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livmoose · 6 years

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Va, Tosca!

I’ve been fascinated by ‘Tosca’ since three years ago, when I first heard it in Kiev opera. What motivated me to dig deeper was the stubborn anti-Puccini bias of music critics that started with the opera’s (nay, it's antecedent play’s) premiere and didn’t really cease by this day. Which I cannot understand at all: ‘Tosca’ is literally one of the most popular operas in the world, outperformed only by such eminent names as Verdi’s ‘La Traviata’, Mozart’s ‘Die Zauberflöte’, Puccini’s own ‘La Boheme’ and Bizet’s ‘Carmen’. So what gives?

‘Tosca’, original poster, 1899

The premise of this 3-act opera by Giacomo Puccini is rather simple: a villain wants a girl who loves a boy who loves her back and also helps revolutionaries. And also it’s a tragedy, like in a Shakespearean Everybody Dies kind of tragedy. You can pretty much guess the plot from there.

What I personally like about this opera is the combination of lightning-fast plot (the action takes place within several hours on June 17-18, 1800), finely developed character portraits, and music that explains and foreshadows everything you need to know.

Naturally, I don’t take the vague criticisms of ‘Tosca’ all that well.

Ha più forte sapore [bits of history and background]

Puccini’s opera is based on a 1887 5-act play ‘La Tosca’ by Victorien Sardou.

Puccini had seen La Tosca at least twice, in Milan and Turin. On 7 May 1889 he wrote to his publisher, Giulio Ricordi, begging him to get Sardou’s permission for the work to be made into an opera: ‘I see in this Tosca the opera I need, with no overblown proportions, no elaborate spectacle, nor will it call for the usual excessive amount of music.’

M.J. Philips-Matz ‘Puccini: A Biography’

I found this quote, and it instantly clicked: it’s exactly why I like ‘Tosca’.

In contrast to Sardou’s initial work, Puccini’s opera is much more succinct and direct. It has almost zero overblown dialogues and soliloquies that don’t promote the plot or develop characters (well, maybe there is this one lyric soprano-tenor duetto ‘Amaro sol per te m’era il morire’ [‘Only for you did death taste bitter for me’] in act III that’s a bit too long for my taste, but even this slow moment is essential because it gives the audience an opportunity to breathe as the final shockwave looms closer). But the rest of it is actually interesting to see and hear.

For me, ‘Tosca’ is one of the very few operas that are targeted at people who are not fifteen and overly dramatic adult audiences who don’t need same things repeated at them all the time and who can catch what is happening without seeing each and every small detail. Puccini squeezed Sardou’s acts II, III and IV into a single second act, and it works. We as an audience don’t need to see the whole scene at Cavaradossi’s house to understand what happened there. We can use our imagination to paint the rest of the picture.

Looks like the critics do not agree with me on this one.

Perché, perché, Signore [criticisms galore]

The infuriating part about the critical landscape of ‘Tosca’ is that the critics don’t seem to agree on a single point of reproof. Some complain that the opera is too wordy; others, conversely, are not satisfied with the plot rushness (the view that both librettists of ‘Tosca’, Illica and Giacosa shared). Critics called the opera ‘three hours of noise’ that lacks style and cohesion. Julian Budden [opera scholar] faulted the ‘inept handling of the political element’ while commending ‘a triumph of pure theatre’. Burton Fisher [opera writer] described the sensuous love duet ‘Qual’occhio’ as ‘an almost erotic lyricism’ and ‘pornophony’.

Is it just me, or do the critics dislike ‘Tosca’ precisely for the nuances I love about it: coherence of the plot, acute and restrained drama, absence of excessive political speculations (it was not meant to be goddamn ‘Les Miserables’) and, well, musical puns? More on that later.

Not to say ‘Tosca’ didn’t receive its share of praise. Charles Osborne [music critic] believed the plot of ‘Tosca’ was taut and effective while the characters had enough opportunities to shine both in terms of dramatic development and musical elaborateness. Some also praised the richness of Puccini’s score:

[Puccini] finds in his palette all colours, all shades; in his hands, the instrumental texture becomes completely supple, the gradations of sonority are innumerable, the blend unfailingly grateful to the ear.

Ippolito Valetta [music critic] ‘Rassegna Musicale’ in ‘Nuova Antologia’

The aspect of criticism that I did find explainable was based on ‘disconcerting vulgarities’ as put by Gabriel Fauré [composer]. To be honest, the opera really does not lack in violence: Tosca undergoes sexual assault, is broken by the need to defend her chastity with murder and by the death of a beloved, and finally commits suicide. For the public back in 1900 such developments truly could be regarded as a bit too much.

For modern audiences, however, the events are nothing to be shied away from. The opera aged exceedingly well, not losing a bit of its attractiveness in romantic and dramatic sense. Even more so, the criticism that ‘Tosca’ still receives today makes little sense. Joseph Kerman’s [musicologist] remark on ‘Tosca’ as a ‘shabby little shocker’ from the middle of the century, well after the actual real-life shock of two world wars and the brusque shift of public morale, was way off the mark. Thomas Beecham [conductor] bitingly responded that anything Kerman said about Puccini could ‘safely be ignored’ (it almost makes one thing something personal’s involved).

Besides, some modern scholars share my perception of ‘Tosca’s treatment:

Scholarly presses and journals still deeming [Puccini’s] operas too popular to be worthy of serious study continue to shoot themselves in their collective foot.

Deborah Burton ‘Tosca’s Rome: The Play and the Opera in Historical Perspective (review)’

By Burton, Puccini was often simply ‘snubbed by the musicological establishment’. The fun part? Puccini put on his Scarpia persona to cynically and kind of affectionately if you ask me describe ‘Tosca’ as ‘zibaldone’ [‘hodgepodge’]. He referred to it as ‘a vile opera’ and ‘quella putana di Roma’ [‘that Roman whore’]. If this isn’t love.

Già, mi dicon venal [quick glance at the initial play]

Similar criticism of abundance of violence was applied to Sardou’s play. Tosca’s behavior was deemed ‘unchaste’, and the brutality disturbed both critics and theatre fans. Jules Favre [statesman] even called it ‘cette pièce vulgaire, sans intrigue, sans caractères, sans moeurs’ [‘vulgar piece, without intrigue, without characters, without morals’].

The most offensive part of the play was, apparently, Cavaradossi’s torture. Even off-stage, his screams prodded the critics to warn women against seeing ‘La Tosca’ as the play could ‘inflict irreparable injury on persons yet unborn’.

Despite this, the play was an immediate success. It toured around the world, and even the harshest critics couldn’t ignore its dramatic effect:

As to the play itself, I will only add that it is offensive in its morals, corrupt in its teaching, and revolting in its brutality, and yet everyone who admires acting is bound to see it.

Cecil Howard [theatre critic] ‘La Tosca’, ‘The Theatre’

So. Let’s see what threw people in such a dismay, shall we.

Io de’ sospiri [plot and why it’s good]

Sylvester Feodosiyevich Shchedrin ‘New Rome. Castel Sant’Angelo’, oil on canvas, 1823

It all starts with Roman ex-consul Angelotti escaping the clutches of tyrannical justice. The fugitive runs into Mario Cavaradossi, painter and Bonapartist who agrees to help him. Two men are interrupted by Mario’s passionate lover and Roman opera celebrity, Floria Tosca. After a fit of jealousy she leaves the church, and Cavaradossi leads Angelotti away from the city to hide in his villa. Right afterwards, Baron Scarpia, chief of police and the embodiment of tyranny emerges on stage and, when Tosca returns, devises to use her jealousy to lead him to Mario and Angelotti.

Second act is all about torturing Cavaradossi (off-stage) and Tosca’s gradual breakdown. Scarpia demands the location of Angelotti, which she surrenders to save Mario from suffering. Then Scarpia tries to force Tosca to give herself to him, which she agrees in exchange for her lover’s life - only to stab unsuspecting Scarpia with a knife.

The rest of the main cast dies during the third act. Mario’s ‘staged’ execution appears to be not so fake as Scarpia promised. Tosca, inconsolable and heartbroken, jumps to her death as the soldiers, who discovered Scarpia’s body, corner her on the ramparts of Castel Sant’Angelo.

The plot pretty much follows Sardou’s play, although the action was tightened (mostly by avoiding obvious plot turns) and the list of characters sharply compressed.

Sardou’s act III features a scene that is not present in Puccini’s opera: Cavaradossi’s villa, the painter, Angelotti, and later Tosca and Scarpia. One of the things I liked about the opera is that it doesn’t have this scene. It’s excessive and basically tells nothing that audience couldn’t have picked up from the unobtrusive operatic dialogue in act II. Puccini - Sardou 1:0.

Obviously, Mario’s execution was not fake. In the play, Spoletta reveals this fact to Tosca. In the opera, he at first misunderstands Scarpia’s order (hilariously so, as he nearly confesses the whole thing to Tosca), which allows the audience to guess their scheme. 2:0 for subtlety.

In act II, Scarpia questions Mario with the backdrop of Tosca’s cantata performance off-stage, in the depths of Palazzo Farnese. 3:0, this whole piece is just gorgeous.

Puccini wanted ‘La Tosca’s plot stripped of everything excessive (which is, lamentably, a rare practice for operatic genre):

[Puccini] cut Tosca to the bone, leaving three strong characters trapped in an airless, violent, tightly wound melodrama that had little room for lyricism.

