How foul it is; what rank diseases grow
Henry IV Part ii, Act 3, Scene 1
Disease is ever present in our world, but in Shakespeare’s time, malnutrition, poor sanitation and ineffective remedies all contributed to much higher death rates. Personal health was understandably something of a preoccupation for Elizabethans and Shakespeare seems to have been more preoccupied than his fellow playwrights. Disease, in some form or other, is mentioned in every Shakespeare play. Mostly it is casual asides, incidental dialogue or a minor event on the sidelines of the main action of the play. A large proportion of Shakespeare’s huge stock of insults are disease-based. If a character disliked someone they might literally wish them ill – ‘make him / By inchmeal a disease!’ (The Tempest). In cases of real hatred, particularly nasty diseases might be selected for an especially malicious curse – ‘Boils and plagues / Plaster you o’er, that you may be abhorr’d / Further than seen’ (Coriolanus). But in several plays the role of disease is much more developed.
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The diseases that people in Renaissance England lived and died with were very different from those that worry us today. Bacterial infections such as typhoid, syphilis and scarlet fever, that once killed millions, have been brought under control by the discovery of antibiotics in the twentieth century. Viral infections, such as measles and smallpox, which destroyed countless lives, have been tamed or eliminated completely by vaccinations.
In Shakespeare’s day, old familiar diseases, such as tuberculosis, influenza and leprosy, fought for victims alongside virulent newcomers such as syphilis and typhus. It was a crowded and competitive field and not all infectious agents survived. New diseases generally outcompeted old diseases for victims.
The ‘English Sweating Sickness’, for example, was only a temporary visitor. It appeared in 1485 without explanation and disappeared just as mysteriously in 1551. Cases were confined to England and English-held regions of France; even foreigners living in these areas appear to have been completely unaffected. The symptoms of high fever and profuse sweating appeared overnight or in the morning and continued for 24 hours, after which patients were either on their way to recovery or dead. Mortality rates were around 30 per cent. For reasons unknown, sweating sickness caused particularly high mortality among the upper classes and therefore there was a lot of fuss made about it at the time. In Measure for Measure Mistress Overdone, a brothel owner, complains that the sweat, among many other causes of death, is having a detrimental effect on her business: ‘Thus, what with the war, what with the sweat, what with the gallows and what with poverty, I am custom-shrunk.’ The fact that the play was written in 1604, long after the disease had disappeared, and is set in Vienna, where the disease never occurred, shows how much impact it had made on the public consciousness. Though many theories have been put forward, including scarlet fever, influenza and hantaviruses, there is no completely satisfactory explanation of the disease.
One ancient disease, leprosy, saw a notable decline in cases during the fourteenth and fifteenth centuries that coincided with an increase in tuberculosis (TB). As town and city populations swelled, transmission of tuberculosis increased and killed off its victims more quickly. Anyone already debilitated by leprosy was likely to succumb more rapidly to an infection of the TB bacteria.
That leprosy was an unpleasant disease and lepers were generally feared or despised is demonstrated by Timon’s reference to leprosy in vitriolic verbal attacks on the people of Athens. Meanwhile the lethal nature of TB, or consumption as it was known at the time, is turned into a joke in Much Ado About Nothing. Beatrice and Benedict, despite being at daggers drawn for most of the play, are tricked into falling in love. To show Beatrice has lost none of her fighting spirit she tells Benedict she only agreed to marry him because ‘I yield upon great persuasion; and partly to save your life, for I was told you were in a consumption.’
Malaria (literally ‘bad air’ because the disease was associated with swamps and other damp areas) was known as ‘ague’ in England up until the eighteenth century. It is mentioned in eight of Shakespeare’s plays, most notably in The Tempest, which is set on a magical malarial island. Prospero, a powerful sorcerer, lives on the island with his daughter Miranda, a spirit called Ariel and the monstrous Caliban, who has been enslaved to do Prospero’s bidding. More people arrive on the island because of a shipwreck.
Caliban curses his master by wishing malaria on him: ‘All the infections that the sun sucks up / From bogs, fens, flats, on Prosper fall’. The curse shows an understanding of the environmental conditions that led to malarial outbreaks. They mostly occurred in late summer and affected people living close to brackish water. Malaria is transmitted by mosquitoes, insects that breed in stagnant water. The disease itself is caused by a plasmodium, a type of single-cell parasite that develops inside the mosquito and is injected into a vertebrate host (such as a human) during a blood meal. The parasites then multiply in the host’s liver cells before entering the bloodstream to infect red blood cells. This destroys the host’s red blood cells, resulting in the malaria symptoms.
