Warning: This post will include pictures of human remains and descriptions of medical conditions. If these are offensive or disturbing to you, turn back now.
Also, spoilers for Phantom of the Opera musical and novel. But if you haven’t seen the musical by now … dude.
In every class wherein I have an excuse to do so I try to show pictures of advanced treponemal disease because a.) it is amazing and b.) there is no better way to convince young people to wrap it up when boning. Also, I really like grossing out eighteen-year-olds. They think they’re so cool. But anyways I only deal with these things in dry bone and theory so I don’t typically work with people who are both alive and have these diseases. And for that reason despite having an unhealthy and kind of unfathomable love for Phantom of the Opera, I didn’t until recently make the connection that Erik almost definitely has syphilis.
We’re going to do this right so first I want to lay out his symptoms and do some differential diagnosis.
Erik is past his prime and there’s a bit of what I think is retconning in the later version of the musical, but we don’t know really if his deformation is congenital, developmental, or acquired. But we do know he’s an older murderous gentleman. In all of his descriptions his face is messed up. In the novel he’s described as having a death’s head for a face and in the musical as well as the first movie he is missing his nose. He seems to be reasonably athletic and dexterous and he doesn’t seem to have any cognitive issues, but he is absolutely off his rocker bonkers town (medical term, that), and in the musical he implies that he’s impotent. Well, what he says is “this fate which condemns me to wallow in blood has also denied me the joys of the flesh.” So I assume either he’s impotent or his pee-pee is all tore up. (Also a medical term.)
So we’re working with sexual disfunction, neurological disturbances, facial lesions, and rhinomaxillary destruction. Depending on the make-up we the lesions may be asymmetrical and he may also have hair-loss, but I’m mostly going to chalk that up to the makeup done in the musical. Joseph Bucket sings a line about him having no nose and yet the Phantom in the musical always has a nose meaning that we are going to have to deal with a few inconsistencies here.
In the musical during the masquerade just after Erik jumps in and is like, “haha! you party without me? No! I Edgar Allen Poe this sh**!” Raoul and Madame Giry — who is basically the stand in for “the Persian,” in the musical — have this whole conversation about how Erik was part of a “freak show,” that visited Paris, but he’s also a genius architect who was murdering people for some Sultan’s amusement because remember this is all based on a novel — and I use that term loosely — written in 1909 when people were even more openly racist and anti-disability than they are today.
And there’s also a line in the musical:
“This face which earned a mother’s fear an loathing,”
which implies that Erik’s deformity is actually congenital or appeared initially when he was an infant or a small child. But again, Erik is somewhat of an unreliable narrator. By this point in the musical he doesn’t have a super high body count but he does have a body count and in the book he kills multiple members of the opera staff, tortures and kills at least one person we don’t even meet, and murders Raoul’s elder brother. And he plans to blow up the opera house. What I’m saying is you can’t necessarily trust that he’s not trying to manipulate you.
So, okay, differential diagnosis. Well, I’m heavily leaning towards either acquired or congenital syphilis, but we could also be looking at Hansen’s disease, Paget’s disease, a really nasty form of osteomyelitis, Proteus syndrome, or simply plagiocephaly gone a bit wrong.
So I’ll hit this all backwards and/or out of order because … I mean … we’re talking about a fictional character’s diagnosis so what does anything mean anyway?
Plagiocephaly is a pretty catch-all term referring to cranial asymmetry and deformation in neonates and infants which if left untreated may be associated with neurological developmental delays. Osteologically speaking, it’s usually associated with premature fusion of cranial sutures which, as you can probably imagine would cause issues as the individual grows. I have actually seen an adult skeleton with pretty clear plagiocephaly where the cranial sutures on one side were entirely obliterated causing his cranial-facial complex to be … well, weird looking. I cannot imagine he was a handsome fellow in life.
So, this does match with Erik’s claims that his mother rejected him, his perceived ugliness, and possibly his emotional disturbances, but it doesn’t really explain his lesions, sexual dysfunction, or the descriptions of his rhinomaxillary destruction.
