Transient Global Amnesia

December 31, 2008

Transient Global Amnesia (TGA) is a rare disorder of unknown cause. It is seen mainly in patients between the ages of 55 and 75. It commonly follows a stressful event, but at least 50% of episodes occur with no previous stressor. The sole feature of the disorder is the sudden loss of antegrade memory.

The patient is oriented to person but can retain no new information for more than a few seconds. Memory of past events is usually impaired as well. Since the disorder is rare, physicians who have never seen a patient with it will suspect a stroke as the cause of the amnesia. But a physical exam performed during an episode will clearly differentiate TGA from a CVA. Here is a typical case:

A 67 year old woman was brought to the emergency room by her husband. A teacher, she had left her school and was in her car when she became aware that something was very wrong. She was able to phone her husband and drive home. He returned home and found her confused. She did not remember calling him nor did she remember driving home. He brought her to the ER. In the ER she was oriented to person, but could not remember where she was. She did not know that her mother was dead (she had died 10 years ago). She could not remember anything she was told and kept repeatedly asking the same questions. She did not know the year. Her blood pressure was 190/105  Her neurological examination was entirely normal except for the memory loss. CT and MRI of the head were normal. She was admitted to the hospital. Her memory started to return six hours after the onset of her problem and was completely normal the next morning. Her blood pressure (which had been normal before this episode) was controlled with atenolol and subsequently has been controlled with 10 mg of lisinopril twice a day. She is now asymptomatic. She has no memory of the period of amnesia.

After the patient’s memory returned she remembered taking 30 mg of pseudoephedrine on the morning of the day she suffered the episode of TGA. The role of this drug in precipitating the episode and its accompanying hypertension is unclear.

The diagnosis of this syndrome requires the following:
1. The attack be witnessed
2. There be loss of recent memory (antegrade amnesia)
3. No history of head trauma or epilepsy
4. No clouding of consciousness
5. Neurological examination is normal except for memory loss
6. The attack resolves in less than 24 hours

The incidence of this disorder may be as high as 235 per million in patients over 50 years of age. It may be more common in people with migraines. Though there has been speculation about disruption of blood flow to some parts of the brain, the cause of the syndrome is unknown. What’s important is that the correct diagnosis be made and that patients and especially their families be reassured about its benign prognosis. Repeat episodes are unlikely. The range of recurrence is said to be 3 to 25 %. More details about this disorder can be found at the sites below.

http://www.med.ucla.edu/modules/wfsection/article.php?articleid=38
http://emedicine.medscape.com/article/1160964-overview
http://www.mayoclinic.com/health/transient-global-amnesia/DS01022

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Medicare’s Overhead

December 26, 2008

Rep Pete Stark chairman of the House Ways and Means Committee’s health panel is once again on the warpath The California Democrat delivered his latest zinger last week, saying he wouldn’t negotiate with insurance companies on a health-care overhaul. “I think their intention is to see the Democrats fail, regardless of what it does for health care in this country,” Rep. Stark told reporters. He went on to say that  Medicare has lower overhead than the private insurers . Stark is a true believer and like all true believers he admits no possibility of error and is recklessly intolerant of contrary views.

Stark’s attitude towards health care reform reminds me of Richard Feynman’s quip about the universe:  “The universe is not only stranger than you think; it’s stranger than you can imagine.” If we can get just one issue straight we might have a chance of getting on the right path. Medicare says that their overhead costs are 2 – 5%. When they say this they are being disingenuous. Their overhead is low because they don’t count all of it. It’s like congress spending money and then putting the costs off the books. If Medicare were a private insurance company Patrick Fitzgerald would be taping their staff meetings.

Medicare imposes an almost infinite number of unfunded mandates, rules, and regulations on medical providers. These mandates consume vast swatches of time and impose huge costs. Costs which of course are passed on to patients and taxpayers, but which Medicare doesn’t count. Talk to your doctor and ask him about Medicare’s regulatory regime. Be prepared for a lot of frustration. Why do some doctors favor a government run single payer health care system? There are a number of reasons, but likely most prominent among them is that most of these doctors don’t spend a lot of time taking care of patients.