In the play one of the castaways, the butler Stephano, meets Caliban when he is in a drunken stupor. He mistakes his alcohol-induced trembling and delirium for an attack of malaria: ‘hath got, as I take it, an ague […] he’s in a fit now and does not talk after the wisest’. Stephano tries to help Caliban through the worst of the attack: ‘He shall taste of my bottle: if he have never drunk wine afore it will go near to remove his fit’. The wine was expected to ‘shake your shaking’. Alcohol may have made the patient feel better but it wouldn’t treat the infection itself. Effective antimalarial treatments, such as cinchona powder, were not available in England until 1660.1 Malarial outbreaks in England declined as cinchona remedies became more widely available. The drainage of marshes and fens for agricultural use also meant there were fewer places for the mosquito to breed.2
Once contracted, malaria can persist for years with occasional relapses caused by the blood stages of the plasmodium’s life-cycle. Fevers described as tertian or quartian referred to the regular cycle of fevers, and match well with the symptoms from infections of malarial species P. vivax and P. falciparum. The reference to a tertian quotidian in Henry V suggests it might have been malaria that killed Sir John Falstaff (see Chapter 3).
In Shakespeare’s day infection and illness would have been common and accepted as part of life, but a handful of diseases were particularly dreaded because of their high mortality rate or social stigma. Smallpox, caused by a virus, killed a large proportion of those it infected and left disfiguring scars on those it didn’t kill. Syphilis, a bacterial infection known as the pox, was associated with illicit sexual behaviour and could affect a person’s health as well as their social standing for years. Above all others, plague terrified communities because of its sudden appearance and swift and devastating mortality rate.
For a disease that was so pervasive in the Elizabethan and Jacobean eras, it is surprising that there is no plague play, or certainly none that has survived, and references to the disease in existing plays are minimal considering the impact it must have made on people at the time. The references that do exist, are usually insults or remarks to express disgust. Shakespeare is liberal with using plague as a general curse, generally against people, but also against anything annoying, from drums (All’s Well That Ends Well), to the weather (The Tempest) and even pickle-herrings (Twelfth Night). It either shows an absolute and serious hatred for recipients of the oath, or gallows humour of the blackest kind. Laughing at adversity may be one way Elizabethan audiences coped with grim reality. The pestilence held the population in constant dread. No playwright depicted plague in any realistic way or detailed its awful effects. It is almost as though the topic were too terrifying to mention or show onstage. The theatre was an escape from everyday worries and audiences didn’t need reminders of the reality of the terrible pestilence.
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Plague had been endemic in England since the Black Death in the fourteenth century, with occasional devastating major outbreaks. In the seventeenth century scarcely a year went by without at least a few deaths from plague until the last major outbreak in 1665. Plague shaped Shakespeare’s life. It closed theatres and killed his fellow actors; it even turned the playwright into a poet when he was forced to find alternative sources of income.
Plague outbreaks were more than an inconvenient interruption. It struck without warning, was agonising and unpleasant to suffer, and there was a high chance it would kill you, so people were justifiably frightened. In Romeo and Juliet, when Mercutio is fatally wounded, he spits out the most terrible curse he can think of on those responsible: ‘A plague o’both your houses!’
The plague bacteria, Yersinia pestis (commonly known as bubonic plague, after the buboes or swellings that are characteristic of the disease), can infect over 200 different species, not just humans. The natural hosts of the disease are burrowing rodents that have lived with plague for thousands of years and have therefore developed resistance. But when the plague jumps from rodents to humans it becomes particularly virulent. Sixteenth-century Europe was an environment with many opportunities for plague to cross over from rodents to humans.
It was, however, an exceptional period. Over the course of human and plague history our exposure to the disease has been too infrequent for our species to adapt and evolve to defend ourselves. There is evidence that some people who survived plague acquired some kind of immunity, but this was not passed on to future generations. Recurring outbreaks would be expected to affect all ages, but in the sixteenth and seventeenth centuries it tended to be mostly children that were infected. Maybe Shakespeare’s early exposure to the bacteria as a child helped him survive the numerous outbreaks he was exposed to as an adult.3
Plague is transmitted not by the rodents themselves but by their fleas. All fleas bite, but not all flea bites are the same. Some are particularly good at transmitting plague, especially Xenopsylla cheopis, the oriental rat flea. This is because the bacteria can form a blockage between its oesophagus and mid-gut. This blockage is a mixture of the last blood meal and sticky plague bacteria. This is bad news, both for the flea and for the animal it bites. The blockage means the flea will eventually starve to death, but not until a few days of vigorous biting have passed. When it tries to take in a new blood meal this cannot pass into the gut, so, instead, it is vomited back into the animal that has been bitten, along with the plague bacteria.4
Once inside the body Yersinia pestis moves through the blood to the lymph nodes where it replicates. The bacteria carefully conceal their activities from the immune system of their new host. They are able to hide by forming a protective envelope that resists the normal process of elimination, phagocytosis (being swallowed up and digested by immune cells). Yersinia pestis also prevents immune cells from signalling distress that would bring more immune cells to fight off the infection. So at this early stage of infection there is no inflammation, or tell-tale sign that the victim is infected, and the bacteria continue to multiply unhindered.