Next up is Hansen’s disease. This is more commonly known as leprosy. Now, Leprosy does, at its final stages, cause rhinomaxillary destruction, and even relatively early on it causes visible sores which can appear on the face. It can also cause selective hair loss, and as it causes nerve damage sufferers often do not notice when they’ve been injured. This could explain Erik’s line about being deprived of “the joys of the flesh.” Hansen’s disease would well explain his lack of a nose and his visible lesions, and it could explain his hair loss and sexual dysfunction, but there’s a huge glaring problem here if it were Hansen’s disease.
Erik plays the organ. And he composes regularly. He’s also quite strong. Hansen’s disease, usually before rhinomaxillary destruction occurs, causes loss of sensation to the extremities, muscle weakness, loss of vision, and can result in reabsorption of the phalanges of the hands and feet. So if Erik had such advanced leprosy that his nose was affected it is unlikely that he would be able to walk around without some sort of aid and he almost certainly would not be able to play an instrument or compose.
(I also briefly considered Tuberculosis because he’d be more likely to contract TB than Hansen’s disease and in some rare cases it does cause bone deformities and abscesses. But, it typically appears in the vertebrae or long bones as opposed to the skull and it is usually accompanied by fatigue, fever, weight loss, and forms of paralysis.)
Okay so … onto Proteus syndrome. Y’all probably know this one. It’s what the “Elephant Man,” had. This one has basically the same issues as plagiocephaly. Proteus syndrome does appear in an individual’s first months or years of life so that does square up with Erik’s claims that his condition is congenital, and it does cause asymmetric bone growth and can cause some neurological issues in some cases. But the problem here is it doesn’t involve skin lesions and it usually effects the entire skeleton. So literarily speaking it is interesting for Erik to have Proteus syndrome and see him have a really malevolent response to society’s reaction to him whereas with “the Elephant Man,” both in real life and in the various fictions surrounding him it was more of an indictment of society, but the syndrome just doesn’t fit Erik’s full battery of symptoms unless we allow for a comorbidity.
On to osteomyelitis. To be entirely honest, I just threw this in because osteomyelitis grosses me out and I kind of love it. Basically, if you have osteomyelitis, things have gone VERY wrong. I’m not saying its you’re fault, because it isn’t, but oh my god, do not get this. It’s exactly what it sounds like: an infection of the bone. You can get this via sepsis or an injury to the bone itself. And yeah, it can kill you. (You can also get inflammation or infection of the periosteum and honestly like, if you get a choice, maybe don’t do that, but it’s not as bad as osteomyelitis.)
Anyways, besides the gross-out factor, my logic in including this is osteomyelitis does cause deformations to the bone and can result in open lesions on the skin. You can also get holes in the bones called cloaca where the puss has bust out. It’s truly amazing. So gross. Anyways, as you can imagine besides deformation and visible lesions it would also probably cause a fever and fatigue. And while it is possible for osteomyelitis to occur in the skull it is more commonly found in humans in the femur and tibia. Lastly, it is usually acute so besides the idea of Erik running around murdering people with a pretty awful case of fatigue, fever, and severe pain he would also have to have kept up this level of nasty infection for decades on end.
Chronic osteomyelitis is a thing but it doesn’t really fit well with his symptoms. He might have had carious lesion as a child that developed into osteomyelitis of either his mandible or maxillary and then, because it wasn’t treated became chronic, but if that were the case it is unlikely he would be able to sing without pain. So, this one’s actually a plausible explanation, but it’s pretty unlikely, would likely cause him to have a lot of fatigue and malaise most of the time and it doesn’t explain a lot of his other symptoms.