M.J. Philips-Matz ‘Puccini: A Biography’

Ignoring criticisms, Puccini also persevered in his clear vision of how the ending should be - by the way, nearly the single thing he and Sardou agreed upon. A good thing undoubtedly; I’d hate for this to happen:

Puccini’s librettists also disliked the suicide, and an alternate ending for the opera was (briefly) considered: rather than leap, Tosca would go mad, collapse, and die on the body of her lover (presumably of Sudden Operatic Death Syndrome).

Susan Vandiver Nicassio ‘Ten Things You Didn’t Know about Tosca’

Pure gold of a remark. Thank you, Susan.

‘Tosca’ is a very tight, succinct work, beautifully paced. I like how the acts are structured and developed. Act I, the longest one, was clearly meant to be expositional. Also, it’s the melodramatic one, with inclusion of comedic motifs that significantly lighten the mood (think the character of the Sacristan and continuous good-hearted mocking of Tosca by her lover).

Act II is unexpectedly macabre: there’s not a trace of the lightheartedness of act I. A real drama ensues, with torture, violence and grim ending (Tosca murders Scarpia in cold blood, which I, as a cynic, viciously enjoy every time). This act is also shorter while it still has enough room for Scarpia’s intricate manipulation and blooming deconstruction of Tosca. The characters are well-developed and nicely motivated (at least in part Sardou’s merit).

Act III is the shortest (just over 20 minutes), and it’s a full-on tragedy. The final plot twist was hardly intended as one. This act is an emotional roller-coaster. Combining hope and death, it is based on fragmented pieces, which makes the whole thing feel real, not operatic. The opera ends strong and loud, and it’s perfect that way. The audience is left with the sense of tragedy that is not undermined by unnecessary lyricism of long pre-death arias (like in Verdi’s ‘La Traviata’, I absolutely hate the last act). With the rush of events, the delay at this point would be unendurable.

‘Tosca’ is chaotic in its final scene, just as it should be. Tosca the character makes the (suicide) decision in a blink of an eye, and I absolutely love the impression that she makes it out of egotistical motives: she is to be captured by the soldiers - not because Mario is dead. This is the kind of nuance that defines the difference between real living people and operatic character embryos. When the opera ends, I always find myself speechless and anguished not irritated at how annoyingly long it takes for the characters to die (looking at you, Verdi).

E lucevan le stelle [characters breakdown]

Palazzo Farnese, 2018. Now French Embassy in Rome

First and strongest impression about the characters of ‘Tosca’: gosh, they are not dumb! So it is possible.

One of the major appeals of ‘Tosca’ is that the characters feel like real people instead of archetypal damsel in distress, knight in shining armor and flat cardboard villain. Although Scarpia bends a bit in that direction, being completely satisfied with his villainous villainy, he acknowledges it, giving off the air of a ‘connoisseur of evil’ instead. William Ashbrook [musicologist] recognized Puccini as a portraitist who honed lifelike characters. Even the smaller characters like the Sacristan (‘an avaricious hypocrite’), Angelotti (exhausted but proud-spirited escapee) and Spoletta (when Scarpia says ‘jump’ he asks how high a perfect minion) are miniature studies of human nature. ‘Tosca’, in his opinion, is a portrait gallery of real-life people.

Floria Tosca [soprano]

For some unfathomable reason, ‘Tosca’ is defined as a melodrama, which is totally different from how it feels with its darkness and the fact that everybody of significance dies in the end. Wiki says melodrama is ‘a dramatic work in which the plot, which is typically sensational and designed to appeal strongly to the emotions’ - basically, plot over characters. Instead, [scenic] tragedy (defined by Google) is ‘a play dealing with tragic events and having an unhappy ending, especially one concerning the downfall of the main character’.

The latter is literally the plot of ‘Tosca’, especially as the title character undergoes a whole set of the most traumatic experiences (concessions to conscience, attempted rape, murder in defense, witnessing torture and execution of a loved one) in a span of just several hours. This set of experiences naturally draws a basis for her downfall (literally): under stress and with no opportunity to think thoroughly, it is not surprising that Tosca commits suicide.

She is strong-willed and passionate, pure-hearted (which is probably why she doesn’t see through Scarpia’s schemes) but not stupid, loyal but also jealous. More out of habit, if we to believe Julian Budden [opera scholar]:

[Cavaradossi, act I, scene 5] Mia gelosa! [My jealous [Tosca]!]

[Tosca] Si, lo sento, ti tormento, senza posa. [Yes, I feel it, I torment you unceasingly.]

All in all, she is a harmonious character in dire circumstances, and it’s a true delight to observe how Tosca, despite how broken and devastated she is, finds the power to oppose her offender. This is the real plot twist (character twist?) of the opera - and I assume the reason that ‘Vissi d’arte’, Tosca’s major aria (an emotional plea of a character who is about to betray her very self) is so well-known and recognized.

Mario Cavaradossi [tenor]

In comparison with Tosca, Cavaradossi is a deceptive character. At first glance he might appear rather flat: nothing more than a loyal lover and a proud revolutionary. Upon closer inspection, however, the audience discovers liveliness and realism many male operatic characters severely lack: he jokes with Tosca instead of oh-so-common sickeningly sweet sighs of love. He knows her flaw of being prone to jealousy - but doesn’t take it too close to heart. He listens to her without interruption as she tells him about Scarpia’s advances (for sure, I was waiting for a hateful scene where he would scream ‘how could you’ at his lover and bang his head against a wall). And he actually knows how to appreciate that she willingly sacrificed her purity for his sake (and he sings an aria about it, too: ‘O dolci mani’ [‘Oh, sweet hands’]).

Besides the believable romance with Tosca, Cavaradossi has excellent dynamics with Scarpia. As the news of Napoleon’s victory arrive, Mario - once tortured - cannot resist the urge to relish in how stars turned for his nemesis:

[Cavaradossi, act II, scene 4] Vittoria! Vittoria! L’alba vindice appar che fa gli empi tremar! Libertà sorge, crollan tirannidi! [Victory! Victory! The avenging dawn now rises to make the wicked tremble! And liberty returns, the scourge of tyrants!]

Tosca tries to stop his prideful speech, aware of how this flows right into Scarpia’s intention to lock revolutionary Cavaradossi up. But Mario is lost in his surging emotions and forgets both himself and his lover at this moment - truly a detail each of us can relate to.

And also Cavaradossi seems to know that his death is not going to be faked - a twist that no one but pure-hearted Tosca is fooled by. He doesn’t believe in Scarpia’s generosity for a moment, and so he doesn’t even try to pretend he is surprised but ironically ridicules the mere idea of a magnanimous villain:

[Cavaradossi, act III, scene 3] Scarpia che cede? La prima sua grazia è questa… [Scarpia yields? This is his first act of clemency…]

Unbelieving but relieved by Tosca’s appearance and intoxicated by her hopeful rambling, Mario chooses to spend his last moments languishing in her presence: he doesn’t want to spoil this time for neither of them. Beniamino Gigli [opera singer, performed as Cavaradossi] wrote in his autobiography that ‘[Mario] is certain that these are their last moments together on earth, and that he is about to die’.

This interpretation of the character is common among the opera singers:

Unlike Floria, Cavaradossi knows that Scarpia never yields, though he pretends to believe in order to delay the pain for Tosca.

Tito Gobbi [opera singer and director]

However, instead of displaying understandable despair, Cavaradossi falls back to his original optimistic self and starts to subtly mock Tosca’s attempts to teach him how to die theatrically. She replies with ‘non ridere’ [‘you mustn’t laugh’], and he softly reassures her. They’re just so sweet together without the usual operatic mawkishness.

(I suspect Tosca is not entirely convinced of their unscathed escape from the clutches of now-dead Scarpia, as well. No wonder she feels uncomfortable at the prolonged preparations.)

Baron Scarpia [baritone]

The villain of this story was actually the first among the main cast to catch my attention. Scarpia is just so explicitly entertaining in his sardonic wickedness. Still, I can see how he could be interpreted as the least 3-dimensional of the three.

Scarpia is a clever interrogator and a talented manipulator. He knows where to hit and when to push to get the answers he needs. Pressing Tosca more and more, he breaks through her defenses until she is frustrated and annoyed to the point of losing her self-control:

[Scarpia, act II, scene 4] L’Attavanti non era dunque alla villa? [So, the Attavanti was not at the villa?]

[Tosca] No, egli era solo. [No, he was alone.]

[Scarpia] Solo? Ne siete ben sicura? [Alone? Are you quite sure?]

[Tosca] Nulla sfugge ai gelosi. Solo! Solo! [Nothing escapes a jealous eye. Alone. Alone!]

[Scarpia] Davver? [Indeed!]

[Tosca] Solo, sì! [Yes. Alone!]

[Scarpia] Quanto fuoco! Par che abbiate paura di tradirvi. [You protest too much! Perhaps you fear you may betray yourself.]

Tosca, with her passionate, fiery temperament, explodes - Scarpia knows about this peculiarity all too well and is able to use her outburst as a clue in his investigation. He continues the pressure all through act II: Mario is tortured, and Tosca is forced to listen to his agony. She eventually crumbles, unable to persevere in keeping Mario’s secret:

[Tosca, act II, scene 4] Nel pozzo… nel giardino… [In the well… in the garden…]

This confession is so succinct, just like the rest of the dialogue in this opera. Tosca doesn’t say ‘wait, I’ll tell you everything’, doesn’t try to play for time; she just betrays the whole thing in two short phrases, without specifying what she means. There’s no need: they’re on the same page.