At some point the growing ball of bacteria will become so large that it bursts the immune cells and spills into the bloodstream. A sudden influx of bacteria into the blood system would normally cause septic shock that would kill the host before the infection could be passed on (fleas don’t bite dead animals). So the plague bacteria modify the body’s normal response. A molecule on the surface of the majority of disease-causing Gram-negative bacteria, known as Lipid A, is responsible for most of the bacteria’s toxicity. At normal body temperature the plague bacteria produce a modified version of Lipid A that is much less toxic. This allows the bacteria time to evade the immune system and for a flea to feed on the infected blood and transfer the bacteria to a new host.
A person can feel quite well for up to six days following the initial infected bite. Then they will be suddenly struck down when the infection reaches a critical point. By the time symptoms appear, their tissues are already riddled with bacteria. To Elizabethans it seemed as if the plague appeared out of nowhere without warning – ‘Even so quickly may one catch the plague?’ (Twelfth Night).
The well-known symptoms, buboes in the groin, armpit and neck, are the lymph nodes swollen with bacteria. The buboes become huge and exquisitely painful: ‘a boil, / A plague-sore, an embossed carbuncle’, as Shakespeare puts it.5 Multiple buboes can arise from multiple flea bites, producing ‘plague tokens’, ‘God’s tokens’ or ‘death-tokens’. In Love’s Labours Lost, a play full of verbal tricks and cleverness, Biron plays on the multiple use of the word token (love/death-token and Lord’s/God’s token) when he teases the ladies that they have fallen in love with their suitors after receiving their gifts: ‘They have the plague, and caught it of your eyes; / These lords are visited; you are not free, / For the Lord’s tokens on you do I see.’
Sometimes these buboes turn black and rotten. Sometimes they slough off to leave behind rotten tissue, exposed muscle and occasionally even bone. Alternatively the buboes ripen and discharge large quantities of pus; undoubtedly an unpleasant experience, but in the past this scenario offered the best chance of recovery. Nevertheless, once contracted, the prognosis was poor – ‘He is so plaguy proud that the death-tokens of it / Cry “No recovery”’ (Troilus and Cressida). Between 40 and 60 per cent of those affected died. This is a terrifyingly high proportion considering one of the most dreaded diseases of modern times, smallpox, killed 20–30 per cent of those infected.
Although Yersinia pestis has evolved brilliant methods for evading the immune system and facilitating its transmission between hosts, those hosts would normally be rats. Rat fleas prefer to feed on rats, not humans (humans have their own variety of fleas). Fleas are fairly homey creatures, and tend to stick with their dinner once they have found it. They amble around with the rat as it goes about its business, biting their host three or four times a week. Only when the rat dies will the flea reluctantly leave to find a new host. Yersinia pestis has to kill the rat host eventually in order to spread. During a major outbreak, when lots of rats die, the fleas start to look for alternative accommodation, and humans are a convenient substitute even if we don’t taste quite as good.
In the late sixteenth and early seventeenth centuries humans and rats lived in particularly close proximity. Housing was rarely of a quality that would keep out rodents. They also easily became dependent on human detritus left on the London streets. The clustering of plague cases in the poorer, more densely populated and dirtier parts of town illustrates the problem.
Rats are also not very adventurous creatures, rarely travelling more than a few streets away from where they were born. The spread of plague over vast distances is the result of human activity. Trade provided the methods of transport that brought these hosts and their infected fleas from one city to the next in wagons, or from port to port in ships. Shakespeare describes the potential problem of large numbers of people travelling regularly and over long distances in the Renaissance era. He has a carrier stop off at an inn during his travels and complain of the poor quality of accommodation, caused by so many people passing through: ‘I think this be the most villainous house in all / London road for fleas: I am stung like a tench’ (Henry IV Part I).
Fleas were far more common than they are today and the poor state of personal hygiene would only have attracted more of them. People often wore the same clothes and slept in the same bed-linen for long periods of time without washing them. In The Merry Wives of Windsor the Fords are a prosperous couple with money to spend on clothes and laundry, but their affluence does not mean their lives are flea-free. In the play Ford is searching a laundry basket for the man he thinks is having an affair with his wife, but she warns him, ‘If you find a man there, he shall die a flea’s death.’