Now we come to Paget’s disease. This is another I’m largely just throwing in because this is how nerds have fun. Normally, and even as you age your bone repairs and restores itself interacting with your metabolism through a gradual process of osteoblastic and osteoclastic activity. If you have Paget’s this process becomes unbalanced and you may initially have some osteopenia or bone loss but most sufferers end up with abnormal amounts of bone growth. It can cause sort of dull aches and pains as well as deformities in the skull and long bones. There’s some association with genetics and possibly lack of vitamin D so particularly with Erik insisting on living in a subbasement of the opera house he would be particularly susceptible to any disease where vitamin D deficiency is part of the pathogenesis. Paget’s disease is relatively common, but doesn’t usually appear in people younger than 50. It is possible Erik is over 50 as he is an “older man” and he does seem to have a significant back story — supposedly he was in Persia for quite some time as an adult and he designed the Paris Opera House.
But Paget’s disease does not cause sexual dysfunction, neurological disturbances, or skin lesions so even if we ignore that the typical onset for it is well later than Erik reports the start of his own symptoms and possibly older than Erik actually is now, it’s probably not his diagnosis.
Now we get to discuss why I think Erik has some form of syphilis. There’s … basically three different types of syphilis you can get.
- Acquired Syphilis: this is sexually transmitted and better known among Europeans because Europe is a relatively cold climate where historically people went about with a lot of clothing and so the only time they were likely to transmit this disease is during sex as older adolescents or adults.
- Congenital Syphilis: This is exactly what it sounds like. If a mother has syphilis while she’s pregnant and doesn’t receive treatment the kid probably is going to have it as well. (The rate of transmission is somewhere between 60–80%.)
- Yaws: This type is more common in warmer wetter climates where people typically wear less clothing and does not require sexual contact to spread. Children often contract it from skin to skin contact and it can cause serious lesions and deformities. However, it can also create immunity for acquired syphilis.
In all three you get lesions. Congenital syphilis and yaws will present pretty frequently with lesions on the face, which honestly really sucks, but it happens for sufferers of acquired syphilis as well, just a lot later on. Congenital syphilis and yaws also include lesions on other parts of the body including the hands and feet. Notably though, Erik is always very well dressed and while we don’t know what he was wearing when he was in Persia, while in Paris he usually appears in white tie attire complete with gloves. He could have lesions that we simply never see.
But let’s go through these in a bit more detail and see which one fits Erik best. And yes, I do appreciate that I’m having this poor unloved man try on diseases like they’re tuxedos.
Let’s start with Yaws which is both the least awful and the least likely in my opinion for Erik. So, I kind of lied. Kind of. Yaws is syphilis … basically, but in much the same way that Hansen’s disease is tuberculosis. They’re caused by the same genus of bacterium and usually cancel each other out through immunity, but they’re not the same species. The reason so many indigenous people died specifically from syphilis at or around European contact was because Europeans simultaneously wiped them out through other means and imposed their dress on them which lowered the transmission of yaws in indigenous populations and made them more susceptible to acquired syphilis.
Y’all thought you were safe from a discussion of colonialism when you came to this article, didn’t you? Much like the Spanish Inquisition, you’re never safe from colonialism!!!
Erik is named Erik because Gaston Leroux thought that was sexy and exotic. Andrew Lloyd Webber was like, “hard disagree.” Except, he said it with a super posh accent. But yeah, that’s why Erik is never dead-named in the musical. But … Gaston Leroux apparently had a pretty huge hard-on for all things Norse because for a gothic romance/mystery set in Paris there are just so many Norwegians. Or Danes. or Swedes. Honestly not sure, he just has a thing for the Nordic. (Christine Daaé in the novel is Swedish.)
But I bring this up because if Erik and his mom were Nordic and either from Northern Europe or actually living there around his nascence, yaws is exceptionally unlikely. I mean, I dunno if you’ve been to the north of Europe, but it’s cold. You could go naked if you were really dedicated to nudity but that would be weird and I am somewhat doubtful that Treponema pertenue which causes yaws could survive in that environment long enough to be transmitted. If Erik and his mother were for whatever reason in a tropical area and he was running around naked he could have contracted it, but his story is written as if his world travels were largely his own deal after he parted ways with his mom.
