Will You Be Cured of Your Infirmity?
I know when one is dead, and when one lives.
King Lear, Act 5, Scene 3
Shakespeare’s plays are full of characters dying, both onstage and offstage. There are discussions about death too, and threats to kill.1 Loss of life in the tragedies and histories is expected, but death lurks in the comedies too, where plays that are usually associated with laughter and romance also have characters who are threatened with execution (Comedy of Errors, Measure for Measure) or appear onstage in mourning (Twelfth Night). In Love’s Labour’s Lost, a play full of frivolity and witty word play, the announcement of a death brings the comedy to a juddering halt.
Advances in medicine have extended our average stay on earth considerably when compared to those living in Shakespeare’s day, but death is still inescapable. No matter how much we may try to prolong or cheat the inevitable, ‘All that lives must die, / Passing through nature to eternity’ (Hamlet). The manner of our death, however, is likely to be very different from the experiences of our predecessors in the sixteenth century.
Today our final moments will most probably be spent in a hospital or care home where medically trained staff are close at hand. Sixteenth-century London had only three hospitals: St Bartholomew’s, St Thomas’s and Bethlem hospital for the insane. These institutions were strictly for the poor and few of those who entered expected to leave. Pistol’s beloved Doll is the only one of Shakespeare’s characters to go to a ‘’spital’, where we are told she died of the ‘Malady of France’ (syphilis).2 Her death comes in the same play, Henry V, as the demise of Shakespeare’s great comic creation, Falstaff, but his death is the more typical experience of the day as he dies in a domestic setting surrounded by friends.
In the sixteenth century, and for some considerable time afterwards, births and deaths usually occurred in the home surrounded by friends, family and local gossips, rather than by the professional medical support expected today. Only the most shameful of illnesses such as syphilis, or contagious diseases such as plague, kept visitors away. Few of those living during this time could have escaped witnessing death at close quarters.
Death itself was considered natural, with the exception of murder, suicide and witchcraft. But dying suddenly, alone or in disreputable circumstances was considered a bad death. This is not to say that the Elizabethans were complacent about dying and did nothing to avoid it. Medical treatments of various kinds were administered, wounds were treated by surgeons and attempts were made to revive the apparently deceased, as is shown in Shakespeare’s plays.
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The complexity of the human body means there are many points of vulnerability that can potentially bring about our end. Most of the time our bodies carry on doing their complex essential tasks without us really paying them much attention. But we are quick to notice when those processes aren’t working properly, and seek medical help to make us feel better and prevent things becoming serious, or even fatal. The Elizabethans were no different in being preoccupied with their health and seeking medical help. The form of help they received, however, was very different.
There were many options for consultations open to patients in Shakespeare’s day, but choice was governed by a patient’s ability to pay rather than medical expertise. Options ranged from the highly regarded, university educated and very expensive physicians, to the much cheaper choice of the nearest wise woman. However, the size of the fee and education of the practitioner didn’t improve the chances of recovery. The harm done by common forms of treatment generally outweighed any benefits linked with expertise or price.
In the sixteenth century and beyond, women were central to medical treatment and shouldered the bulk of the health-care burden. The range of female medical providers ran from friends and relatives offering basic nursing, to wise women who offered cures and treatments, and midwives who assisted at births. The skills of midwives were certainly highly regarded, and no pregnant woman would have considered having a male practitioner attend the birth other than under the most extreme circumstances. Despite this, midwives were certainly at the bottom of the professional medical hierarchy.
At the top were licensed physicians, called doctors because they had been educated at Oxford or Cambridge. Physicians learned from Latin texts, made diagnoses, treated internal ailments and prescribed medicines, but they did not cut into the body. Anything requiring a knife and involving bleeding was left to surgeons, found on the next rung down of the medical hierarchy.
Surgeons not only bled their patients, a common medical treatment of the day (see later); they also performed minor surgery such as removing stones, amputations, trepanning (drilling into the skull) and stitching up wounds. Barber-surgeons cut hair as well as flesh, hence the traditional sign outside barber shops of a red and white striped pole, signifying the blood and bandages of their profession. At a similar level of respectability were apothecaries who made and sold remedies, and may have carried out some unofficial diagnosing.
As well as medical people with accepted professional status, right at the bottom of the pile were all manner of unlicensed healers. Quackery was rife, but the lack of a licence did not necessarily mean the individual was a quack. Many cheap, and sometimes effective, treatments might be offered by women and men who had no official training, but vast experience.
All of these various types of medical practitioner are depicted, or at least mentioned, in Shakespeare’s plays. Apothecaries appear on stage to sell poisons; surgeons are sent for to treat the wounded after altercations with swords; wise women are consulted; and doctors are depicted, both real and fictional. Shakespeare went further than all of his contemporaries in his portrayal of medicine and use of medical terms in his plays. There are hundreds of medical references in his work, direct and oblique, showing an understanding of health and anatomy far beyond that of any other playwright of his day.