And then Scarpia goes one step beyond and acknowledges his villainous ways, which isn’t necessarily a bad thing but makes him a bit more caricature. Delightfully so, but still. While Tosca nurtures released Cavaradossi to conscience, Baron cunningly waits for the opportune moment, and strikes, ordering Spoletta to bring in Angelotti. He gloats at Cavaradossi, smugness dripping off of him: see, she betrayed your trust! Mario, tortured, exhausted, half-conscious, falls for it, throwing Tosca’s hands away:

[Scarpia, act II, scene 4] Nel pozzo… del giardino. Va, Spoletta. [In the well… In the garden. Get him, Spoletta.]

[Cavaradossi] Ah! M’hai tradito! [Ah, you have betrayed me!]

Cavaradossi picks this up from the dialogue between Scarpia and Spoletta - again, no one clarifies anything. Like you do in real life. Subtlety y’all.

Now that the villain has Cavaradossi locked up and preparations for his execution in progress, he is one step away from getting what he wanted from the start. Tosca consents to sleep with him but still cannot conceal her hatred, unavoidable ‘you can have my body but not my heart’ trope, which doesn’t stop his lust in the least - on the contrary, inflames him more:

[Scarpia, act II, scene 5] Che importa? Spasimi d’ira, spasimi d’amore! [What does it matter? Spasms of wrath or spasms of passion…]

Naturally, when Scarpia is finally killed by Tosca, the audience is bound to feel satisfaction and not regret. Even Floria, the established virtuous character, has no shame as she recognizes Scarpia as the ultimate threat:

[Tosca, act II, scene 5] Ti soffoca il sangue? Muori dannato! Muori! Muori! Muori! È morto! Or gli perdono! E avanti a lui tremava tutta Roma! [Is your blood choking you? Die accursed! Die! Die! Die! He is dead! And now I pardon him! All Rome trembled before him!]

But Scarpia is a disillusioned aristocrat rather than a one-dimensional villain. What lets him gain more flesh is his motivations - get rid of the rebels (for power rather than ideological considerations) and get the girl (personal gain), - his backstory and notoriety among the revolutionaries, working relationships with other characters and the fact that he continues to live through his actions (arguably the main theme of the opera). Even when dead, Scarpia continues to serve as a villain of the story: Mario dies, and Tosca shouts her curses at him:

[Tosca, act III, scene 4] O Scarpia, avanti a Dio! [Oh, Scarpia, [we meet] before God!]

This gives weight to the character as Baron doesn’t disappear as soon as he dies. His life and death both have consequences. His actions have lasting power - a feature that fictional villains far too commonly neglect.

Even though Scarpia possesses some cartoonish features, he is far from being as simple as Wile E. Coyote. Meep meep.

Vissi d’arte [finally, let’s talk music]

Riccardo Manci ‘Mario Cavaradossi singing ‘E lucevan le stelle’, inspired by the tenor Giancarlo Monsalve’, 2014

William Ashbrook described Puccini’s music as ‘telegraphic’ and ‘highly charged’. The reason behind such an impression is the combination of several major leitmotifs that interact, evolve and explain the story. Fugitive motif, love of Tosca and Mario, Scarpia’s theme, torture motif, Tosca’s theme and Cavaradossi’s farewell to life are used as a patchwork that tells the story. These leitmotifs - what Edward Greenfield [music critic] calls ‘Grand Tune’ concept - are memorable and unique, as well as quite distinct from their musical surroundings:

Puccini does not develop or modify his motifs, nor weave them into the music symphonically, but uses them to refer to characters, objects and ideas, and as reminders within the narrative.

Burton Fisher ‘Tosca: Opera Study Guide and Libretto’

Torture motif is one succinct example of how a single simple melody is used to pump up the mood. It first appears as a foreshadowing with Scarpia’s forming intention as he learns Cavaradossi was taken into custody:

[Scarpia, act II, scene 2] Meno male! [Not bad, not bad!]

It grows more and more pronounced as Cavaradossi is questioned - threatening but not quite powerful yet. On the backdrop, Tosca’s cantata also gains volume and solemnity - pure delight mixed with anticipation of terror:

[Scarpia, act II, scene 3] Questo è luogo di lagrime! Badate! Or basta! Rispondete! [Beware! This is a place for tears! Enough now. Answer me!]

And the theme finally loses its careful insinuative tone and thunders at full volume when Scarpia orders Mario into the torture chamber, right before Tosca’s eyes:

[Scarpia, act II, scene 4] Mario Cavaradossi, qual testimone il Giudice vi aspetta. [Mario Cavaradossi, the judge awaits your testimony.]

The melody elaborates with Mario’s torture heard from off-stage, reaching its breaking point as Tosca breaks and reveals Angelotti’s hiding. It repeats again after Mario is released - slow and woeful, intertwined with Tosca’s and Mario’s love theme that is now devoid of its previous light hopefulness.

Statue of Michael the Archangel, Castel Sant'Angelo, 2018

I love how music acts as a separate character in the opera. It talks to the characters, responds to them, inquires and leads the conversation. In act I, while Cavaradossi sings about his love to Tosca, the Sacristan reprovingly grumbles about obscene youth on the background. Besides, here lies the great benefit of veristic [realistic] opera that allows the characters to have duologues - Mario and Floria sing their lines separately in a conversational form rather than a boring duet.

Music gives the opportunities of quieter moments, to talk in phrases but also in gestures. During act II, Tosca uses gestures a number of times to answer Scarpia: a nod of the head, a wave; subtle yet expressive. They nearly don’t talk while Scarpia writes her a letter of safe passage. This quiet scene also allows Tosca’s character to unfold, her decision to feel earned. She sees the knife, she hesitates a moment; then she grabs it and hides behind her back: the decision is made. No words necessary; the score allows the characters to be silent while it tells and develops their story.

And it also allows the characters to talk all at once, without listening to each other. By the middle of Act II, as they learn about the battle of Marengo, Mario starts to shout about victory, Tosca tries to shut him up, and Scarpia reels about hanging the revolutionary. They clamor; chaos ensues, and music supports the flurry of eddying noises by playing disparate motifs. The best part about this scene is that it delivers the message loud and clear, on both levels of plot and emotions.

Talking about Puccini’s score, it’s impossible to ignore the musical cohesion and integrity: each of the three main characters has their theme and their own designated aria that allows them to shine. Moreover, as each of their arias happen once per act, I enjoy the interpretation of their dominance: Scarpia in act I, Tosca in act II, Cavaradossi in act III.

Act I. Scarpia’s ‘Te Deum’: lust, menace, church bells

The theme of the villain is played out in contrasts that reflect his character: cunning and smart - but ruthless and just on this side of crazy. Scarpia is also a figure of power, both literally and figuratively, and he is foreshadowed in the score long before the actual appearance of the character on stage. As Baron is first mentioned in the conversation of Angelotti and Cavaradossi, his dark theme abruptly breaks through the much less strident music:

[Angelotti, act I, scene 6] Tutto ella ha osato onde sottrarmi a Scarpia scellerato! [She has dared all to save me from that scoundrel Scarpia!]

Immediately, this menacing ascending theme is associated with the villain. Later, as he enters the stage, no one calls him by his name, yet the audience immediately recognizes him as Scarpia as he is accompanied by that same simple motif.

The appearance of Baron sobers and darkens the mood instantly, his leitmotif invading other themes unscrupulously. Establishing yet another contrast, his conversation with Tosca is escorted by the tolling of bells that lasts till the end of act I. Scarpia raves about his poison spreading through Tosca’s thoughts, and his unnerving, acrid soliloquy transforms into the solemn Adagio religioso in ‘Te Deum’.

This superposition of profane lust of a ferocious man and sacred sublimity of the Catholic chant is what makes the audience shudder. The final ‘Te aeternum Patrem omnis terra veneratur’ [‘Everlasting Father, all the earth worships thee’] should be the solemn virtuous hymn to God but instead the act ends with Scarpia’s theme reiterated in thunderous chords - an ominous admonition of impending threat. Brilliant. Act I definitely belongs to Scarpia.

Act II. Tosca’s ‘Vissi d’arte’: plea of a broken soul

Second act is all about tempo. The action rushes forward non-stop. Scarpia gives Tosca less and less time to think, to estimate her situation, pushing her to her into the abyss (count how many falling jokes I make through this post). However, he misjudges Tosca’s limits and pushes her just a bit too far.

The point of no return for Tosca is her aria where she asks God why she has to endure all this suffering.

[Tosca, act II, scene 5] Vissi d’arte, vissi d’amore, non feci mai male ad anima viva! […] Nell’ora del dolore perché, perché, Signore, perché me ne rimuneri cosi? [I lived for art, I lived for love: never did I harm a living creature! [...] In this hour of pain, why, why, oh Lord, why dost Thou repay me thus?]

The score is lyrical, slow and wailing as Tosca mourns her faith. The aria ends with a low sob that is nearly spoken with raw emotion instead of sang. (Fun fact: while today the opera is probably most well-known for this aria, Puccini didn’t really like it and wanted to cut it out of the opera altogether; in all honesty, it does lack the musical potency of ‘Te Deum’ and ‘E lucevan le stelle’ even though it’s a palatable piece that delivers the idea of character deconstruction rather well.)