Additionally, yaws usually clears up even without medication in about six months. It can leave pretty severe scars and it can be sort of chronic, but Erik would have to have a really bad chronic case to have lost his nose and have such bad scarring or open lesions that he felt a mask and spending his entire life as reverse Batman was appropriate. It explains the Schumacher movie Erik, but no other Eriks.
Also, while yaws can have some pretty serious complications they’re not really as common as for the other forms and don’t generally involve sexual dysfunction. So I don’t think Erik’s issue is yaws.
Sooooo …. next up …. is … acquired syphilis. And just, I mean, yaws is not pleasant, but acquired syphilis is an actual horror show. I go back and forth whether or not I think this is Erik’s problem. It could be and in fact just about everything except for that one line about his mom abandoning him and his need to cover up super young points to it being acquired, at least at first. There’s a few issues, and we’ll get to them.
Acquired syphilis is *ahem* acquired pretty much exclusively through sexual contact with an infected individual. So you have to do the nasty or have the nasty done unto you to get it. It is a sexually transmitted infection caused by Treponema pallidum. Now it’s pretty easily treated. If you test positive for treponemal bacteria you get a course of an antibiotic like penicillin, you complete it and you’re good to go. Maybe wrap things up for your next merry go-round.
(Little PSA: if your doctor prescribes you a course of medication complete the course as directed even if you, “feel better,” because otherwise you may have a few little buggers still running around in your system that survive and become resistant to medication. It’s bad for everyone because you have created something infectious that’s hard to kill and it’s bad for you because now you have an infection that may not be killable.)
But, penicillin wasn’t really a thing until 1929, and Le Fantôme de l’Opera was published circa 1910 and set in the 1880s. If Erik did the do with someone who had it he would not have been able to receive treatment. He would have had to just live with it as long as he could.
So, let’s go over the symptoms:
Acquired syphilis is sneaky and tends to go dormant for years making infected individuals believe they’re safe. But when it comes back, it comes back with vengeance. There’s three stages to this and my guess is, if this were Erik’s diagnosis, he’d be in the tertiary stage.
The primary stage involves a sore or sores around the anatomical area that was infected, so either genitalia or mouth. There will also possibly be a skin rash and sort of general you-have-an-infection symptoms including fever, general malaise, swollen lymph nodes, aches and pain, and loss of appetite.
The secondary stage is more or less the same as the first but a little bit louder and a little bit worse. It’s all the You-Have-An-Infection symptoms from before plus a few more and hair loss, headaches, irritability, and possibly ocular and auditory issues. If untreated the secondary stage can come back from time to time.
Some people do get lucky and die before the tertiary stage occurs and not everyone with the infection actually progresses to this stage but we have penicillin now and there’s no reason to take the gamble so, don’t be like Erik.
Tertiary syphilis is BAD TIMES. You’ll have had no symptoms possibly for years and then kaPOW, neurological and cardiovascular complications alongside rhinomaxillary remodelling and “gummata,” or lesions just … all over …. both inside and out. So when Christine sings that line, “it’s in your soul that the true distortion lies.” She’s not … wrong … depending on how you define “soul.”
But the problem is, tertiary syphilis as well as it describes what’s going on with Erik’s — and I hesitate to use this term — face, is really really really bad. Like, REALLY bad. In untreated tertiary syphilis you do get caries sicca on the cranial bones and what I called rhinomaxillary remodelling or destruction. All this means is that the bones of your skull and face are being destroyed by the bacteria and your body is (unsuccessfully) trying to restore it so you end up with holes in your face. As in your nose and hard palette can be destroyed. These appear with what look like open sores on the face. And all of this is consistent with Erik’s look, but the problem is we are not done with the crazy that is tertiary syphilis.
The problem is tertiary syphilis doesn’t just make you look ratchet. It also basically eats your brain. It’s theoretically possible that Erik is just kind of lucky in the way the disease attacks him and it’s just made him a murderous, irritable, jealous meanie, but a far more likely progression would be that it took away his ability to walk, play the organ, sing, compose, and so on. He might think he’s still a sexy bombshell, but it would be a delusion as he wastes away in his opera basement crypt.