One example of Shakespeare’s in-depth medical knowledge was his apparent references to the theory of the circulation of the blood. This discovery is usually attributed to William Harvey and was first described by him in a lecture he gave in 1616 (although Harvey didn’t publish his theory until 1628, after the playwright’s death). However, the theory was certainly known before 1616 by a few medical men in mainland Europe and is hinted at in several Shakespeare plays, decades before it was accepted by the English medical establishment. Lines such as, ‘You are my true and honourable wife; / As dear to me as are those ruddy drops / That visit my sad heart’ (Julius Caesar) and ‘The tide of blood in me / Hath proudly flow’d in vanity till now’ (Henry IV, Part ii) certainly suggest an appreciation of blood flowing, even if Shakespeare didn’t explicitly state that blood flows in a continuous circuit.3
Where Shakespeare gained his knowledge has been speculated over for centuries. Some have suggested that he must have known William Harvey personally to gain insight into his theories. There is, however, no proof that they were acquainted. There were no compendium-style medical textbooks to study, but there were a lot of written treatises on specific ailments and medical theories that he could consult. Questioning medical practitioners directly might have been another route. Aside from personal experience of consulting medical practitioners for himself and his family, one doctor Shakespeare certainly did know was Dr John Hall, who married his daughter, Susanna, in 1607. The medical information contained within his plays certainly became more detailed after their wedding.
Shakespeare often poked fun at medical practices, the state of medical knowledge and the dire remedies that were doled out, but he held the doctors themselves in high esteem, with one notable exception. Dr Caius in The Merry Wives of Windsor, a pompous, self-important man much ridiculed by those around him, may be based on Dr Theodore de Mayerne, a prominent French physician who treated several French and English sovereigns. De Mayerne was president of the College of Physicians and apparently appeared very scholarly and sure of himself; perhaps he was a figure ripe for having a little fun made at his expense.4
Notable among Shakespeare’s collection of doctors, quacks and apothecaries is the (fictitious) female practitioner, Helena, in All’s Well That Ends Well, who successfully treats the King of France after all other male physicians have failed. Indeed, the doctors made him worse. Her medical knowledge is said to come from her physician father, Gerard of Narbon. Women were officially barred from studying medicine but knowledge was often shared through correspondence between practitioners and women. The character and the story of All’s Well That Ends Well are not original to Shakespeare, who adapted the tale from Boccaccio’s Decameron. Both versions illustrate how many women were respected for their medical knowledge, gained through informal methods of learning and sharing information, as well as personal experience of treating the sick.
Women are portrayed in all the usual medical roles that might be expected of them in Shakespeare’s day. Though they don’t appear on stage, wise women are mentioned in both Twelfth Night and The Merry Wives of Windsor. Twelfth Night, and several other plays, also includes one of the more curious methods used for diagnosing disease and prognosticating over the fate of sixteenth-century patients – urinoscopy. Flasks of a patient’s urine would be collected and sent off to a doctor or wise woman for inspection, just as Falstaff does in Part ii of Henry IV:
Falstaff: Sirrah, you giant, what says the doctor to my water?
Page: He said, sir, the water itself was a good healthy water, but, for the party that owed it, he might have more diseases than he knew for.
The upper echelons of the medical hierarchy turned their nose up at urinoscopy but it continued to be popular. Examining the colour, clarity and odour of urine was supposed to offer clues to the state of the patient’s health and temperament. Elaborate colour-wheels of shades of urine were produced to assist diagnoses. As Speed says in Two Gentlemen of Verona, ‘these follies are within you and shine through you like the water in an urinal, that not an eye that sees you but is a physician to comment on your malady.’
In reality, only the most crude assumptions could be made by this type of examination and urinoscopy certainly didn’t deserve the trust many placed in it. Blood in the urine obviously indicates a serious problem with the kidneys, a sweet taste would be caused by diabetes and blue or dark urine can be a sign of porphyria or other diseases, but it is far from an exact science. Testing urine today can reveal vital information about a patient’s health but this was simply not possible before the advent of modern analytical techniques.
Instead, the College of Physicians recommended measuring the pulse and judging fever by feeling the patient’s forehead with the back of the hand, neither of which were terribly effective without stethoscopes and thermometers. All a physician really had at his disposal was his knowledge and observation through visual inspection, smell, taste and listening to the patient’s complaints.
After diagnosis a treatment would be recommended to the patient and could differ greatly depending on which school of medical thought the doctor subscribed to. There were two theories of medicine battling to save lives in the sixteenth century. There was the traditional Galenic system of humours: good health was enjoyed by those who had the correct balance of four humours – black bile, yellow bile, phlegm and blood.5 An imbalance of humours brought on illness and so physicians tried to restore the equilibrium through recommending special diets, blistering, sweating, purging (vomiting and excreting) and bleeding. The system of humours was more or less abandoned by the late seventeenth century, even though patients continued to be bled long after that. But traces of it can still be found in modern English; we still talk of good and bad humours to describe a person’s temperament. Such phrases would have had a more literal significance in Shakespeare’s day.
The alternative approach to health competing for attention in the sixteenth century was a new theory from Paracelsus (a Swiss physician almost exactly contemporaneous with Shakespeare), based on observations and a belief that everything was due to chemical processes (though his chemistry was very different from the modern science). He pioneered the use of synthetic chemicals and minerals as medicines.