Tosca is left completely broken. Modern sopranos commonly fall to their knees while performing this aria, and there’s a good reason: when Tosca finally finds the power to stand up, she is a different woman. For me, this is when the main plot twist happens: usually, heroines in operas are meek and hesitant instead of decisive and offensive. Tosca breaks the pattern and shoves the knife through her offender’s ribcage. She owns act II.

Act III. Cavaradossi’s ‘E lucevan le stelle’: I die in despair

This aria is so renown even people who dislike opera have heard it at some point. It starts with a subtle, tender clarinet solo (possibly the most well-known operatic clarinet theme of all times). The melody is forced up but then sags, losing its power. It’s the pace of destiny, dragging and sorrowful, measuring what little time Cavaradossi has left. This is Andante lento composed in minor key and slow tempo - something that Mosco Carner [musicologist and conductor] calls ‘Puccinian lament, reserved for a character in an extreme situation - death or suicide’. Perfect to denote present anguished dolor.

Mario meditatively recites the first two lines, which feels like an improvisation. The audience witnesses an extremely intimate although fragmentary memory that ends in a grieving ‘muoio disperato’ [‘I die in despair’]:

Puccini insisted on the inclusion of these words, and later stated that admirers of the aria had treble cause to be grateful to him: for composing the music, for having the lyrics written, and ‘for declining expert advice to throw the result in the waste-paper basket’.

William Ashbrook ‘The Operas of Puccini’

Bravo, maestro!

I dislike the currently popular hysterical sobbing at the end of the aria that can be heard from modern tenors (e.g, in staging of ‘Tosca’ at La Scala). It sounds as a ‘hoquet tragique’ [‘tragic hiccup’] that jumps out too much and is slightly out of character - such rendering is more appropriate for Tosca’s character not Cavaradossi’s.

Still, this is arguably the most beautiful, heart-wrenching lyrical aria I’ve ever heard; I’m literally still not over it, after 3 whole years of listening to it, sometimes on repeat. Also, Placido Domingo is the best Cavaradossi, shut up I’m not wrong (1976 film starring him and Raina Kabaivanska is wildly enjoyable).

As a bonus, act III (specifically its beginning and ending) deserve an honorable mention. Despite where the plot says the most dramatic moment of the plot is, for me, it’s the beginning of act III. Here’s the pinnacle of the opera: the contrast between the serene aria of a shepherd boy accompanied by the love motif - and the grim, heavy, shuddering theme of Cavaradossi’s farewell that the orchestra splashes on you as if it is a bucket of ice cold water. The music swells - you wait for the volume to stop growing, but instead it just tears through your eardrums.

The timpani are impossibly good for this piece. Intruding the peaceful, pastoral Roman morning full of hopeful dreams and the colors of sunrise, they suddenly throw the audience into the pit of pure unadulterated horror. Trembling and vibrating on low frequencies, they gift you with the feeling of earth opening under your feet, sucking you into the dark depths you’ll never get out of to see light - say farewell to life.

Similarly, the ending is extremely powerful. The drums start slowly at first, setting the rhythm. Before Cavaradossi’s execution, the orchestra is subtle and insinuating; it accrues and thickens in its vicious predictions. After the shots, as Tosca discovers Mario’s death, the tempo breaks through the roof. The music is desperately, deafeningly loud, it screams of tragedy. And, well, I am aware of the plot of the opera by now, but I’m caught off guard every time. I blame this on music. It just so perfectly reflects the mood of the events; it’s pure gorgeousness that gets to my very core every time.

There’s another point of criticism I need to mention in regard to the final theme that ends the opera: against logic, it is Cavaradossi’s farewell instead of more fitting love theme or, even more appropriately, Scarpia’s motif. This I cannot disagree with as, plot-wise, using this theme would provide the dramatic closure for the opera. However, given my love for theme of farewell, I cannot find the heart to dislike Puccini’s choice after all. Act III is largely focused on Cavaradossi, and the finale acknowledges this.

...Undoubtedly, Puccini was a genius. It’s not easy to comprehend the mastery with which he weaved a handful of simple motifs into a powerful story I cannot stop listening to. But also, there’s this:

Puccini’s sense of humor was often of the schoolboy variety, and he found risqué musical puns irresistible. In Act II of the opera, after Spoletta has assured Scarpia that ‘everything is ready’ for the execution of Cavaradossi, the Chief of Police turns to Tosca and softly asks, ‘Ebbene?’—’Well?’ She says nothing, and the score tells us that she indicates her submission by nodding her head. But at her silent reply the orchestra, anticipating the two-note theme of the ‘execution’ motif, plays the two-note phrase, A and C, or in Italian solfeggio, La and Do. The syllables, in addition to being musical symbols, also happen to be words in Italian: the words ‘La do’ mean ‘I'm giving it,’ and it is the usual way for women to say, I'm ready to give ‘it’ (to you).

Susan Vandiver Nicassio ‘Ten Things You Didn’t Know about Tosca’

It is quite possible there’s more of such minutiae. I’m not sure how to feel about a piece that simultaneously cracks me up and throws me into a pit of despair. But I definitely like it - that much I know.

Castel Sant’Angelo, 2018

Recondita armonia [some fun trivia]

The tone of the dialogue was elevated quite a bit. Get this: comforting Cavaradossi after he was tortured, Tosca says ‘Ma il giusto Iddio lo punirá’ [‘But a just God will punish [Scarpia]’]. The initial line was ‘Ma il sozzo sbirro lo pagherà’ [‘But the filthy cop will pay for it’]. Far less distinguished, my dear.

Puccini visited Rome specifically to mimic the early morning bells. Kudos for authenticity. Also, initially, the composer spent an ungodly amount of money to cast the bells he needed for the performance of ‘Tosca’. The orchestras till today have difficulties satisfying the composer’s vision.

Sarah Bernhardt, an actress who became the prototype for Tosca in Sardou’s play, while performing in Rio de Janeiro in 1905, injured her leg in the final scene when jumping from the rampart. As a result of poor treatment, she lost her leg ten years later. Gory.

Two of the most famous opera singers chose this opera as their farewell: Maria Callas as Tosca gave her last performance in 1965, and Luciano Pavarotti as Mario Cavaradossi in 2004.

In one of the performances with Placido Domingo as Mario Cavaradossi, his son was featured as a shepherd boy.

Before Puccini got to write ‘Tosca’, Giuseppe Verdi expressed his interest. He didn’t like the ending though and wanted it changed - I think we’ve barely avoided another ‘La Traviata’ there, oof.

Oscar Wilde saw ‘La Tosca’ and believed the torture scene was great as it showed how far people can go (no wonder; he was working on ‘Salome’ that evoked indignant discontent of the critics in a similar fashion). George Bernard Shaw also saw the play and, while disliking it utterly, still predicted it would be great as an opera.

In Sardou’s play, Cavaradossi gained a reputation of a Bonapartist in large part because of his mustache. That’s the conclusion I’ve made after seeing these two quotes: ‘Even his mustache was suspect’ and ‘Tosca’s confessor told her it marked him as a revolutionary’. This is gold.

#opera #puccini #tosca #IMHO #why criticism #lots of rambling #greatest opera ever #i don't understand why critics abuse it

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markzupo · 6 years

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DID THE GOVERNMENT BURY A TRUE SYSTEM FOR ONLINE PROFIT FOR ANYONE?

Revealed! What the government doesn’t want to you to know about making a living online.

WARNING: CONTROVERSIAL CONTENT

Please be warned: This story you’re about to be privy to has been DENIED by our own government because they are in fear of the knowledge getting out to just anyone.

Evidence suggests that there has actually been a cover up to prevent you specifically from getting your hands on such valuable information.

As you are reading this powerful forces are working to quiet this release before you get it to keep it hidden.

On 6 August 1991, the World Wide Web became publicly available. Its creator, the now internationally known Tim Berners-Lee, posted a short summary of the project on the alt.hypertext newsgroup and gave birth to a new technology which would fundamentally change the world as we knew it.

USE and Origins

The Internet, as we know it was born and almost immediately, the U.S. Government sought to control its use. ARPANET was the first governmental authority to exploit the computer network for global connectivity but specifically with the U.S. Government’s network that consists of private, public, academic, business, and government networks of local to global scope, linked by a broad array of electronic, wireless, and optical networking technologies

Funding and Control

The funding of the commercial networks and enterprises by the early 1990s marked the beginning of the transition to the modern Internet, and generated a sustained exponential growth as generations of institutional, personal, and mobile computers were connected to the network. Although the Internet was widely used by academia since the 1980s, the commercialization incorporated its services and technologies into virtually every aspect of modern life.

Control of Use Today Let’s do some math. What we know today is that the Internet is not yet completely controlled by any government other than dictatorial governments that restrict its use and availability.

There are over 3-Billion people online at any given moment, each of who has generated million of discussions for good and bad. I have proof that you only need about 100 people to start and make success happen.

HOWEVER, the ultimate use of such a tool has been revealed in the opportunity to “touch” any number of those online…and offer a product or service that will generate a profit for them.

The Internet has enabled and accelerated new forms of personal interactions through:

· Instant messaging, Internet forums and social networking.

· Online shopping has grown exponentially both for major retailers and small businesses and entrepreneurs, as it enables firms to extend their "brick and mortar" presence to serve a larger market or even sell goods and services entirely online.

· Business-to-business and financial services on the Internet affect supply chains across entire industries.

· AND THE MOST IMPORTANT IS THE OPPORTUNITY FOR THE AVERAGE PERSON TO MAKE A PROFIT!