Certainly, you could make a case for the events in the end of the musical, particularly the magical bits where he’s throwing fireballs and mind-controlling a chorus, to be a product of Erik’s fantasy as his incapacitating disease slowly destroys his mind. Now that I think of it, that could have been an amazing angle for the Phantom of the Opera movie. But if he had tertiary syphilis there’s a good chance the bones of his face would be remodelled to the point that he could not lift his palette to sing properly, he’d lose sensation and control of his fingers and be unable to write music or play the organ, and eventually he’d become so weak he would not even be able to overpower a tiny and compliant eighteen-year-old former ballet dancer let alone Joseph Bucket and Signor Ubaldo Piangi.
Anyways, let’s move on to congenital syphilis which I believe is his issue. Survival for neonates and children with congenital syphilis is somewhat impaired which is all the more reason to practice safe sex and get regular check ups particularly if you are sexually active. You don’t want to infect your baby-mama with this and if you are someone’s baby-mama you don’t want your kid to have this. It’s bad times. As I said before an infected mother has somewhere between a 60–80% chance of passing the infection to her fetus. There’s also a huge (read: 40%) risk of “stillbirth.” Not great.
But back to Erik. Since he clearly survived into adulthood. Physical if not emotional.
The symptoms of congenital syphilis can arise relatively quickly after birth and initially include rashes on the hands and feet and possibly sores on the face. Kids with congenital syphilis can have what are called “Hutchinson teeth,” and really … well I’ll provide a picture because they sort of defy description. Congenital syphilis also can cause blindness, deafness, thickening of the brow and flattening of the nasal bridge. In some cases this deformity of the nasal bones is so severe that the child more or less looks like they don’t have a nose. So that is consistent with the description of Erik’s face in both the novel and the musical and it also matches with his claim that he’s always been like this and his mother was so revolted by his appearance that the first thing she put on him was a mask.
A mask, my first unfeeling scrap of clothing — Erik, circa 1880
And I am just going to take this moment and seriously comment that a lot of people with malignant psychological disorders are that way not really due to an underlying condition, but because they did not receive enough care and love in their infancy and childhood. This is often true of dictators, terrorists, serial killers, rapists, and lesser bullies, and apparently it’s sort of meant to be true of Erik. He’s written to be brilliant and have this superb musical talent that he genuinely wants to share, but he’s also emotionally stunted which causes him to have these violent outbursts when people don’t behave the way he wants them to. This is not an excuse for violent behaviour because it just sort of perpetuates itself, but it’s so easy to prevent that when this sort of violent psychology presents it is dangerous, but it’s also just deeply tragic. Hug your kids.
Now back to diagnosing a fictional character.
Congenital syphilis is now both preventable and treatable. But Erik is in fictional pre-penicillin Paris, and presumably he was never able to access anachronistic antibiotics for one and just general health services for another. And this is quite unfortunate for him because while I do think congenital syphilis matches him best, it is also a horror show.
I’ve focussed on the facial deformities that can be caused by this disease, but congenital syphilis also can cause deformation throughout the skeleton, loss of hearing, loss of vision, developmental delays, and neurological damage which can result in partial paralysis and even seizures. Erik can clearly hear and quite well and he seems to be sighted. But we just don’t know if he had developmental delays, if he sometimes seizes when alone or suffers from periodic paralysis. Given how much care he takes in dressing and planning he probably is hiding a skeletal deformity and probably does have impairments that we just never get to see.
And there’s actually a really interesting point in the musical that I really think points to Erik being disabled and having chronic flare-ups. There’s a massive time jump during intermission. Act I of the musical progresses pretty fast. We see the company rehearsing Hannibel, an accident causes Carlotta to run off, Christine is tapped to step in, she has her debut, Raoul reintroduces himself, Erik jealously kidnaps her, Carlotta demands her position back and “in the production of Il Muto,” Erik throws a fit, murders Joseph Bucket, Christine and Raoul declare their love for one another while she’s supposed to be changing, and then Erik cuts the chandelier down in yet another fit of rage.