Shakespeare was well aware of both theories and satirised the competition between the two in All’s Well That Ends Well, ‘Why, ’tis the rarest argument of wonder that hath shot out in our latter times.’ But, with a few notable exceptions, such as laudanum,6 there was little medical benefit in any of the treatments on offer at the time, and some of them threatened considerable harm to the patient. As Timon of Athens puts it to a thief, ‘Trust not the physician; / His antidotes are poison, and he slays more than you rob.’
Helena’s treatment for the King in All’s Well That Ends Well claims to be completely harmless and promises to cure the King’s fistula (an abscess in the chest) within two days. This benign remedy, whatever it might have been, and its rapid and complete success, is in stark contrast to the medical treatments available at the time. Regardless of whether the Galenic or Paracelsian system was used, treatment was for symptoms and not the underlying disease. There was little concept of disease as a distinct entity. For example, fever was seen as an illness in itself, rather than a symptom exhibited by many different diseases.
People did not expect healers and medicine to cure them and they certainly didn’t think that taking medicine would make them feel better. Most of the medicines that were prescribed would have made the patient feel very ill indeed. They would have been well advised to take Macbeth’s advice and ‘throw physic to the dogs’.
Even though it must have been evident that medicines rarely worked, they usually made the patient feel much worse, and people often died during treatment, the healer was rarely blamed for the death. Unsatisfactory results were explained away either because the malady was too severe for the treatment, or because the patient had failed to follow the often very detailed medical advice correctly. One surgeon, Tristram Lyde, ended up appearing in a Rochester court after he prescribed mercury treatments for several women suffering from syphilis who subsequently died. His defence was that the women were gravely ill and had failed to follow his instructions properly. The judge accepted the explanation and Lyde walked free.
Until germ theory was developed in the nineteenth century, medical practitioners were left guessing as to the cause of many diseases and therefore had little hope of treating them. Advances in medical treatment were also severely hindered by an almost complete lack of knowledge of physiology or pharmacology.
In spite of their best efforts, before the beginning of the eighteenth century, medical professionals had little impact on the population they treated. Death was rarely stopped or even slowed in its progress. Even identifying when death had occurred could be tricky, as we shall see.
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In the overwhelming majority of cases death was easy to identify – vast personal experience would have made the process of death easily recognisable. Mostly, death in England before the sixteenth century was the concern of individuals, and their family and friends left behind to grieve. The state had little interest in the passing of its citizens. Things changed as the population grew and burial space, particularly in the capital, diminished. From 1538, parishes throughout England were required to record weddings, christenings and burials, but these records were kept locally without any wider coordination. However, burials became of acute interest during times of plague.
In the major outbreak of 1592, authorities in London started collating weekly tallies of burials within the parishes of the city, called the ‘Bills of Mortality’. The practice continued until 1597 when the plague abated and was revived again in 1603 when the pestilence returned to the capital, and records were uninterrupted thereafter. In 1611, King James gave the task of producing annual mortality statistics to the Worshipful Company of Parish Clerks. In 1625 they were allowed a printing press so that the weekly bills could be published and the scale and statistics of death could be more widely known. However, the Bills of Mortality only focused on the 96 parishes within the city walls and 13 without.
As time went on more detail was added to the records, such as the age of the deceased and the cause of death. Determining the cause of death was the job of searchers, women employed by the parish to visit a home when a death was announced to inspect the corpse and collect information to report back to the parish clerks. According to their reports from the early seventeenth century, one could die of such diverse ailments as smallpox, plague, old age, grief, lunacy and ‘teeth’.7 Searchers received no medical training and many historians have subsequently decried their level of expertise and therefore mistrusted the information produced in the Bills. But, as we have seen, women were highly regarded in terms of medical knowledge and besides, many of the sick would have already been visited by some kind of medical practitioner. The cause of death would very likely already be known by the deceased’s family and the searchers were simply gathering information from them. Mostly their job was to seek out cases of plague and check for signs that someone might not have died of natural causes.
Even in their limited state the Bills of Mortality have proved to be a fascinating and useful resource for researchers ever since. Today, detailed government statistics are recorded and determination of death and its causes is the province of professionals. The level of training invested in doctors and pathologists shows how difficult and complex their job can sometimes be.
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Despite death being a universal experience, with millions of witnessed examples and centuries of scientific study, it is surprisingly difficult to define exactly what it is. As the author Christine Quigley put it recently, ‘the dead are most often just like us, minus life’. From a technical point of view, death is the complete cessation of vital processes within the body, but many processes continue long after a person is generally accepted to be dead. Cells die at different rates; neurons (nerve cells) are the most vulnerable, dying within minutes, but cells such as fibroblasts (connective tissue cells) can survive for days. Death is a process, not a single event and, depending on the circumstances, this process can take a relatively long time. Waiting for all these functions to cease is not generally necessary for a person to be declared dead.