Human fleas, Pulex irritans, probably contributed to the spread of pestilence as well.6 They do not form the same gut blockage that makes rat fleas such a good transmitter of plague bacteria. But frequent biting still makes Pulex a likely means of transmission between individual members of a household who were often living in cramped homes and sharing beds.
If bubonic plague wasn’t bad enough, there were other forms of the disease that were more terrifying still. Plague comes in three main varieties: bubonic, septicemic and pneumonic. Bubonic plague is by far the most common form. Septicemic plague is the rarest, infecting the blood rather than the lymph nodes. It causes a breakdown in blood-clotting processes. Lots of tiny clots form throughout the body, depleting clotting resources, so that uncontrolled bleeding then occurs because new clots cannot form. Untreated it is almost always fatal.
In some circumstances (the details are still not certain) Yersinia pestis can move to the lungs to produce the third form of plague, pneumonic, the most frightening of all. Infection in the lungs produces hacking, bloody coughing that can transmit the bacteria directly between individuals via droplets of blood expelled from the lungs, meaning there is no need of an intermediary flea. Pneumonic plague kills its victims within three days and virtually no one survives. The Black Death of fourteenth-century Europe was such a devastating plague outbreak because the pneumonic form was present as well as bubonic and septicemic forms. In Macbeth Ross describes the miserable life in Scotland under Macbeth’s rule: ‘good men’s lives / Expire before the flowers in their caps, / Dying or ere they sicken’, but he could as easily be talking about life during the Black Death.
There were at least five major outbreaks of bubonic plague in London during Shakespeare’s lifetime and though these outbreaks didn’t reach the devastation of the Black Death, they all had a major impact on the population, particularly in towns and more populated areas. Wealthier Londoners often took Chaucer’s advice, written during the Black Death, to ‘run fast and run far’. At that time there were few uninfected corners of Europe that you could run to. At least a quarter of Europe’s 75 million population died in the mid-fourteenth century.7 The plagues of the Renaissance were a different matter. Escaping the city during the fifteenth- and sixteenth-century outbreaks would have significantly improved a person’s chances of survival. Shakespeare was fortunate to have a house and family in Stratford that he could retreat to when plague appeared in London.
There was some recognition that plague was contagious, even if the mechanism was far from understood. Some suspected it was brought to London by foreigners. Others tried to blame outbreaks on an unusual alignment of the planets. The 1593 plague was blamed on the position of Saturn in the night sky ‘passing through the uttermost parts of Cancer and the beginning of Leo’ as it had done 30 years earlier when there had been another terrible outbreak. Shakespeare was certainly aware of the planetary theory, as in Timon of Athens the playwright has Timon urge Alcibiades to take revenge on Athens: ‘Be as a planetary plague, when Jove / Will o’er some high-viced city hang his poison / In the sick air’.
The mention of vice in the same passage acknowledges that many saw plague as punishment from God. It was just reward for the licentious living for which city dwellers were renowned. This position was difficult to maintain when priests, expected to visit the sick and dying and therefore especially susceptible to infection, suffered particularly high mortality rates from the disease. What was clear was that when one person died of plague others closely associated with the sick often became ill themselves.
Civic authorities did what they could to manage outbreaks when they occurred, but without a true understanding of the disease and how it was transmitted, they could put up only limited effective defences. Public-health measures during disease outbreaks were patchy at best. Bonfires were lit in the streets in an attempt ‘to purge and cleanse the air’ and stray dogs were culled. But most efforts were concentrated on trying to contain an outbreak when it occurred. Ships were held at anchor, travellers on foot were held in special hospitals for forty days (quarantine derived from quaranta, Italian for ‘forty days’) before entering the city and playhouses were closed, though churches remained open.
Some plague victims were taken to ’spitals (hospitals) or the ‘pest-house’ where nursing care was notoriously poor. Once inside you were not expected to re-emerge. Mortality rates in the pest-houses have been estimated at 98 per cent during the 1665 plague outbreak. Many of these measures amounted to simply separating the sick poor from the nervous rich.
If plague was discovered in a home, the house would be sealed up with the sick and the well trapped together inside until the plague had passed. A red cross was painted on the door as a warning to others. But red crosses and locked doors did nothing to prevent rats from moving in and out of houses, and in fact the idea of preventing the spread of plague by containing it may have resulted in more deaths. Cooped up together, transmission between individuals would have been easy. And at least one family died of starvation because they were shut up in their house in London during the 1592–3 outbreak.