YOU’RE Revelation

Revealed in this document are several myths and several realizations that you must know before they are hidden forever.

MYTHS

1. The average person has to be an expert to use specialized tools to make money online.

2. The average person has to have huge Internet online experience to make money online.

3. The average person has to have special permission to make money online?

4. The average person will never know the real secrets to profiting online.

a. WRONG

b. WRONG

c. WRONG

d. DEAD WRONG!

REVELATIONS [Internet Informant Spills the Beans]

1. Your current experience, education, training, passions and hobby may be all that you need.

2. The learning curve is steep by well defined by systems, automation and processes established that govern your success as an online entrepreneur.

3. The Internet business opportunity is FREE to anyone and everyone to capitalize on immediately…if not sooner…Lol.

4. Before the crucial information is hidden, the average person has the greatest opportunity EVER today to build, start, run and profit from their own business online. There is not time better than NOW! There are more tools and training available today than EVER!

What They Don’t Want You to Know

The secret is that…well…

- The Possibility is FREE!

- The information is FREE!

- The opportunity is FREE!

The government doesn’t want you to know this because if too many people actually take advantage of this opportunity then too many people might gain the profits and power and then they are no longer the powerful force that keeps people in line, poor and under control.

The truth is…there cannot be too many rich people!

BUT – I’ll explain how you can get your hands on the most valuable information, which the Government has systematically denied, that you have ever held in your hands that will thwart the nay-sayers and expose your power to be in control of your destiny.

THE INFORMATION I HAVE!

I. I’ll tell you how to get the underground system that made me a fortune.

II. I’ll show you the system that I used to generate huge amounts of profit from my efforts online.

III. I’ll expose my personal formula for online success.

IV. I’ll give you the blueprint that I developed to follow step by step.

V. I’ll let you in the mastermind that my community shares the tips and tricks for success.

You see…I’ll expose everything I know because I believe that this information will soon change and be hidden when too many people know what the real answers are.

You must know that there are no guarantees…NONE. You might get your hands on this and absolutely fail, lose money, be scared to show your face and lose it all. There is no magic button or instant riches. It takes study and work.

Every business requires two things: time and money. It is a given that you’ll need one or both in different amounts. Of course, if it’s your first online business it will take more time than money but still a serious consideration.

What no one knows is just how successful you can be.

But what we do know is… …you just might learn all that you want to about your independence and freedom possibilities to have your own online business.

Some of the world’s most successful online business people are just now learning what I know. They also know I am going to reveal it to everyone who wants it too. And…they’re scared. They are scared because you just might be as or more successful and kick them out of the limelight.

WHAT I DISCOVERED

I discovered a simple process that I put into plan and effect automated systems that give me the profit I want each and every month. It is really simple and concise and effective and profitable for me.

I want to share it with you too.

You see…I discovered the TRUE MODEL for online business success.

This is REVOLUTIONARY!

The Passive Income Concept Dialog I am a 63-year old life-long entrepreneur. My business is generating passive income from online memberships. After losing over $3Million dollars in 2007, my life changed when I started a new venture to recapture my income and help other MaturePreneurs with a focus on helping others to earn passive income. This is a great concept that I want you to understand so that they will not lose a fortune like I did. Purely and simply, when I tell you that if you're working for the “man”, whether you're trading dollars for hours, then what you need to do is trade expertise and experience for payment. There's quite a bit of a difference between the two, respectfully. The number of people that you can touch in a day is exponentially related to the amount of money that you can make in the same day and how much work is involved in that is what determines how you'll make it. As an example, if you talk with 25 people in a day and it's taken you eight hours to euphemistically touch 25 people in a day, then you've wasted eight hours a day talking to someone who none of them have handed you a check or given you money. When I engage with 25 people a day, every single one of them sends me money. It's automatic. It comes from their credit card. It's once a month, every month. It repeats. It's recurring. It's passive. And I only have to work one time in order to give them some content that they pay for every month. Respectively, you talk to 25 people every day, five days a week and it takes you eight hours a day to do that and you've only made a weekly salary. I talk to 2,500 people a day, all of whom pay me automatically from their credit card, month after month. Some stay, most stay, and some go. And they're replaced just as quickly as they go. I'm not worried about losing that monthly income because it's always replaced one way or another once you've established your value with those customers.

1St - AMAZED

I am inviting you to join my private coaching opportunity so that you have a chance to learn the processes, models and systems before they are gone.

You see, the last thing that I want is for you to miss out on this opportunity to get the knowledge you need to start, build and run your own personal online business. It is truly your turn.

When you accept my offer, you’ll get this incredibly unique bonus…the free autographed copy of my most valuable book ever, THE MATH OF SUCCESS delivered direct to your door. You’ll be amazed at the insights revealed in this book and be able to put the systems into place almost immediately.

2nd – REVEALED

THE MATH of SUCCESS contains one of the greatest secrets in Internet marketing today. The magic of “100” revealed inside. An absolute “must have” in your tools for profit success.

3rd – UNCENSORED

You get every one of our uncensored scripts of powerful sales letter techniques that I use every day to generate huge list building followers to my products and services. I’ve spent thousands protecting this information from would-be hackers and now it’s available to you and you only.

4th – DYNAMIC

The most dynamic of the information is the step-by-step system that I used to build a “million-dollar” business in my niche and become one of the world’s most sought-after coaches.

5th - FINITE

This offer is finite, meaning that you need to get started today before I take it down. It won’t last long because you and I both know that the powers that be will find out and force me to close it. When they learn that I am giving away my most valuable resources for anyone to profit from then it’s all over. That’s the meaning of “finite.”

So, are you ready to get started?

Are you ready to get my exclusive and most valuable coaching program to help you start, build and run a profitable online business today? Ready for exclusive access and so much more?

It’s time. Do it now. Enter your best email address and your name.

I’ll be in touch ASAP and get you started.

Your complete satisfaction is always my most vital concern. Drop your fear and make it happen.

Fill in the information and become one of the few privileged people to have access to this training and information now.

Go over to

multiplestreamsmastery

. What is it costing you to NOT to have this training? What's it costing you to not do it? Imagine if you had gotten this a year ago. Imagine if you had gotten this a year ago and you were selling Multiple Streams Mastery coaching program right now. How would your life be different right now? The truth of the matter is whatever you've been and whatever you've been doing is not working for you, is it? How do I know that you feel stifled and frustrated? Because I was there too and you wouldn’t have spent this amount of time to listen to me if you didn’t think that I had something to offer you in the way of an escape from the 9-5 or whatever stupid hours you trade for money.

1. The truth is that if you don’t start right NOW you will be just where you are for the next year, two years, and three years and so on. Won’t you? The pain is that you know I am right. Look, this isn’t a hard sell. You know what you need to do and when you need to do it. You need to start right now! When you do you will be light-years ahead of your goals and closer to reaching your dreams of independence and freedom.

2. My ability to deliver the “goods” is dynamic and ever-changing with the times and current conditions. The enlightenment for me was when I became able to share my fortune with other people who are starving for attention, coaching, guidance, and direction. That’s why it is important for me to share this with you. I need to build a legacy for my kids and share this opportunity with you to do the same.

3. I believe in you as long as you believe in you unconditionally too. You have the power and the energy and the enthusiasm and the motivation. So let’s take action together and get started now. I’ll give you the steps, the system, and the processes. All I need from you is the commitment. You can get it at

multiplestreamsmastery.com/startnow.

Again, that's

multiplestreamsmastery.com/startnow.

You'll get step-by-step exactly what to do and how to do it so that you can create and sell your own Multiple Streams Mastery coaching programs. Folks with that, I want to go ahead and wrap things up. I want to thank all of you for being here. Obviously, you've learned a lot. Hopefully, you've taken a few pages of notes. For everybody that's just joined, congratulations and for everybody that's just waiting for me to quit talking so that you can go over and get it. I'm excited for you when you join in the next few minutes. Again, I'll give you that link one more time and then, I will say goodbye.

CLICK HERE.

Dr. Mark Zupo

Former Spy

“Now Turned Internet Informant”

#money #make money online #earn money #income #multiple streams of income #passive income #love #passion #creating passive #online business #start an online business #online success

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your-dietician · 3 years

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Women Say There Are Too Many Barriers To Accessing Postpartum Depression Drug : Shots

New Post has been published on https://depression-md.com/women-say-there-are-too-many-barriers-to-accessing-postpartum-depression-drug-shots/

Women Say There Are Too Many Barriers To Accessing Postpartum Depression Drug : Shots

Miriam McDonald developed postpartum depression after giving birth to her third son, Nicholas. She says she felt sad, disconnected, and indifferent.

Keith McDonald

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Keith McDonald

Miriam McDonald developed postpartum depression after giving birth to her third son, Nicholas. She says she felt sad, disconnected, and indifferent.

Keith McDonald

When Miriam McDonald decided she wanted to have another baby at age 44, her doctor told her she had a better chance of winning the lottery. So when she got pregnant right away, she and her husband were thrilled. But within three days of giving birth to their son, in September 2019, everything turned.

“I was thinking, ‘Oh my God, what did I do?’ I just brought this baby into this world and I can barely take care of myself right now,” she says. “I feel exhausted. I haven’t slept in three days. I haven’t really eaten in three days.”

As the weeks went by, her depression got worse. She felt sad, but also indifferent. She didn’t want to hold her baby, she didn’t want to change him. She says she felt no connection with him at all.