The two key organs for determining death are the heart and the brain. When the heart stops beating, oxygen-rich blood can’t be pumped to the brain, which stops functioning when starved of oxygen. Conversely, if the brain, and importantly the brain stem, is damaged, the body no longer receives instructions to breathe, and the lack of oxygen entering the bloodstream soon causes the heart to stop. Either way the result is brain damage that current medical interventions cannot reverse.
Medical advances in the twentieth century mean that hearts can be restarted and breathing can be supported if the brain is damaged. The heart, as long as it continues to receive oxygenated blood, will continue to beat even if the brain is no longer functioning. The boundary between life and death has become blurred and so further medical definitions were needed to pinpoint when a person is actually dead. Nowadays many countries define death as the cessation of brain function, but in the past it was generally taken to be the point when the heart stopped.
The period between cessation of the heart activity and brain death is termed ‘clinical death’. This is when cardio-pulmonary resuscitation (CPR) can be used in an attempt to restart the heart and save a life. Without intervention the period lasts mere minutes before the brain, starved of oxygen, is irreversibly damaged. Modern devices such as the electrocardiograph and electroencephalograph can be used to detect faint electrical signals and activity within these organs, showing signs of life, but of course these were not available in Shakespeare’s day.
The critical point at which nothing further can be done for a patient and death is inevitable would have been very different in the sixteenth century. That isn’t to say that recovery was impossible, but there were no reliable standard procedures such as CPR to try to save an individual from dying. This certainly didn’t stop the Elizabethans from trying. Those who were wounded would be carried to the nearest surgeon, if they could afford it. If it was thought that a person might be unconscious, attempts were made to revive them by warming the body or forcing medicine down the victim’s throat. These methods were worlds apart from CPR, blood transfusions, defibrillators and modern medicines that can intensify weak heartbeats or reverse overdoses, but sometimes they were successful.
Revival from apparent death was not a new idea, even in Shakespeare’s day. Pliny the Elder, a Roman author and natural philosopher, wrote in his Natural History, a book Shakespeare possibly read, of several cases of those who were carried to their funeral only to revive. On one occasion the heat of the fire was so strong that the presumed deceased revived, only to be consumed in the intense flames.
In Pericles, there is an example of someone being given up for dead who is later revived, not by incantations or the heat of a funeral pyre, but by the skill and knowledge of a physician. In the play, Thaisa is travelling on board ship with her husband Pericles during a storm when she gives birth to their daughter. The nurse that attends her believes Thaisa has died during childbirth and Pericles accepts the terrible news without question.
The sailors, mindful of the superstitions linked with carrying a corpse on a voyage, wish to commit the body to the waves before the storm destroys them all. Pericles complies, and Thaisa’s body is washed, dressed in her finest clothes and placed in a chest that has been carefully treated and sealed to keep the water out. According to Lord Cerimon, who later finds the chest washed up on the shores of Ephesus, ‘They were too rough, / That threw her in the sea’.8
When the chest is opened, Thaisa’s body is found inside, but without the most obvious and conclusive sign of death – decay. Decomposition begins rapidly after death and can be detected early on by the unmistakable foul smell of compounds such as cadaverine and putrescine. These chemicals, among others produced during the decay process, have a power and a pungency that is difficult to ignore. By contrast, Thaisa’s body in the chest is said to be sweet-smelling.
Surprised by the absence of the smell of decay from what is supposed to be a dead body, Cerimon examines her more closely and detects signs of life. He says he knows of cases of Egyptians who were revived after lying apparently dead for nine hours, and from his examination of the body, he is sure Thaisa has been in her entranced state for less than five hours. With the help of a warm fire and the contents of his medicine cabinet she is restored to life. The story is fantastical but there are at least some aspects that have scientific credibility.
There is nothing surprising about Thaisa’s death – death in childbirth was common enough in Elizabethan times. Even her revival after appearing dead is possible, though improbable. One potential explanation is that the loss of blood during childbirth leads to ventricular fibrillation. But, when the chest containing her body smacks into the waves, the force of the impact gives the heart a jolt that starts it beating normally again. However, without a blood transfusion, Thaisa would be unlikely to survive for long.
Another possible explanation comes from the human response to extreme stress or physical trauma, which can cause the body to shut down to try to preserve life for as long as possible. Perhaps this is how Thaisa survives her time drifting in the sea. Cold water can also put a body into a kind of stasis, allowing someone to be revived later. At body temperatures below 32°C a patient can lose all brainstem reflexes, be bradycardic (have a very slow heart rate) and be unable to shiver, depending on the degree of hypothermia. This has led to the axiom that someone is only truly dead when they are warm and dead. The phenomenon is well documented but unlikely to apply to Thaisa, as she was pitched overboard into the warm waters of the Mediterranean.
There is the added problem of air, or lack of it, inside the chest. The space inside the average coffin is normally only sufficient for 20 minutes of breathable air. Thaisa’s chest would have to have been very roomy or have a few air holes in the top to give her enough oxygen to make it to shore and be discovered.