The total cost of all this federal regulation is not known by anyone, but my guess is were it counted by Medicare as part of its overhead, which it really is, that it would put Medicare equal to or ahead of the insurance companies. Anyone who thinks that Stark and Medicare have the answer of our problems with health care should deeply contemplate Feynman’s quip. Medical care is almost as strange as the universe. Is Pete Stark the guy who’s figured it out? The government can do a lot of things, but it can never save money.

Finally, a majority of Americans are satisfied with their health care coverage. Will this still be true after Rep Stark has his way. I think we’re about to find out.

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Why Nothing Works

December 24, 2008

The title is a bit hyperbolic – almost nothing works. Good service usually can  not be purchased at any price unless you are in the billionaire class. Why do businesses that provide only a service – like the airlines – perform so terribly? In this case (airlines) it’s our fault. We don’t want to pay for good service. We prefer bad service that we can complain about. An airline that provided better service would have to charge for it and would soon find that it didn’t have enough customers to survive. Still they could do better. When you call them on the phone you get the usual dialogue:

For English press 1.
For Spanish press 2.
For Esperanto press 30,409.

If you are a homicidal manic press 1
If you are a compulsive thumb sucker press 69
If this has something to do with an airplane press 2
If you’re so angry that you may go postal we’ll connect you to an operator, but only after you send us a picture of your gun.

If you want to buy a ticket press 1
If you want information about a flight make a guess and then send us a text message because we don’t have any information about anything. We don’t know up from down. How can you expect us to know what’s in the air? And even if we did know something we’d lie to you.

It’s likely not accidental that Southwest Airlines which has human beings answer their phones right from the first ring is also the only line that routinely makes a profit. The telephone answering machine/menu is the perfect marker of bad service. The instant you hear it you know the service jig is up.

Enough about the grounded airlines, let’s consider arts organizations. They’re terminally disorganized because they’re in the business of losing money. They whine about it all the time and constantly beg. If the anti-vagrancy laws were applied they’d all shut down. Much of their “work” is performed by volunteers. These well meaning “workers” come and go ensuring that there’s no organizational continuity. They often don’t communicate with one another. Dealing with an arts organization is often difficult. It’s hard to give them money. They don’t know how to take yes for an answer.

Take the San Francisco Opera. It’s one of the best companies in the country. People come from all over the US to attend its performances. Go to its web site and you’ll find a seating chart which indicates those seats that are available for purchase. You can buy them at the site. But suppose your about to get on a plane (see above for what awaits you) or you are already away from home. The only option to get your tickets is to have them mailed. You can’t have them held at the box office which seems an omission so egregious that you have to suspect terrorism.

Okay, they list a box office phone number and the hours that the box office is open. Well, it’s not open. And the phone connection seems to be routed through Afghanistan or the NSA is listening in searching for a subversive staging of Puccini – easy to find in Europe. Osama Bin Laden couldn’t have thought this up. We’ll give them a pass – artistic license, etc. What do they know about computers and web sites? About as much as the people who make and distribute computers and their affiliated hardware and software.

Buying a computer and getting it to work, not to mention keeping it working, is voyage to the heart of darkness. Some wag said, “If the automobile had followed the same trajectory as the PC, a Rolls Royce would cost $100, get 1000 miles to the gallon, and explode once a year killing everyone in the car.” Try to get a service representative from one of the large computer companies on the phone. He’ll probably also be in Afghanistan and be completely uninterested in your problem. After all, customer service costs the company money; it doesn’t bring any money in. Before you buy a computer call the customer service department and see how successful you are in making contact. My experience with Dell has been that all their customer reps are in a secure undisclosed location which is cut of from all external contact. You can get a sales rep on the phone which puts them a step ahead of the SF Opera.

Now consider the software. Each big program has many thick books telling the user how to get something from the software because no one can figure out how to use a program from reading its manual which was likely written by someone whose first language was not English. Does anyone write Driving for Dummies? Of course not, even though dummies make up a major segment of the market for driving. That even small organizations need an Information Technology Department is proof of the unreliability of computers and their detritus. Bill Gates became the richest man in the world by making products which don’t work terribly well. Build a mediocre mousetrap and the world will beat a path to your door. The secret of his success is that he imposed a standard. It’s like Mussolini making the trains work on time.