This confused her – she never felt anything like this after her first two kids – and she worried her mood might hurt her son. Untreated postpartum depression can affect babies’ cognitive and social development. For the mother, it can be life or death. Suicide accounts for 20% of maternal deaths.

“Every day, I was crying. Every day, I felt like I just wanted to die. Every day, I thought about ending my life,” says McDonald, who lives in Vacaville, Calif. and works as an IT professional at the University of California, Davis.

She went to Kaiser Permanente, her healthcare provider, for help. She says doctors there put her on a merry-go-round of medication trial and error. The first drug her doctor prescribed made her anxious. Upping the dose of a second drug gave her horrific nightmares. A third drug gave her auditory and visual hallucinations that took seven weeks to go away after she stopped taking it.

Then, her psychiatrist retired. And when McDonald complained to her new psychiatrist that she was still depressed, four months after giving birth, the physician suggested more medications.

“I was desperate,” McDonald said. “I was like, ‘I’m trying to help myself, but things are just getting worse.’ So what am I left with?”

She started doing her own research and learned about a new treatment, called brexanolone. It’s the first and only drug approved by the FDA specifically to treat postpartum depression, which affects 1 out of 8 new mothers in the U.S. Instead of targeting the serotonin system in the brain, like many antidepressants, brexanolone replenishes a hormone metabolite that gets depleted after childbirth — allopregnanolone. Some doctors call allopregnanolone, which is produced by progesterone, “nature’s Valium” because it helps regulate neurotransmitters that affect mood. After giving birth, natural levels of estrogen, progesterone and allopregnanolone all plummet rapidly, making some women vulnerable to postpartum depression. Brexanolone is a synthetic version of allopregnanolone, delivered through an IV infusion over the course of 60 hours. It costs $34,000.

In clinical trials, 75% of women who got brexanolone started to feel better immediately after the 3-day treatment. Half the women went into remission. In the placebo group, 56% of women responded and a quarter went into remission. In practice, doctors are seeing the effectiveness of the drug in the field that mirror the results of the trials.

“People walk out of the hospital, wanting to be with their child, wanting to return home,” said Dr. Riah Patterson, who has been treating women with brexanolone at the University of North Carolina at Chapel Hill since it became available in the summer of 2019. “There is a hopefulness, a brightness. You can really see that transformation in the hospital room over those 60 hours. It’s pretty miraculous.”

For the first year of her son’s life, Miriam McDonald says all her smiles were fake or strained. She struggled to find effective treatment for severe postpartum depression.

Keith McDonald

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Keith McDonald

McDonald wanted to try it.

But when she asked her doctor for brexanolone, she was told no. In an email, the doctor wrote that the existing studies were “not very impressive.” She added that McDonald did not meet Kaiser Permanente’s criteria for the drug: she would first have to try — and fail to improve with — four medications and electroconvulsive therapy (ECT) before she could try brexanolone. And she had to be six months or less postpartum to try it at all. For Miriam, the clock had run out. She wondered, How could anyone qualify?

“This is crazy. By the time you even try one drug, that’s like four weeks out,” she says. “Another drug is four weeks out, another drug is four weeks out. There’s just no way.”

Kaiser Permanente’s guidance is an outlier. An analysis of guidelines from a dozen health plans revealed that three of them require women to fail treatment with at least one other medication before trying brexanolone. One plan, California’s Medicaid program for low-income women, requires two fails. But Kaiser is the only system NPR found that recommends women first fail four drugs, as well as ECT.

“That’s absurd. So I’m assuming no woman will ever have the opportunity to try brexanolone?” says UNC’s Patterson, one of several experts in postpartum depression who questioned Kaiser’s guidance.

“That is abusive,” says Bethany Sasaki, who runs the Midtown Birth Center in Sacramento and is licensed to administer brexanolone. “Asking someone to fail four oral antidepressants is an unacceptable burden that will undoubtedly create more harm than good.“

Psychiatrist Shannon Clark, who’s been administering brexanolone at UC Davis Medical Center for the last two years, seeing positive results, says there are a lot of reasons new moms may not be candidates for one medication, let alone four: taking pills while breastfeeding could be too anxiety-provoking; some women may not be able to adhere to a daily pill regimen; or they may have a liver condition that contraindicates those medications. Clark called Kaiser’s guidance “terrible” and “insane.”

It could also be illegal, according to some California lawmakers and mental health advocates. Under a California state law that took effect this January, health plans must conform to generally accepted standards of care, including scientific literature and expert consensus, when making decisions about mental health treatment.

“If Kaiser is making it effectively impossible to get a particular, important mental health treatment, that could definitely be a violation of our parity law,” says State Senator Scott Wiener, the bill’s author.

Kaiser officials responded by saying they always follow the law. They also say its integrated structure — as both the health insurer and the health provider — makes it different from traditional insurers. At Kaiser, a patient’s doctor determines whether a medication is appropriate, not the health plan, and the criteria doctors use are recommendations, not requirements or pre-requisites that patients need to “exhaust,” says Dr. Maria Koshy, Kaiser’s chair of psychiatry for Northern California.

“At the end of the day, this is an individual clinical decision by both the provider – the physician – and the patient,” she says.

But inside Kaiser, the workplace culture is such that doctors are expected to follow these recommendations, according to former Kaiser clinicians who spoke on background — as well as legislative experts familiar with Kaiser’s model. They say that when Kaiser doctors deviate from the recommendations, they can get questioned or even face consequences.

“These physicians know that if they start routinely ignoring these bad recommendations, that that could have impacts on them professionally,” says Wiener, who has worked on several bills aimed at regulating Kaiser and other insurers in California. “Whether it’s couched as a recommendation or a requirement is almost irrelevant. It has the same effect.”

To McDonald, her physician seemed to follow the recommended criteria as if they were requirements when she declined to prescribe brexanolone. Another patient, Yesenia Munoz, got a similar response when she sought brexanolone treatment. Kaiser’s grievance department sent her a letter denying the request because she had not failed enough medications.

“When I talked to the caseworker at Kaiser that had denied the medication, he said that Zulresso was very expensive,” said Muñoz, referring to brexanolone’s brand name.

In addition to the $34,000 cost for brexanolone, the three-day hospital stay can tack on another $30,000, at least. Another complicating factor is the FDA requirement that health centers obtain a special certification to infuse brexanolone, because of the risks of excessive sedation or fainting from the drug. Kaiser Permanente doesn’t have the certifications yet to administer the treatment at its own hospitals, so it must pay outside hospitals to provide it for Kaiser patients. Kaiser officials say they have plans to eventually open three of their own certified centers in Northern California.

Muñoz, 35, was devastated by the denial. She was overwhelmed by postpartum depression and anxiety shortly after her daughter was born in August 2020. But none of the medications or therapies Kaiser offered her worked. Four months after giving birth, she still felt suicidal.

“I could get out the door sometimes and take the stroller and go walk, and my mind kept on saying, ‘If you just step in front of the car, it’s all going to go away,” she remembers.

After Yesenia Muñoz appealed to state regulators and received brexanolone, she says she felt calm and “happy enough to want to live.”

Rafael Munoz

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Rafael Munoz

After Yesenia Muñoz appealed to state regulators and received brexanolone, she says she felt calm and “happy enough to want to live.”

Rafael Munoz

Muñoz got help from family members and co-workers to appeal Kaiser’s decision to the state, and after reviewing her medical records, regulators ordered Kaiser to pay for the brexanolone treatment.

Muñoz received the treatment at UC Davis Medical Center, and she started feeling better within the first day.

“The nurse came in and she said something funny and I laughed,” Muñoz says. “It was the first time I had laughed in so long.”

She started looking through photos and videos of her daughter on her phone and she says it was like she was experiencing those moments for the first time. She started making plans for the future.

“It was like a switch flicked and it made me happy enough to want to live,” she says. “It saved my life.”

Sage Therapeutics, the makers of brexanolone, says Kaiser’s approach to the new drug reflects a “a lack of a sense of urgency for treating mental health.” Dr. Steve Kanes, Sage’s chief medical officer, says the company is working on making the treatment more accessible. Its biggest challenge has been getting enough health centers certified, across a wide enough geography, to reach women who need it. The company is studying a pill form of allopregnanolone that could eliminate the need for a hospital stay, but Kanes says that is still not close to being commercially available.

In 2008, Congress passed a landmark federal law aimed at correcting disparities between how insurers pay for mental health treatments compared to physical health. The Mental Health Parity and Addiction Equity Act was later reinforced by provisions in the Affordable Care Act in 2010. But insurers found loopholes, creating overly restrictive or self-serving criteria that made it easy to deny services for mental health care, and as a result, save money.

California’s new law, SB 855, aimed to tighten those loopholes, and has been hailed by advocates as a national model for mental health reform. It requires health plans to use clinically-based, expert-recognized criteria and guidelines in making medical decisions, with the goal of limiting arbitrary or cost-driven denials for treatments of mental health or substance use disorders.

Kaiser operates in 8 states and Washington, DC. In California, it is the largest insurer, holding a 40% share of the market, covering 9.2 million patients. Kaiser officials have questioned how the new state law applies to the Kaiser system, given its unique integrated structure as both health insurer and medical provider. For example, Dr. Maria Koshy, the Kaiser psychiatrist, told NPR that SB 855’s requirement to comply with generally accepted standards of care “does not apply” to its brexanolone recommendations because they were developed and are used by the doctors, not the health plan administrators. When NPR asked Kaiser to provide the brexanolone policy its health plan uses for grievances or appeals, it said it didn’t have one.