However it happened, Thaisa survived long enough to be discovered and was lucky to be found by someone with the expertise to revive her. Cerimon’s methods of restoring her to life also have some scientific credibility. The warm fire could revive her in the event that she is suffering from hypothermia. Also, Cerimon’s medicine cabinet could potentially contain drugs that would speed up a sluggish heartbeat and intensify contractions of the heart muscle. Belladonna has been used in medicine for centuries. It was prescribed for all manner of conditions, though mostly to treat inflammation and to relieve pain. Atropine, extracted from belladonna and several other plants common to Europe, is used today in emergency medical treatments to improve contractions of the heart, but this is a relatively recent medical discovery. Shakespeare, and therefore Cerimon, was probably unaware of the potential benefits of using belladonna.
The play ends happily with Thaisa being reunited with her family after many trials and tribulations. These days her traumatic experiences would lead to lawyers getting involved and lawsuits issued against those who had falsely declared her dead and thrown her into the sea. But in the play no blame is attached to the nurse, or to the sailors. Everyone in the play accepts that Thaisa is dead. A particular case from the seventeenth century shows how credible the story would have been to Shakespeare’s audiences. In 1645, Françoise d’Aubigné, the daughter of a French governor, was thought to have died while at sea. She was sewn into a sack and was about to be dropped overboard when a meow was heard coming from inside the sack. The girl’s pet cat had crawled in before the sack was sealed, and when they re-opened it to release the moggy, they realised the child was still alive. It just shows how difficult it was to be sure.
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The risks of childbirth were well enough known to Elizabethan audiences and Thaisa’s death wouldn’t have been surprising. But when there was no obvious cause, no signs of disease or injury, it was all the more difficult to establish whether someone was really dead.
In The Winter’s Tale Hermione dies of grief (more of this in Chapter 10) and there are calls to try and revive her, ‘if you can bring / Tincture or lustre in her lip, her eye, / Heat outwardly or breath within’, but to no avail. There are four indications of death given in this short speech: pallor, lustreless eyes, the loss of animal heat and no sign of breathing. Though Hermione receives no medical attention, that isn’t the end. Towards the end of the play, decades after her death, a statue of Hermione is brought to life and she is reunited with her husband and daughter. This is the realm of fantasy, far beyond modern ideas of emergency medicine, which try to restore life only to the very recently deceased.
Hermione’s revival is brought about by incantations and charms, and is perhaps closer to Frankenstein-type experiments that reanimate lifeless matter. Her situation may never have been intended as anything but fanciful and was an excellent excuse for special effects and a bit of stage magic. Nevertheless, the signs of death given in The Winter’s Tale are not unreasonable, but they can also be exhibited by people when they are alive. For example, bodies are sometimes pale, and a pale complexion can be due to a non-fatal illness. Dead bodies may not be cold, and living bodies may not be warm, depending on the circumstances.
The most obvious signs to look for were lack of movement, breathing and pulse. However, those still alive but in catatonia (a state of stupor or unresponsiveness) can have a rigid immobility that can be mistaken for rigor mortis, and conversely, rigor mortis does not always occur in dead bodies. Another possible explanation for lack of movement, coma, is often diagnosed when the brain is rushed with endorphins to deal with extreme pain thresholds. The comatose person is not capable of moving their limbs; some nerves may twitch and shallow breathing can continue, but they certainly look dead to the untrained medical eye. Shallow breathing can be difficult to detect and prolonged listening with a stethoscope over the trachea or lungs is necessary.
Stethoscopes only became available in the nineteenth century, but Shakespeare details several crude alternatives that would have been used in the sixteenth century. For example, King Lear, desperate to believe that his daughter Cordelia is still alive, asks for a looking-glass to see if her breath will fog the surface. He also holds a feather to her mouth and nose and believes he sees some faint current of air disturb the soft barbs, but tragically he is mistaken. Yet another method that might have been tried in Shakespeare’s day was placing a bowl of water on the chest and watching for tiny disturbances on the surface.
If a pulse couldn’t be detected by fingers pressing against the skin, there were other methods that might be used. For example, string could be used to tie off the ends of the fingers, and if there was still a pulse, though faint, the tissue beyond the string would swell or change colour. A more accurate, but unpleasant way of checking for a pulse was to cut into a vein and see if blood flowed, but care had to be taken to ensure the blood wasn’t just flowing because of gravity.
It is also possible to carry out crude checks for basic brain function, without sophisticated technology, by testing certain reflexes. For example, shining a bright light in the eyes normally causes the automatic contraction of the pupil. The eyes can also be tested for ‘oculocephalic reflex’, or the ‘doll’s head reflex’, by holding them open and moving the head rapidly from side to side. If the reflex is present the eyes move in the direction opposite to head movement, but if they remain in the midline it is a sign of brain death. These kinds of tests have been around for centuries, but modern techniques are capable of determining even tiny eye movements.
After death the pupils dilate as muscles relax, and the eyes soon lose their roundness and take on an appreciable flatness. The surfaces of the eyes lose their gloss and a dull film appears. These are the earliest signs of decomposition and this may be what Shakespeare is referring to when he mentions Hermione’s lustreless eyes.
In Shakespeare’s day, waiting for a corpse to start showing signs of decay was pretty much the only failsafe option for knowing that a body was definitely dead and not just in a deep coma.9 Given the difficulty of determining death back then, it is not so surprising that several of Shakespeare’s characters are mistaken for dead and others convincingly fake it.