This one really deserves a separate entry – and perhaps I’ll post more on this later. Almost all new PCs are now sold with Vista 64 bit on them. You have to have a 64 bit OS if you want to address more than 4 GB of RAM.  Yet much essential software doesn’t work on Vista 64 bit. Adobe doesn’t have a flash player for the OS. Google desktop doesn’t work on Vista 64 bit.  Dell sent me a long rambling email that I’ll post later apologizing for all the problems with getting things to work on Vista 64 bit, but they’re still selling computers with the OS. The usually crash proof Firefox routinely crashes on my Vista 64 bit machine, but never on my Vista 32 bit machine or my XP machines. I may go back to the abacus. Even the Weatherbug occasionally crashes on the 64 bit program. Computer games are what drives the constant upgrade of computer hardware. Many recently released resource intensive games like Spore and Fallout 3 have trouble with Vista 64 bit. Electronic Arts sells games via downloads from their web site, but their downloader requires Adobe’s flash player thus gamers with Vista 64 bit can’t buy games directly from EA. Those who bought games this way and then got a new machine with a 64 bit OS on are getting refunds from EA because they can’t download previously bought games to their new computer. What a great business model. PC Tools Spyware Doctor with Antivirus doesn;t have a 64 bit version. Vista 64 bit had been out for more than a year. What are these guys doing? Working doesn’t seem to be a choice.

I won’t say much about government. Everybody thinks the government doesn’t work very well and simultaneously wants more from it. Everyone disparages politicians yet keeps returning the same ones to office. We get the government and politicians we deserve. In addition the government has limitless money which it’s going to spend. We’re all going to be rich. So maybe the government’s really our friend. But if we’re going to bail out the domestic auto industry I want a car. The government is going to make us pay for cars we won’t buy so we should get a car even if we don’t really want it.

Driving is congested and maddening no matter where you live. The reason is that there is too much traffic for the roads. Of course sometimes the cause is  is too little traffic for the roads. I live in a city where traffic is snarled because of the latter problem. The government provides money for road construction, even if it’s not needed. Nobody passes up money from the government. Road construction funds are the college fund and retirement plans for contractors. In Lubbock Texas (population 200,000) where the roads are adequate for a population of at least one million we are building roads that could handle four million. Thus you can’t easily get anywhere because of all the construction. We are constructing a mammoth diagonal road that will have the automotive density of the Gobi Desert and which cuts the city in two like a dehiscence. In Lubbock you don’t get stuck in traffic, you get stuck in road construction.

I’ve saved the best for last – hospitals. From start to finish you’ll wait. People hang around ERs waiting for a disposition for days. By the time the ER finishes with you death may seem preferable to another visit. I’ve already made such a decision. My living will directs my heirs to let me perish in preference to dialing 911.  Once you make it out of the ER and into the hospital you enter a lost world. I mean a world where everything gets lost. Sometimes even the patients get lost. I recall sitting in the Nurses Station next to another physician who couldn’t find his patient, the patient’s chart, the order sheet, the patient’s X-rays, her lab results, the charge nurse, the ward clerk, and the bathroom. He put his head and moaned in my direction, “If the patients only knew.” Well, they don’t and if they did they wouldn’t believe it. Truth is usually too painful to bear.

So what’s wrong? The answer is simple. Our technology is space age, but the rest of us is still in Cave 65. The fault is not in our systems, but ourselves. Our systems have evolved faster than we can. So let’s all suck it up and muddle through.


Early Diagnosis of Cancer

December 23, 2008

Wired.com, of all places, has an excellent article about the early diagnosis of cancer: Why Early Detection is the Best Way to Beat Cancer by Thomas Goetz. The problem is that early detection is a way to beat cancer, but it almost certainly is not the best way. First of all the article is very good and well worth reading. It is far more sophisticated than virtually anything one sees in the lay press.

The best way to beat cancer is not by treating it, no matter how early in its course, but by preventing it. Mr Goetz comes close to this approach in his discussion of Pap smears and cervical cancer – one of medicine’s greatest triumphs. Regular Pap smears result in the treatment of lesions of the cervix before they become malignant. Now with the understanding of the role of human papilloma virus in the pathogenesis of the disease new prevention strategies are possible.