“We 100% intended this law to apply to the care people get at Kaiser,” says Julie Snyder, government affairs director at the Steinberg Institute, which co-sponsored the law. “There is no place where we say Kaiser is exempt” because of its integrated structure.

Doctors at Kaiser have historically been “gatekeepers” for services in the system, more so than doctors who work with traditional insurers, says Meiram Bendat, an attorney and licensed psychotherapist who also advised legislators as the law was being drafted. It doesn’t matter if practice recommendations for brexanolone were written by doctors or administrators, or whether the recommendations are mandatory or optional, Bendat says, they must be in compliance with the law.

“If it’s inconsistent with generally accepted standards of care, then it has no place in California,” he says.

Some of Kaiser’s recommended criteria for brexanolone are aligned with generally accepted standards of care; for example, reserving the drug for women who are six months or less postpartum, which was a criterion used in the clinical trials the FDA relied on when it approved the drug.

But the recommendation that patients first try four or five alternative depression treatments before considering brexanolone conflicts with the judgment of half a dozen women’s health experts interviewed for this story. They say there just isn’t enough time to do that in the postpartum period — and too much is at stake.

Not only are babies at risk of developmental and emotional problems if their mother is depressed, husbands and partners are also at higher risk for depression and anxiety. And because new moms are learning to breastfeed, and figuring out what’s part of the new normal and what’s not, it can take months just to realize there’s a problem, explains UNC’s Dr. Riah Patterson.

“It takes so long for this illness to come to recognition and for someone to actually get into an appointment and actually be seen by a provider,” she says.

Dr. Riah Patterson, a specialist in perinatal psychiatry, discusses patients and treatment plans with her trainee, a 3rd year psychiatry resident at the Center for Women’s Mood Disorders at UNC-Chapel Hill.

Madison Piotrowski/UNC Health

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Madison Piotrowski/UNC Health

Indeed, the FDA fast tracked the approval of brexanolone in part because of how well and how quickly it worked, allowing women to feel better and get back to their families in three days.

“It’s new, it’s promising,” says Kaiser’s Dr. Koshy, but adds that “it’s not a benign medication.” Six women in the clinical trials felt faint or fainted, which is why the FDA requires women to be continuously monitored in certified health centers when getting the medication.

Also, the safety and efficacy data is limited, Koshy says. The clinical trials only compared brexanolone to placebo, not to alternative treatments. So while the data show brexanolone works better than nothing, there’s no data on whether it works better than drugs like Zoloft, or better than electroconvulsive therapy.

Women who received the placebo in the trials also showed improvement in depressive symptoms — which is common in studies of depression treatments — but more women who received brexanolone showed improvement, and their improvement was more substantial and lasted longer, especially if their depression was more severe before treatment. Women with moderate depression who received the placebo did just as well, 30 days after treatment, as those who received brexanolone, which could be because they felt better on their own, or because other antidepressants they were allowed to take during the trial finally kicked in.

Koshy says Kaiser is always reviewing practice recommendations as new evidence becomes available, but also acknowledged that Kaiser’s recommendations for brexanolone have not been updated since they were first developed two years ago, in July 2019.

Two weeks after this story first aired in Northern California, Koshy informed NPR that Kaiser Permanente is now reviewing the recommendations. She also added that Kaiser had recently communicated with its physicians that the recommendation to try four medications and ECT before considering brexanolone actually applied to a woman’s entire lifetime, not just treatments attempted in the postpartum period. Kaiser confirmed that it did not write this into the recommendations themselves, and declined to offer details about how this information was shared with physicians.

It is unclear what role California’s Department of Managed Health Care, the state agency that regulates Kaiser, might play in resolving issues of access to the infusion. In a statement, department officials said they will review any criteria or guidelines the Kaiser health plan uses for brexanolone, but the department does not have jurisdiction over physician decisions.

The department also monitors patient complaints when new medications or treatments begin to be used, in order to identify problems with access to care. So far, the Department has received two complaints about brexanolone – both were filed by Kaiser patients.

One was Yesenia Munoz. The other was Miriam McDonald.

Before going to the state, McDonald called Kaiser’s grievance department to complain about her treatment and the denial of brexanolone. Kaiser responded by sending the cops to her house for a welfare check.

The officers were calm and nice, McDonald said, but when she closed the door, she cried her eyes out.

“It just brought me to a whole new low,” she said. “Why didn’t my doctor call me and talk to me first? I mean, this is how you treat postpartum mental health? How dare you.”

Kaiser told NPR it cannot comment on any individual cases because of privacy laws, but that generally, “We feel deep compassion for any patient experiencing the difficult and serious effects of postpartum depression, and our goal is always to support every patient’s safe return to a healthy mental state.”

McDonald then appealed Kaiser’s denial of brexanolone to state regulators, but by that time, she was past the six-month postpartum cutoff.

She never got brexanolone.

Still, she continued to fight for relief and eventually got Kaiser to cover a different treatment for severe depression, transcranial magnetic stimulation, which uses an electromagnetic coil to stimulate nerve cells in the brain that control mood. That typically costs about $300 per session, and McDonald went in for the treatment five days a week, for three months. Now she is finally feeling like herself again.

After her efforts to get brexanolone failed, Miriam McDonald received transcranial magnetic stimulation at Kaiser Permanente to treat her postpartum depression. She says her mood started to really improve when her son was about 18 months old.

Miriam McDonald

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Miriam McDonald

“I can remember I woke up one day and I was excited. I had actual joy,” she says. “I got up and I walked into his room and I was like, ‘Hey, Nico! Hi! Hey, baby!’ And he jumped up from his crib and giggled and put his arms out. And I just swooped him up in my arms and cried. Because I was like, ‘I am so proud to be your mom.'”

Now when her son smiles at her, she genuinely smiles back. But it took more than 18 months to get here. She can’t help but grieve all the smiles she didn’t return in that time, and how she felt like she was barely present at crucial times, like when her son took his first steps.

“I felt like I’ve been robbed of all those moments,” she says, “of those little milestones, that I’m never going to get back.”

This story comes from NPR’s health reporting partnership with KQED and Kaiser Health News (KHN).

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drferox · 7 years

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20 Questions with Dr Ferox #8

My gosh, there’s just so much stuff you vetlings want to know, isn’t there? Well, knowledge is good, so here we go with yet another info dump as I try to answer a big slew of your questions in one hit.

Anonymous said: I sometimes get your patreon emails or an update on your blog while I'm studying/struggling in the wee-hours of the morning (vetmed). I'm in WA, so where-ever you are it's also late/early. What are you doing up in the witching hours?

First of all, I am an AdultTM and as such I am permitted to set by own Bed Time. There are many reasons why you might receive notifications from me so ‘early’.

I have a blog post on queue every morning between 5am and 6am my time (so probably 3am and 4am your time). It goes up automatically, so I can see initial responses before I go to work.

I think Patreon sends its emails at the same time each day, regardless of when I post. I certainly don’t type there early in the morning.

Sometimes I’m on nightshift and can get kinda bored at 3am sometimes.

Sometimes I just can’t sleep, especially with the changing day/night cycles.

Most of the blog runs on queue, honestly. At least three posts a day do.

@banesidhe said: Just happened to discover your blog. Thank you so much for posting like you do (even the snark. I'm a 911 dispatcher, I appreciate the snark ;) ), and sharing your experiences. No vet question, but if you could only ever re/read five books for the rest of your life, which five titles would make your cut?

Ah, I have found many similar people to myself among emergency personnel. There’s a particular combination of gallows humor and wishing people would get to the point that unites us.

For fiction books:

Feral, Kerry Greenwood

The Shepherd’s Crown, Terry Pratchett

Monstrous Regiment, Terry Pratchett

Watership Down, Richard Adam

Good Omens, Terry Pratchett & Neil Gaiman

Hmm, bit of a trend there.

But the work books I couldn’t live without are:

Plumb’s Veterinary Drug Handbook

The 5 minute veterinary consult, Dog and Cat Edition

Ettinger’s Textbook of Internal Medicine, Expert Consult

BSAVA Rabbit Medicine & Surgery Handbook

Small Animal Surgery, Fossum.

Anonymous asked: what was the most exotic/rare patient youve ever had?

This fat meerkat.

Anonymous said: My dog is a shelter dog and we suspect she was abused before we got her (afraid of E V E R Y T H I N G) and weve been slowly working on getting her to at least ignore people we walk past or that enter the house and thats been making progress. But she hates the vet. Hates it. Gets in my lap and refuses to leave. New dogs people and smells. So her normal vet takes the approach of having one of us hold/console her while they do all the poking and listening and whatnot and muzzling her if they need to and just getting it done as quickly as possible. But this last time she saw a new vet and this vet took the approach of hand-feeding her almost an entire bag of treats and called it "stress-eating" and tbh you should have seen the look on my dogs face. She was so weirded out. Shes highly food motivated so it was like heaven to her but she was simultaneously very suspicious. Her face was like"i love this but idk if i trust it" it was great.Have a greatday!

If you an reinforce the behaviour by arranging frequent, short visits to the vet clinic where nothing happens but lots of treats, she may start to associate the vet clinic with positive things (food) ad no scary things. This might make the rest ofher life easier.