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In Cymbeline, Imogen, disguised as a man named Fidele, is feeling under the weather and so swallows medicine she hopes will revive her. But, due to a complicated series of events (see Chapter 8), the medicine is actually a drug intended to give the appearance of death. Her unresponsive state is convincingly death-like and she is buried, but later in the play she is restored to health and reunited with her husband and family. It is a similar set-up to the most famous fake death in Shakespeare, that of Juliet in Romeo and Juliet, but with a decidedly happier ending.
Juliet’s case is slightly different from others in Shakespeare’s plays as she deliberately attempts to appear dead, rather than appearing dead by accident. The drug given to her by the Friar will not kill her but will make her seem dead for 42 hours. Judging by how often this was used as a plot device, and not just by Shakespeare, the idea that poisons could be tempered in some clever way to bring someone close to death but not kill them was a common one.
The story of Romeo and Juliet was not original to Shakespeare. As with the majority of his plays, he borrowed and adapted from existing work. There were many versions of the tale of the two star-crossed lovers from rival families circulating in the sixteenth century. Shakespeare’s may not have even been the only version of the story being acted out on the Elizabethan stage, though it is the only theatrical version that has survived.
Some claimed the story to be true, or at least based on real events. Girolamo Dalla Corte dated the events to 1303 in his History of Verona, published between 1594 and 1596, and there certainly were two warring families in Verona at that time. But there is no evidence that the tale of the two lovers from opposing families is real. Each new version of the tale appeared with embellishments, extra characters and details added. The manner of the lovers’ deaths also varied. For example, in one version Juliet, instead of stabbing herself after discovering Romeo’s poisoned body, holds her breath until she expires, something that wouldn’t actually be possible. The time of Juliet’s unconsciousness also varies between 16 hours and two days. But the idea that she deliberately faked her own death is constant.
The details of the substance she used also varies. In some versions she is given a powder to dissolve in water, others have a liquid added to wine, or concoctions swallowed undiluted. Frustratingly, none of these versions gives a name to the substance, real or imagined, that could be used to do this. Without a name we can only use symptoms to guess at any substance that might have inspired such an idea.
Shakespeare’s version of the well-known story is taken mostly from the poem by Arthur Brooke that contains many details not found in other accounts.10 Even so, there are elements, such as the death of Paris at Romeo’s hand outside the Capulet tomb, that are unique to Shakespeare.
In Shakespeare’s play, it is the Friar who comes up with the plan and gives Juliet the vial of ‘distilling liquor’, describing the symptoms she can expect:
all thy veins shall run A cold and drowsy humour, for no pulse Shall keep his native progress, but surcease: No warmth, no breath, shall testify thou livest; The roses in thy lips and cheeks shall fade To paly ashes, thy eyes’ windows fall, Like death, when he shuts up the day of life; Each part, deprived of supple government, Shall, stiff and stark and cold, appear like death: And in this borrow’d likeness of shrunk death Thou shalt continue two and forty hours, And then awake as from a pleasant sleep.
From the symptoms, it sounds as if she is given a strong sedative. Today comas can be induced and maintained using controlled doses of barbiturates but these were not available until the twentieth century. One sedative in use in Shakespeare’s day, and for a long time before, was prepared from the roots of the mandragora plant. The plant was well known to Shakespeare, as he mentioned its sleep-inducing properties in both Othello and Antony and Cleopatra: ‘Give me to drink mandragora / That I might sleep out this great gap of time / My Antony is away.’
Juliet herself talks about ‘Shrieks like mandrakes torn out of the earth’. But she is referring to the myth that claimed the plants were the living link between plants and animals (underneath the green foliage its bifurcated root looks like a pair of legs), and that they screamed when they were uprooted.11
The root of the mandragora plant was used for millennia to induce unconsciousness; there are even references to it in the Bible. The active components in the plant include atropine, hyoscine and hyoscyamine, which all act in a similar way by blocking chemical signals to nerves in the central and parasympathetic nervous system. It could help with sedation, particularly when used with other drugs like opium, and it would cause the pupils to dilate, which also happens after death. But in other respects it would be a poor mimic of a death-like state. Juliet’s heart would race and she was more likely to be flushed and hot than pale and cold.
Opium also sedates and slows breathing, but it causes pupils to contract, and the time of sedation is around eight hours rather than the 42 hours in the play. Upping the dose does not prolong the period of unconsciousness. Instead, it intensifies the level of sedation, to the point where, in the case of an overdose, breathing stops.
Shakespeare’s play, and other sources, suggests that normally fatal poisons could be moderated in some way so that they would stop short of killing someone, but this is simply not possible. Chemical reactions can be used to manipulate the structures of compounds extracted from plants, to make them less toxic and minimise side effects. But in the sixteenth century it wasn’t even known what the active substances were within the plant, let alone how they might be isolated and modified.