But during the opening number of Act II Monsieurs Andre and Firmin comment that they’ve been Phantom free for six months. Erik comes in and busts up the party but he is dressed even more resplendently than usual and this time, his mask covers the entirety of his face. He claims that he was gone because he was finishing his opera, “Don Juan,” but then he has a temper tantrum in the general direction of Christine.
I don’t know how long it takes to write an opera but when Christine wakes up in his lair he’s playing the theme to his opera. (I will say, I find it hilariously funny, that she wakes up not to the audio bombast of the organ not two metres away from her, but the tiny little monkey music box he apparently brought over to her.) So he already had that thing mostly written six months ago, he hasn’t used the time to get over Christine or work on his clear emotional issues, he just gets right back to where he was six months ago and he does it wearing even more clothes.
During the entirety of Act II he does his intimidating lurk a lot but the only time we see him being athletic or even really see his silhouette is in the very final scene where he lassos Raoul, somehow manhandles Christine into a wedding dress — and given 1880s clothes that’s not so much scandalous as it is improbable — and then tells them he’s going to murder-kill Raoul if Christine doesn’t decide to marry him.
In the Schumacher movie he does have a swordfight with Raoul in the cemetery which, beyond Minnie Driver, is really the only reason I own a copy of this movie. (And yes, I, an irredeemable Mozart stan with years of classical vocal training, do own a movie in which the singing is so obscenely horrible that there are multiple spoofs of it where the vocals are actually considerably better. Let’s just skate on past that. We’ve got fictional characters to diagnose here.) But in the musical he just shoots fireballs at Christine and Raoul like he was larping so hard it actually started working.
My point is, he’s kind of acting like a man who doesn’t have a lot of energy. He stays put when he can, he delivers his threats and orders from afar, he does not appear in person when he can avoid it, and when he does appear he usually keeps his distance and wears costumes or a cloak that entirely cover and obscure every inch of his body including his scalp and face. To me this sounds like a man who had a flare up, is not fully recovered, and is trying to hide what he perceives as a weakness.
So, there’s my diagnosis. I think Erik has congenital syphilis with osteological involvement and chronic flare ups. I think his mother abandoned him possibly because she herself was too ill to care for him or because she did not at the time understand what was wrong with him, and as a result he has some really horrible psychological issues which have caused him to be emotionally stunted and violent. He’s intellectually gifted, but does not believe he’ll ever be accepted or loved so he’s an over-achiever in all things intellectual, but simply does not understand that an eighteen-year-old orphan is not herself emotionally equipped to give him the sort of dedicated love and attention he needs.
I’m genuinely embarrassed to admit this sort of in the same way I’m genuinely embarrassed that I also stan Puccini, but I love Andrew Lloyd Webber’s Phantom of the Opera. I love it. I seriously thought I was going to play Christine when I grew up and honestly, it’s going to be one of my regrets when I lay dying despite the fact that I daily bust out Queen of the Night and Casta Diva and the like. Phantom the musical was my gateway drug into opera and honestly, you can tell me it’s camp gothic horror all day; I will STILL go to see it when I can. Get mad at me for not stanning Into the Woods as hard if you must, but sorry guys, ridiculous scores and horrible disfiguring and now treatable disease is totally my jam. Evidently.
This was brought to you in part by Lindsey Ellis and in part because performing artists in the UK are going through a really rough time right now. Andrew Lloyd Webber is currently involved raising money to offset some of the pressures and let his musicals be screened on youtube as part of a fundraiser. Here’s a link to his site if you are feeling generous and would like to make a donation either to artists or to the NHS.
Regarding syphilis or really any of the diseases I’ve mentioned, I’m trained in Palaeopathology. You really don’t want to be on my table because if you’re there something has gone horribly wrong. As in, not only have you died, but one of us has also time travelled. So I would encourage you to have an open dialogue with your board certified doctor and be proactive in your health. Not all of what I mentioned is curable, but a lot is variously preventable and treatable and there’s just no reason you shouldn’t receive good care.