to life!
O joy![28]
She falls. Dr. Grenvil takes her pulse. She is dead.
In this final act, Violetta's martyrdom is completed. Her death by tuberculosis is romanticized, of course. Not only is it portrayed as painless but also as spiritualized, idealized, and even joyful. After all, Violetta's last words—the words of the consumptive courtesan transformed by her tuberculosis, her love, her feelings of guilt for her past, and her sacrifice—are "O joy!" The title of Verdi's opera is sublimely ironic, therefore, because "La Traviata," "The Fallen Woman," has become a spiritualized, idealized, awe-inspiring being.
Case History: The Fallen Woman
Do real people with tuberculosis behave in any way like Violetta?
I recall one unforgettable case I treated—unforgettable because it was a very difficult case; because it taught me a lot about
tuberculosis, illness, and romanticizing, and because it could also be called, for very different, but also ironic, reasons, The Fallen Woman.
During a whole lifetime as a physician, certain cases stand out when you know that your particular medical management has played a crucial role in determining whether a patient has lived or died. I had one such case when I was an intern.
When Mrs. T, age sixty-five, was admitted to my service, she did not seem like a very interesting case. Because she had a slight cardiac arrhythmia, she was admitted to the C.C.U. During her workup, however, we learned that she had numerous other medical problems. Since she had an abnormal chest X ray and had been suffering from fevers and weight loss, we suspected a diagnosis of tuberculosis, which we subsequently documented.
We started her on the conventional triple therapy (three different antibiotics) while she was in the hospital. Instead of improving after the first week, however, Mrs. T got worse. We discovered that she was having a relatively rare and unusually severe toxic reaction to the antibiotics, which had produced liver necrosis. It was probably one of the worst cases our hospital, a major university teaching center, had ever seen.
The sequence of events was like a nightmare. First, Mrs. T went into hepatic failure, which led to kidney failure, respiratory failure, and a very puzzling type of autoimmune problem that prevented us from giving her any transfusions. She also developed secondary infections. Naturally, we had to put her in the I.C.U. and on a respirator. At one time or another, almost every major organ system in her body went into failure, and we had to call in virtually every subspecialty in the hospital to consult on her case.
Since we knew that all her problems were idiosyncratic and iatrogenic, we had the feeling that everything was reversible, if only we could get her over each acute insult or crisis. But she was such a metabolic and immunologic disaster that every day a new—and life-threatening—crisis would occur
Because Mrs. T. was my patient and because her case was so complicated, I was actually the only doctor who could keep track of all that was happening to her. The nights I was on call, in addition to admitting all new patients and taking care of all my other patients plus all the other interns' patients (when those interns
had gone home), I had to stay up through the night trying to get Mrs. T stabilized. And the nights I was not on call I would often stay late to make sure that all her tests had been done so that she would be stable enough to get through the night when another intern, who would not know all her problems, was covering for me. Needless to say, it was an unbelievable struggle to keep her alive. At one point, her problem list included respiratory failure, cardiac arrhythmias, bleeding from a gastric ulcer, possible small bowel obstruction, liver failure, renal failure, pleural effusion, hemolytic anemia, a bleeding disorder, and possible meningitis. And that was when things were not too bad.
Mrs. T was in the I.C.U. for about two months. On at least three occasions, I had called members of her family to inform them that I thought her death was imminent and to suggest they might want to come in and be with her
Finally, things slowly began to reverse themselves one by one, and Mrs. T began to recover. I think that all the doctors who participated in her care felt this was one instance where virtually tireless, obsessive work plus modern medical technology had been able to pull a patient from death. Of course, I had a tremendous emotional investment in this patient, even though I did not really know her After all, she had been conscious only during her first week in the hospital. Subsequently, with all her catastrophic complications, she had been semicomatose or unconscious most of the time. In addition, she had been hooked up to a respirator; that, of course, prevented her from speaking. I, really had no idea, therefore, what kind of person she was. But I did begin to realize as she improved, became more alert, and was taken off the respirator, that she was not very bright or particularly pleasant In fact, the more conscious she became, the less I liked her But I put that out of my mind.
When almost all of Mrs. T's problems reversed themselves, she was transferred from the I.C.U. to the regular medical floor. By then, I had rotated to another service, but I still checked up on her from time to time to see how she was doing.
When Mrs. T was ready to be discharged, she was scheduled for my outpatient clinic since she was really my patient. I was to see her in about three weeks. I looked with great fondness on Mrs. T's case because of the tremendous amount of time, effort, and
energy I had put into it and because I presented it at Grand Rounds, where there was a tremendous amount of interest in it It was, in fact, a memorable case for everyone.
The week finally came when Mrs. T was to see me in my outpatient clinic. The doctors in Infectious Diseases had been seeing her regularly because she was on secondary tuberculosis drugs, and I had heard from them that she was doing fantastically well.
The day of her appointment I got a message that Mrs. T was calling me. I imagined that it was probably to confirm her appointment with "The Wonderful Doctor Who Had Saved Her Life." I answered the telephone in a kind of joyous tone, only to find that Mrs. T was canceling her appointment because, she said, There's a bit of snow on the ground and it's too much trouble to go out and get into the cab." Trying to be helpful, I said, "we could make the appointment another time," but she answered, "I don't see why I have to see any more doctors. I'm feeling fine now."
I hung up in disbelief. This great case of mine, this woman whose life I had been instrumental in saving, had absolutely no understanding or appreciation of what had happened or of what my role had been in her care. Far from being a symbol of the Great Healer, I was, in her eyes, some kind of annoyance. It was a lesson I did not soon forget.