There is, however, one compound that has been known to give a very convincing appearance of death: tetrodotoxin (TTX). There are many cases of humans ingesting TTX and being certified dead before later reviving. TTX blocks the transmission of nerve impulses along nerve fibres to muscles, including the diaphragm. If muscles do not receive nerve signals they will not contract, and therefore the poison can cause respiratory paralysis and death. There is a very narrow window where breathing, and heartbeat, can be slowed to almost undetectable rates, but not stopped completely. The brain may continue to function, and the individual may be awake and aware of what is going on, but cannot signal their distress. As the body slowly breaks down the toxin from the body, normal nerve function returns and a person can revive.
TTX is a heat-stable neurotoxin produced by bacteria. Some animals that come into contact with the bacteria, including the blue-ringed octopus, some species of salamander and the Californian newt, accumulate the toxin deliberately. These animals use it either as a defence mechanism or as a way of paralysing prey so they can be more easily caught and eaten. TTX poisoning in humans is most commonly associated with eating improperly prepared puffer fish. Puffer fish accumulate TTX in their liver, ovaries and skin. Preparation of puffer-fish sushi (fugu) requires great skill and years of training to prevent dangerous levels of TTX from being transferred to the flesh of the fish. Restaurants in Japan need special licences to sell fugu but, despite all the precautions, mistakes have been made, usually by fishermen who decide to eat some of their catch, or supermarkets that mis-identify fish being put on sale. The Japanese are therefore well practised in treating puffer-fish poisoning, which is done by artificially supporting breathing until the toxin is cleared from the body. Survival rates are now very good. Things would have been very different 400 years ago.
TTX may be a strong candidate for Juliet’s death-defying poison but it falls down on one key point – puffer fish were not known in Europe until the time of Cook’s voyages in the eighteenth century. One remote possibility is that trade with south-east Asia brought the knowledge, or rumour, of such substances into Europe much earlier and inspired stories of death-simulating potions.
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Fake death or mistaken death was very much the exception rather than the rule in Shakespeare’s plays. In the vast majority of cases death was obvious. When Mistress Quickly sees Falstaff on his sickbed she says, ‘I knew there was no other way’ (Henry V). Several deaths in Shakespeare’s works show he had a sophisticated appreciation of death as a process rather than a single event. In more than one character he describes the slow progress towards their death as the body shuts down, bit by bit.
Falstaff is a case in point. His final moments are described to the audience by Mistress Quickly in Henry V. He was delirious, his feet were cold and chill spread up his body as his heart failed to effectively circulate his blood. She adds, ‘I saw him fumble with the sheets and play with flowers and smile upon his fingers’ ends’. Plucking and picking at small objects is referred to technically as ‘carphologia’, and is a sign of extreme exhaustion or impending death.
It is a very mundane end to the exuberant life of the fat knight who featured in three of Shakespeare’s plays.12 Audiences are forewarned of his death at the end of Henry IV Part ii, and they are told that Falstaff will die of a sweat, perhaps a reference to the sweating sickness, or even plague.
Famed for his love of women and sack,13 Falstaff was hardly living a healthy life and threats to his wellbeing might have come from anything from venereal disease to alcoholism to diabetes, as well as all the usual hazards in Middle Ages England. But no specific cause of death is given as we would understand it today. Mistress Quickly says Falstaff was suffering from a ‘burning quotidian tertian’. This is a very precise diagnosis, for the sixteenth century anyway, and describes a combination of fevers (or agues) that were considered particularly dangerous. These symptoms could have been due to the fever caused by the sweating sickness, or maybe malaria finally felled this great Shakespearean character (see Chapter 7). Another suggestion is that the delirium described in the play was caused by typhoid.
Whatever the cause, Falstaff’s life of excess certainly wouldn’t have helped his chances of survival. The play suggests that Henry V (Prince Hal in Henry IV) also contributed to the death by breaking Falstaff’s heart when he so callously dropped his friendship with the knight the moment he ascended to the throne.
Another drawn-out death portrayed in considerable detail by Shakespeare is that of Henry IV. At least this time Shakespeare was depicting a real-life person and we have historical records to refer to in an attempt to get at the truth. But still, the exact cause of death is unknown and has been speculated about by scholars ever since. The only thing that is certain is that it was due to natural causes.
Henry IV suffered from several illnesses during his life, some of them psychosomatic. However, in 1408 the King suffered a mild stroke and his health deteriorated from that point. He suffered fainting fits and some kind of heart complaint, and was occasionally incapacitated to the point that he could not walk. He was certainly under considerable stress; the insecurity of his position on the throne and constant criticism from those who considered him an usurper can’t have been helpful to his mental health. Some have asserted he was struck down with leprosy because of eruptions on his skin. It was said he became so disfigured that no one could bear to look at him. The French believed his toes and fingers had fallen off, another sign of leprosy. At least these reports have some semblance of credibility. Other accounts of his illness are more ridiculous – the Scots said that he had shrunk to the size of a child.
However, his death mask, and the examination of his well-preserved face during the exhumation of his body in 1831, suggests that accounts of his disfigurement were exaggerated. One modern medical opinion is that it could have been tubercular gangrene (in rare cases tuberculosis can lead to gangrene), combined with erysipelas (a skin infection, typically with a rash), which produces a burning sensation. This would at least explain accounts of him crying out in agony saying he was burning.