The problem with early diagnosis of cancer is that it may not work in all forms of the disease. In some cancers the opportunity for cure may be gone as soon as the first malignant cell appears. Also early diagnosis of cancers that may cause little or no harm carries a risk benefit ratio that is unfavorable. Prostate cancer is a disease where the value of early diagnosis is fiercely debated. Goetz is fully aware of this problem.

Colon cancer is another disease where early diagnosis makes a positive difference, but it’s also a disease we know how to prevent. Colonoscopy, though inconvenient and expensive, often finds premalignant lesions the removal of which prevents the later development of cancer.

Screening for disease has a long and mostly unsuccessful history. Despite much effort there are only about three screening tests that are of unequivocal value. Two are mentioned above (Pap smears and colonoscopy) the remaining one is blood pressure measurement. Virtually everything else is debatable. For example do regular mammograms (though the procedure is standard of care) convey a benefit over self examination? Is the decline in breast cancer mortality due to earlier diagnosis or better treatment? The answer to these questions is still debatable.

Similarly, regular physical exams in asymptomatic patients convey no benefit. This doesn’t mean that in the future we won’t get new screening tests or procedures that are medically useful and cost effective. It just emphasizes how difficult it’s likely to be to get these tests and procedures.

Goetz discusses at length screening for ovarian cancer. He presents calculations that define the size of of an ovarian cancer small enough to cure if it could be diagnosed. The numbers given are entirely made up or if you prefer entirely an assumption. There’s no way to know at what size an ovarian cancer is too big to cure. It is possible that some ovarian cancers may never be small enough to cure. Thus its hard to know how valuable early diagnosis of this cancer will turn out to be.

But even if I’m completely wrong about all of this it should be obvious that of the two alternatives – treating a cancer that has already appeared versus preventing the cancer from developing in the first place – the latter is far better than the former. Given that for many cancers we can’t do either, I’d put my research money on prevention. No matter where you stand on the issue read Goetz’s article – it’s a gem.


Turandot Without the T

December 22, 2008

Today’s Puccini’s 150th birthday. To commemorate the occasion NPR’s Performance Today had an interview with noted Puccini expert Fred Plotkin. During its course Plotkin followed the now conventional practice of pronouncing Puccini’s last opera with its final t articulated. While this practice is pretty small beans in the course of human events it’s pedantic and based on how the name was pronounced before Puccini got to it rather than on how he wanted it pronounced.

Listen to this excerpt from the first complete recording of Turandot in 1938, just 12 years after the opera’s premiere. Note the absence of a final consonant. Patrick Vincent Casali has written a long article  (Opera Quarterly 13 (4): 77–91, 1997) detailing Puccini’s intention that his opera be pronounced Turando[t]. Here’s a 1962 interview with the Met’s John Gutman and Rosa Raisa the first Turandot:

GUTMAN: In addition to being the very first Turandot, I know,
Mme Raisa, that you appeared in other world premieres and several
American premieres. Would you tell our audience, please, what some
of those premieres were?
RAISA: My pleasure, Mr. Gutman. In addition to Turando[t], which
is pronounced the way I pronounce it and also [the way] it was
pronounced by Puccini and Toscanini, so, [therefore] it is really
“Turando[t],” not Turandot!”
GUTMAN: [taken aback] Thank you very much, Mme Raisa. This
interests me very much. I know that this has been a controversy for a
long time and . . . ah, we certainly take your word for it, since you were
the original Turando[t].
RAISA: Thank you.

Here’s another with Robert Lloyd and Dame Eva Turner a famous Turandot who was at the opera’s first performance.

LLOYD: Dame Eva, there’s one little problem we have to solve before
we can have this conversation.
TURNER: Yes?
LLOYD: I’ve noticed that you say Turando[t].”
TURNER: Yes.
LLOYD: And I say “Turandot.” Can you explain why?
TURNER: Yes. Well, because in my day it was always “Turando[t].” And
you see, I was at the first performance that Toscanini conducted, and
[pause] it was “Turando[t].” And whenever [sic] I sang it for the first
time, or whenever I sang it, I say “Turando[t].” And, I think I have to
confess, I like it. More especially when it involves a musical line, to
keep the continuity going. It isn’t quite so chopped. But of course, it
isn’t quite so Chinese [laughs].

This mispronunciation seems to be the fault of Erich Leinsdorf who inserted it into his 1960 recording of the opera. Its now tradition to use it. But remember Toscanini’s definition of tradition: Yesterday’s mistake. And he should know – he was there.