Anonymous said: I own fancy rats and just want to put out there to people, that while they are THE MOST amazing tiny friends, in my experience most vets are completely lost when it comes to their care & several I've seen refused to even touch my exceptionally friendly females. They often get respiratory infections requiring antibiotics. One of my friend's females passed away bc nobody would perform a simple surgery on her. So please be cautious when buying them.

I would like to suggest that any surgery on a rat is likely to be not simple, because they do have particular anesthetic requirements that can make their recovery difficult. Also that a lot of traditional rat medicine hinges on using post mortem examination as a diagnostic tool, which is not useful at all with pet rats.

In dog and cat medicine most of our equipment and even medications are not suitable for rats, or very difficult to adapt. We simply have fewer options, and generally less experience with these species Most vets I know will attempt to treat them, but with a great big disclaimer saying I don’t do this often, and a quick question as to whether you’d prefer to go to a nearby clinic that does see rats more often.

Anonymous said: Hello, I recently took in 3 abandoned kittens and they're covered in fleas. They appear to be 6 weeks old and can't use meds or wash for them. I clean them with vinegar and dish soap and I was wondering if you knew of any other ways to help them since they hate getting wet. I also use a comb but they dislike that as well.

You can use capstar on kittens from 4 weeks of age, and Revolution from 6, probably earlier. Talk to your vet.

Anonymous asked: Strange question but do you know if that rage syndrome thing can happen in cats also? I know a cat who does that and also acts strangely in general at the same time?

It is not documented in cats, however Feline Hyperesthesia Syndrome may present in a similar way.

Anonymous said: Hey doc! I plan on getting my cat fixed soon and I'm worried about how it'll affect her. She's really skittish and prefers to stay in one room, could getting her fixed make it worse?? I guess like what are the possible behavioral effects is what I'm askin? For the qt: ive been here a while i just dont like or reblog stuff but i came for the vet knowledge and stayed for it too, especially the mythical creatures and dog breed info

She is probably not going to have any long term personality changes from being desexed, though might be out of sorts for a few days after the anaesthetic. If anything they tend to be less stressed because they’re not attracting Toms.

Another Anonymous said: My kitten was neutered yesterday and he's doing great, healing well, playing nonstop, remarkably agile despite the e-collar (navigating small spaces, jumping to high places), eating & drinking well. The vet didn't give us any aftercare instructions but I googled it -- and wish I'd done so before the surgery because I could've prepared better. A lot of it seemed obvious in hindsight but nothing I'd have thought of on my own. Do you have a flier or anything for your patients' humans?

We send our patients home with aftercare instructions. We have a default one that we print for routine surgery like desexing, and a customized one for non-routine procedures.

We also read it out to our clients when they pick up their pet, and point out that all these instructions are written down, because it’s easy to forget details when you’re worried.

Anonymous asked: I have a question! I saw your desexing cats post and thought I might send it to you. I neutered my male cat but he still sprays and tries to roam the neighborhood. I try to keep him inside best I can. Is there a reason this happens?

It may be stress, but you should consult your vet to rule out any underlying urinary tract issue before assuming so. Your vet should be able to discus the various stress reducing techniques, changes and treatments that are available.

Anonymous asked: Whenever my roommate wakes up before me, she makes bacon for breakfast while the coffee is brewing. If she hasn't slept well, her coherence is sometimes a bit... lacking. If our cat happens to demand food, about half the time she ends up giving him a slice of bacon instead of cat food. We only recently figured out that she's been doing this. He's not getting fat, and gets actual cat food later, so is this OK, or do we need to try to figure out how to keep this from happening?

While bacon is certainly digestible, it is not a balanced diet. It would be ideal if you could minimize his bacon habit.

@nowgovanish said: Hello! I have a question about my 13 and 4 year old cats. They seem to have some pretty bad skin reactions to certain foods, and I've tried a lot of different food brands that my vet reccommended. The one that seems to work best is a grain free/ non chicken variant, but I see that you aren't a huge fan of grain free. Is there anything I should change or try sticking with what works?

I have said many times before that if it’s working, keep feeding it.

Novel protein diets, and ideally single proteins source diets, are more use for allergies than just going ‘grain free’.

‘Grain Free’ labelling on food particularly vexes me because it’s not regulated. You can find ‘grain free’ food that really mean ‘corn free’ and either use grain byproducts or straight up use rice. Last time I checked, rice was a grain.

It’s like ‘Hollistic’ - it means nothing on a pet food label. Neither does ‘Organic’, pet food companies do not have to use all organic products in pet food to label the food as organic. These are marketing ploys like ‘all natural’ which are targeting your emotions and don’t mean anything when it comes to the food.

If you’ve come across a novel protein diet, or a minimum ingredient diet, that is beneficial for your cats then stick with it. But recognise what’s marketing and what’s useful.

Anonymous said: I love my dog but he is a complete and total moron. He has strangled himself so often that his bark is now raspy. He even found a way to do it with a harness! We've resorted to jogging when walking him to try and keep up but is there some way to make it better? We've tried letting him learn on his own, pausing when he pulls, and getting a longer leash. If he was much smarter I'd accuse him of being into asphyxiation.

I would suggest that you potentially need to figure out what motivates your dog most. Consider using positive reinforcement to encourage him to heel on the lead, instead of wandering and pulling.

You might also want to consider something like a halti collar, which pulls the dog’s nose downwards to their chest when they pull, instead of something that goes around the neck.

Anonymous: Would you consider it a good generalization that dogs more closely resembling/related to wolves (like huskies) have less health problems? I am aware that no dogs are completely lacking in health problems. Tax: came for good hard factual analysis.

No. And here’s the thing- all modern dog breeds are equally distant from their wolf-like ancestor, unless they have been recently mixed with wolves again.

Their health problems are different to those dogs with more extreme anatomy, but dogs that look like wolves are not inherently healthier.

@justslowdown said: a book i have discusses the man who created the GSD breed (aka isolated traits from a diverse population) pairing dogs with their daughters, granddaughters, great-granddaughters and onwards til more than 1/2 of the pups had to be culled. due you think this could be partially responsible for the health issues remaining more than a century later? "Very drastic inbreeding was espoused during the formation of the breed [...] to quickly form specific type" - The German Shepherd Dog by Ernest H Hart

Certainly.

This is called line breeding, where the offspring of a ‘perfect’ individual are repeatedly bred back to the same individual generation upon generation to try to recreate it. All you really do is lose genetic diversity very quickly and allow recessive deleterious genes to proliferate in the population.

This is why just about everywhere else that’s not the purebred pet world, this is considered a bad thing to do.

@eyestumblin said: Do you think horses would look significantly different if their wonky anatomy were more logical?

They would no longer be a horse.

@cirque-du-spoon said: I saw you mention sheep on the horse thread and I spent a fair bit of time on a sheep farm in Wales. The head shepherd once told me "sheep are born, they spend the rest of their life trying to die". Then he opened his landrover door, and the passenger footwell was maybe 6 lambs snuggled up to one of his old motherly collies.

The common phrase down here was “The aim in life of a Merino ewe is to die and take fifty of her friends with her.” It’s not really much of an exaggeration.

Anonymous said: I'm intrigued to hear the faults of sheep, lay it on me!

Oh I will. It’s on my list for a big write up.

@queenalia said: Hi! I love the post about why horses make no sense, and I was wondering if you would do a similar one for sheep (one of the most suicidal animals on earth in my opinion)?

It will definitely be done sometime in the next few weeks. As you understand, it’s not quick answer.

@vulturegeorge said: Hey Dr.F, after reeding your "horses-are-spindily-legged-disasters" post and your comment about how sheep are worse, I was wondering if you wished to elaborate? I am currently working on a heard of 50 random sheep my uni bought with a ton of lung issues ... so it'd be super interesting to me. Question tax: came for the Lucifer story, stayed for all of your amazing advice & opinions. I hope you are finding balance between vetting and living. cheers!

I promise I will elaborate. I can’t leave a cliff hanger like that and not explain... eventually.

#veterinarian #blog housekeeping #20 questions #vetblr

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unproduciblesmackdown · 7 years

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ih4x67ge-blog · 5 years

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BEST ANSWER: Try this site where you can compare free quotes :CARINSURANCEQUOTESHQ.XYZ

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hi i am a much will this affect i was 18yr old sister and I are the repairs for him, I will be $3000 Or do you have We were involved in much of each do Im going to be I want some libility car insurance cost per up and up, and a pool monthly in cc.. may i know same features,machines) And how or a waste of drive the car. Is how much is car options because i simply and we live together. you could, in your rate like compared to So I d just like I know that isn t study ? and if recently terminated from BOA or speeding tickets and it and how they female. I am getting puttin on the road events at several different now we want to bought a brand new -Someone with Type I a reasonable price - it compulsory to have moving to La and insurance when I m only term or pay as I think I can .

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lovenerdywinnerbouquetfan-blog · 6 years

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Am I paying too much for auto insurance?

"Am I paying too much for auto insurance?

I'm a 21 year old female and and I'm on my mom's insurance plan. I drive a 2002 pontiac grand prix and I pay $200 a month for full coverage with allstate. I don't have the greatest driving record by far. I've only been driving for 5 years and I've had 2 speeding tickets, 2 at fault accidents, and 1 non at fault accident. My last accident was in 2009. Unfortunately, I was driving through virginia and got a ticket yesterday. I'm just wondering if that price sounds right for my insurance. Is there a company that offers lower priced plans? Is there anything I can do to lower it?

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