His last illness began when he was taken sick very suddenly on 20 March 1413, when praying at St Edward’s shrine in Westminster, and was carried to the nearby Jerusalem chamber. He may have suffered another stroke as it states it took him a little while to recover his speech. He was placed on a makeshift bed near the fire to keep him warm but he complained his arms and legs were cold – it was clear to everyone that he was dying.14
Shakespeare’s account of Henry’s final illness from Henry IV Part ii seems to have been fairly accurate. As shown in the play, the King had periods of unconsciousness and during one of these, his son entered the room to take his crown, believing him to be dead. In his dying moments he complains of loss of sight, and wasted lungs – his body is shutting down as the heart fails to pump oxygenated blood effectively. It is similar to yet another Shakespearean depiction of a real-life death, Katherine of Aragon in Henry VIII. She says in her final moments, ‘Mine eyes grow dim’ – parts of her brain, deprived of oxygen, are starting to fail and death is close.
The ultimate cause of all deaths is the failure of oxygen to reach vital structures within the body. As Dr Milton Helpern, Chief Medical Examiner of New York City, succinctly put it, ‘Death may be due to a wide variety of diseases and disorders, but in every case the underlying physiological cause is a breakdown in the body’s oxygen cycle.’
Elizabethans, however, had no concept of oxygen, because the element wasn’t discovered until 200 years after Shakespeare was writing. But the idea of cessation of breathing as an important indicator in determining death was well established. The necessity and life-giving properties of blood were also well known. The idea of the ‘life of the blood’ has a history going further back than Hippocrates, to the Old Testament, where it is stated that ‘the life of the flesh is in the blood’. However, the details of how the blood carried out its life-giving function were anything but clear.
In the moments around death, gravity slowly pulls the blood, and to a lesser extent blood plasma, to the lowest point in the body, ‘descended to the labouring heart’ as Shakespeare put it. In the intervening period the skin can appear mottled or patchy in colour due to uneven vasodilation. The loss of blood pressure leaves skin flaccid and pale, more eloquently put in Henry VI Part 2 as ‘meagre, pale and bloodless’.
Without fresh supplies of oxygen, cells begin to die. The last few moments of life are often accompanied by a short series of heaving gasps, a final desperate attempt to get hold of oxygen. On rare occasions there may be a laryngeal spasm, which causes the ‘death rattle’, brief agonal convulsions, and the chest and shoulders may heave.
All death may come down to disruption in the oxygen cycle, but there are a huge number of ways it can happen. Shakespeare explored many of these different causes of death in his work. Some are true to life and others are created from his imagination, but all of them are interesting in their own way.
Notes
1 Of all the plays, only The Merry Wives of Windsor is completely free of death and any mention of it (although even here, Dr Caius does threaten to cut a man’s throat and Mistress Ford jokes about someone being bitten to death by fleas). If you count Shakespeare’s sonnets as a single work, only one of his poems, ‘A Lover’s Complaint’, contains no allusions to death.
2 Some versions of the text have ‘Nell’ (Pistol’s wife) instead of ‘Doll’. See also Chapter 7.
3 Such detailed knowledge has often been cited as reason to suspect that William Shakespeare is not the true author of the plays and poems attributed to him. It has been argued that it would be very difficult for someone of his position and education to gain such knowledge. Another candidate for the authorship, the Earl of Oxford, certainly did have access to this knowledge, but he died in 1604 and Shakespeare continued to write plays for another 10 years.
4 Another real-life doctor Shakespeare depicted, though in a decidedly more favourable light than Dr Caius, was Dr Butt in Henry VIII, real-life physician to the King.
5 These were related to the four elements: earth, air, fire and water.
6 Laudanum was invented by Paracelsus. It is opium mixed with alcohol. The combination is particularly effective in pain relief and became a staple of medical treatments for centuries.
7 No, I have no idea either. Your guess is as good as mine.
8 Cerimon may be another character Shakespeare based on a real-life physician, Edward Stanley, the Earl of Derby, an amateur physician who ‘was famous for chirurgerie [surgery], bone-setting and hospitality’. Another real-life candidate is Lord Lumley, who founded the Surgery Lecture at the College of Physicians in 1582.
9 In the nineteenth century German fear of premature burial prompted the construction of waiting mortuaries. Strings were attached to bells, that were then tied to fingers, to signal when someone revived (no one did). In sixteenth-century England, mistakes were presumably rare enough, and waiting for decomposition was distressing, so bodies were buried before serious decomposition set in.
10 Brooke in turn based his version on a French translation of another version of the story written by the Italian Matteo Bandello.
11 The screams were thought to be so terrible that they could kill a man, or as Shakespeare put it in Henry IV Part 2, ‘Would curses kill, as doth the mandrake’s groan’.
12 Both parts of Henry IV and The Merry Wives of Windsor. Falstaff doesn’t actually make an appearance in Henry V.
13 Sack is an old term for white wine imported from Spain that was fortified with brandy.
14 Henry IV later died on the same day he was taken ill.