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The Met’s Thaïs in HD

December 21, 2008
Renée Fleming

Renée Fleming

Jules Massenet’s opera Thaïs was premiered in 1894. Since then it has been a little beyond the frontier of the standard operatic repertoire. It’s periodically revived for star sopranos. The Met’s current production is a vehicle for Renée Fleming. Without her there would be little reason to mount the opera. While it has moments that work quite well, its length far exceeds its worth. So how did she do? Very well. Well enough to justify reviving the work.

To start she was radiant in all her beauty. There’s not a wrinkle on her forehead though she’ll soon turn 50. Much of her gorgeous face is immobile. Fortunately she can move her mouth and her vocal cords. Her cosmetic surgeon is surely at the very top of his field. Vocally as well as visually she was in fine shape. Her sound was luscious and she spun out beautiful pianissimi that made the most of Massenet’s patchy score. “Miroir, dis-moi que je suis belle” was sung with feeling and expression except for a little difficulty with its climactic high D. The aria is a precursor of the Marschallin’s soliloquy at the end of Rosenkavalier’s first act. Both characters muse sadly about growing old – fatal for the career of Thaïs and depressing for Strauss’s princess.   My only quibble with Fleming’s interpretation was that she was too wholesome for the part and looked the picture of health during her death scene. After she died I expected her to open her eyes and tell everyone that she was just fooling.

Designer Christian Lacroix was recruited to create Ms Fleming’s costumes. The gowns he made are in the style of the mid 19th century which is where the action was moved. Why here rather than the early Christian era which is where both Anatole France’s novel and the original staging are set is unanswerable. Why a high profile designer was needed to make Fleming look like a Victorian overstuffed sofa is another imponderable. But what do I know about couture? Obviously nothing as all the women at the performance I talked to loved the outfits. I thought Joe the Plumber could have fitted the diva with better duds. I hoping for something like Hedy Lamar’s diaphanous dresses in Samson and Delilah.

Thomas Hampson was fine  as Athanaël the sexually challenged Cenobite monk, though he tended to bellow his way through some of his part’s more forceful sections . He also made a lot of funny faces which were accentuated by the close up shots. Michael Schade (Nicias) has a serviceable light tenor and Alain Vernhes was sensible as Palémon the old monk who warns Athanaël to stay away from loose women – good advice that always falls on deaf ears. Concertmaster David Chan played the opera’s best known number, The Meditation, with beauty and a sure tone. Jesus López-Cobos conducted. His grasp of the score was authoritative. The Met’s orchestra played very well for him. Thaïs is a score outside the mainstream that deserves a production by a major house three or four times a century.

Finally, the sets were not credited to anyone in the program. Opera News says they were designed by Paul Brown. They were serviceable though the desert looked like it was made of Lego blocks. The video direction was again unobtrusive as it should be – a relief after the in your face presentation of the Berlioz Faust. The Met can now put this piece back in the warehouse for another generation until the next beautiful diva arrives. In the meantime we can reengage Ms Fleming as the Met’s HD hostess. Placido Domingo filled in for her during this broadcast. He was obviously unprepared using cue cards during his interviews. In addition to being a great singer Fleming is terrific as the image of these broadcasts. I hope she’s available for the remaining ones.



Thoughts On The Puccini Sesquicentennial

December 20, 2008

puccini-1

Much of the July 2008 issue of Opera News is devoted to Giacomo Puccini who was born in 1858. Anybody who loves the composer’s operas, which is anyone who has ever heard them and who is not a terminal snob, will enjoy reading the articles analyzing various components of Puccini’s amazing ability with melody and stagecraft. The cover story by Fred Plotkin, American Idol, analyzes why Americans adore Puccini whereas Italians rank him, along with everyone else, below Verdi.

The article is interesting even if you reject his initial premise – which I do, at least to the extent that popularity and merit are subsumed. I see no evidence that Verdi’s worth is held in lesser regard in the US than in Italy. Nor do I see any reason to rank the relative artistic worths of the two composers. Puccini needs no defenders, He is one of very small list of composers who stand at the summit of operatic achievement. There are, however, important differences between the two Italian composers.

Most importantly, the two geniuses had different goals. Puccini was, with the important exception of Gianni Schicchi, almost exclusively interested in his heroines. He seemed to identify himself with his leading man – always the tenor. Thus he only wrote a few good roles for the baritone – Scarpia, Michele, Schicchi – and none for mezzo soprano or bass. Once you accept the limitations he imposed on himself you’re left with a composer for the stage who could do anything he wanted.

His sense of theater was unsurpassed; everything that happens in his operas is there for a reason. A director who interferes  always makes things worse. Consider two examples. In the second act of La Boheme Musetta and Marcello get back together with a dramatic sweep that always moves the audience to cheers and applause unless you have a director who thinks he knows more about theater than Puccini. Let the action unfold and you can’t go wrong. The next time you listen to a live performance of Boheme see what happens at this moment.

Another place where it takes a great director to muck things up is in the second act of Madama Butterfly. Cio Cio San’s moment of false triumph when she thinks Pinkerton has returned to her should always be interrupted by applause, but I’ve been to performances that miraculously kill this sure fire moment including the Met’s current production.

puccini-2

Puccini could take the techniques of all the great contemporary composers and make them sound like they had been created for him. Wagner, Debussy, Strauss (all of them), Schoenberg, even Franz Lehar all sounded better when Puccini morphed them into his operas. He was also a master of the chorus. Just listen to the finale of the first act of Tosca and much of Turandot to realize how gifted he was with large forces while making the effect seems effortless. But his most prominent gift was that of melody. A gift that can only be bestowed by a higher power and never acquired. He could set conversation to music that was of as much melodic interest as found in the great arias. Only a handful of composers for the stage have been able to manage this.

In short, he was a master of everything he did. He just decided for whatever reason to concentrate on a slice of human experience. It is this relatively narrow focus that distinguishes him from Verdi.

verdi

Verdi was a universal genius. In the theater the only comparison is with Shakespeare. Verdi’s terrain was the clay of humanity. If you need more evidence to prove that education and erudition do not necessarily coincide with judgment and wisdom consider Verdi’s place among the intellectual elites of his time. Born in 1813, the same year as Wagner, Verdi was held to be a mere popularizer who was not to be taken seriously by the intelligentsia. That he was wildly popular was thought to be further evidence  beyond his work per se that he was not a serious artist. It was like what global warming is today. If it gets hotter or colder the prevailing climate is cited as evidence of continuing global warming. No matter what Verdi did he was not serious or if something appeared that was  so good it could not be denied the only explanation must be that he was copying Wagner. This unease with Verdi’s popularity and greatness still lingers. Pierre Boulez declared not too long ago that he could imagine no scenario under which he would conduct the overture to “La Forza del Destino.” If you want a two word explanation of what’s wrong with modern classical music “Pierre Boulez” will do. Not that long ago Stanley Kaufman (born 1916) the movie critic for the New Republic wrote, “It is becoming increasingly clear that Verdi was a giant of art.” Kaufman’s belated discovery of Verdi’s position in art is typical of those who came to maturity in the 1930s. Verdi was too popular to be great. Fortunately for Kaufman he lived long enough for the scales to fall from his eyes. Boulez, I suspect, will never see the light.

Verdi himself paid little attention to the impact of Wagner or to the opinion of elites. His only declaration of aesthetics was, “Gross ignoramus that I am, there are only two kinds of music – good and bad.” He further advised a young composer to ignore the critics but look instead to the box office. “The theater was meant to be full.”  Regarding  Wagner, Francis Toye, Verdi’s first biographer in English and still indispensable, gets the story straight: “Perhaps Wagner’s most remarkable achievement was that he invented  an idiom that became for more than 50 years the musical language of the world. One of Verdi’s greatest feats was that, almost alone among Wagner’s contemporaries and immediate successors in western Europe, he successfully avoided speaking that language.” Toye’s only problem was that he was too close to Verdi’s time to fully appreciate his worth. He would be a little surprised to find that eight decades after he wrote his fine biography that many critics would place Verdi above all composers for the stage.

I’m sure Verdi knew how good he was, but he approached writing operas as a craft. It was his business and he intended to do it as well as he good. He was the last great artist to lack self consciousness and to be unconcerned about his, or anyone else’s, place in the cosmos. What he did was portray all the key human emotions with the keenest of dramatic awareness combined with melodic beauty and expressiveness that were both unsurpassed and in combination unmatched.

At least 15 of his 28 operas are masterpieces – 16 if you count the Requiem which is a sacred opera. If opera is the hardest art to master, Verdi seems (in Benjamin Britten’s words) to have discovered the secret of perfection. Verdi’s career lasted more than half a century. During that period he gradually increased his artistic span and developed the matchless skill that characterizes his later works. Yet even at the beginning in Nabucco you hear the same voice that sent Falstaff in to the world more than half a century later; his last opera races so quickly that more than 100 years after its birth it’s hard to keep up with its octogenarian author.

Verdi was that rare creator who kept getting better as he aged. But the vigor and almost ferocious energy that bursts from Nabucco is still there at the end of Falstaff. When a great conductor conducts its final number – of all things a fugue – the audience is swept away by its cyclonic force. Rossini called the young Verdi a composer in a helmet, but that same man helmet and all could also write “Va, pensiero”. Listen to the finale of the first act of Nabucco. If it doesn’t make you want to rush out and join the Marines you’re dead. The energy of the finale and the extraordinary beauty of the chorus of the Hebrew slaves yearning for freedom are the foundations on which Verdi’s unique career was built. He started out great and progressively got even better. Now hear the last operatic number written by the 80 year old composer. The early energy and vigor is still there. So is the helmet though now encrusted with jewels. The orchestration is developed to the greatest sophistication as is the part writing, but it’s the same guy.  And the words – All the world’s a joke. What a way to go.

He favors no one vocal type or range. There are great roles for all voices because Verdi is writing about every key human emotion. Much has been made over Verdi’s predilection for father/daughter relationships and it’s there, but so are other intimate conflicts as well as the clash of titanic forces. Who other than Verdi could make one of opera’s most riveting scenes out of a 15 minute confrontation between two basses – a king and a grand inquisitor? And incredibly this scene is just part of a larger one in Don Carlo that contains everything one could  ask of an opera except the tenor, its eponymous character. This scene in the king’s apartment is so grand a creation that it alone would rank Verdi at the top of opera’s pantheon, yet scenes like this occur repeatedly in the master’s succession of masterworks. All those states of consciousness common to all men are illuminated with the light of truth by operas greatest humanist.

Let’s examine a Verdi masterpiece that is not among his most popular operas. Un Ballo in Maschera has been in the standard repertory of all the world’s great opera houses since its premiere in 1859. Nevertheless, it is not as well recognized as Rigoletto, Traviata, Trovatore, or Aida. Yet it is as good as virtually anything Verdi wrote. The center of the work is its love duet which is deliriously passionate and agitated almost beyond the bounds of love and passion perhaps because it expresses an unconsummated love. Ironically, Verdi who wrote some of the greatest love music left behind not a single love letter. This is in keeping with his austere personality more like that of an ancient Roman of the republic than that of a modern Italian. The great love duet dominates this opera in a way unlike any other of the great Verdi love duets.

While almost all of the opera deserves attention especially noteworthy are the almost Parisian gaiety which ends the first scenethe laughing while your really afraid that comes near the end of the first act, and the mocking and mordant laughter of the conspirators (2nd act finale) who find Renato (a baritone naturally) unknowingly escorting his wife back from an assignation with his best friend. This last effect is unparalleled in opera. It would be impossible in a play – the husband and wife expressing fury and terror respectively while simultaneously enduring sarcastic laughter – a tour de force.

No composer wrote as much great music for the baritone as Verdi. Ballo’s great aria for this range is Eri tu which when separated from its dramatic milieu it loses half its impact. The horror and anguish of a man who believes he’s been betrayed by both his wife and his best friend brings an overpowering impact when sung on stage by a great baritone.

If Ballo was the work of almost any other composer it would be classed as his greatest masterpiece, but in Verdi’s canon it’s just one of a long list of wonderful operas such is the uncanny ability of this composer to produce  a seemingly unlimited stream of remarkable work. To be as supremely gifted as Verdi and to be granted so much time to perfect his gifts places Verdi virtually alone in art. He stands so tall that no one can add or subtract from his stature. His wife called him the “Bear of Bussetto”. In reality he was a lion.