The unpleasant and potentially risky task of entering houses looking for signs of plague was given to searchers. These were recruited from the ranks of the most disposable members of the community – elderly women of low social status. They were ‘honest, discreet matrons’ who lived apart and received four to six pence for each plague body they identified. These women had no medical training and undoubtedly made mistakes, not necessarily through malice but through plain ignorance or fear.
Households locked up and separated from the outside world were a familiar sight and therefore a credible plot device for how important messages could be unfortunately delayed. In Romeo and Juliet, plague, or fear of it, prevents Friar John from bringing Romeo the vital information that Juliet will not be killed by the poison she has drunk but merely appear to be dead. Friar John explains:
the searchers of the town,
Suspecting that we both were in a house
Where the infectious pestilence did reign,
Sealed up the doors, and would not let us forth,
So that my speed to Mantua there was stayed.
Shakespeare borrowed the plague plot device from earlier versions of the Romeo and Juliet story and it is surprising that such a simple and credible way of diverting, delaying or even killing off characters wasn’t used more. Plague may be conspicuous by its absence onstage but many others were writing about it. People made huge profits from the sale of treatises, pamphlets and books on the prevention and cure of plague (23 books were published on the subject between 1486 and 1604). Yet more money was made by those selling remedies and supposed cures.
Contemporary treatments for plague were staggering in their number and diversity. And they were all almost completely useless. That didn’t stop them from being sold or bought in great quantities. Exotic ingredients were suggested to those that could afford them. For example, treacle and gunpowder could be used ‘to provoke a sweat’. But the poor were not forgotten and it was suggested that they ‘may eat bread and Butter alone, for Butter is not only a preservative against the plague, but against all manner of poisons’. One recommendation was that a live plucked chicken should be applied to the plague sores to draw out the disease. Smoking came highly recommended as the haze of smoke would ward off the foul smells thought to cause disease. Tobacco, recently introduced to Europe and popularised by Sir Walter Raleigh, was therefore seen as a wonder drug. It was a relatively rational approach to plague prevention as it was understood at the time; unfortunately, the disease was not in the air. Smoking didn’t stop plague but tobacconists made a killing.
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Like plague, dysentery was another lethal infection too terrifying to show on the stage. It was a particular scourge of armies on campaign. One early name given to the disease, ‘the bloody flux’, was certainly descriptive of its symptoms. Dysentery is caused by a number of different bacteria, viruses and parasites, and produces agonising abdominal pains, inflamed bowels and excessive, and bloody, diarrhoea.
Despite depicting many wars in his plays, Shakespeare only referred to dysentery in Henry V, and even there it is only alluded to as a sickness. It is likely his audience was perfectly familiar with the disease and didn’t need a detailed description. Also, Shakespeare didn’t want to dwell on Henry V’s near-failures at the siege of Harfleur, but to promote his successes. At Agincourt he wanted to show that an English army, even weakened by disease, was still more than a match for the French.
At Harfleur, while cannonballs and other missiles pounded the city walls, Henry and his men were camped outside. The people trapped inside the walls had control of the waterways around the town and deliberately opened sluices to flood the fields to the north. This severely hampered where Henry could move his troop and the stagnant water in the heat of the summer soon became a prime spot for breeding bacteria and bugs.
The outbreak of dysentery affected not just Henry’s troops, and those located near the King’s tent in particular, but also those inside the town. Henry had to send over 2,000 troops back to England to recover. These men were effectively lost to Henry’s army, though few lost their lives. Shakespeare has Henry admit as much to the envoy from the French army: ‘My people are with sickness much enfeebled, / My numbers lessened’. Although some contemporary chronicles claim the death rate from disease was very high, there is only direct evidence for 37 deaths and modern historians estimate dysentery killed around 50 people at Harfleur.8
The disease had no respect for rank; it killed the meanest foot soldier and kings alike. The death of Bishop Courtenay during the siege of Harfleur was a considerable worry. Not only had the disease claimed a man of the cloth, but the Bishop had often stayed in the King’s quarters. Henry was lucky to escape infection on that occasion but his luck ran out seven years later in 1422. Again he was on campaign in France. At the siege of Meaux, Henry contracted dysentery but struggled on towards Paris. As the disease progressed he was in such pain that he could not ride his horse and eventually had to be transported by boat along the Seine. By the time he died he was skeletally thin. Shakespeare tactfully ignored Henry’s miserable death and ended his play on a high note with the acquisition of the French Princess Catherine as his bride and, by implication, the French throne.
Henry V was not the only king to die of dysentery. King John fell prey to the disease while fighting against his own barons. Though he had hoped to continue his campaign, he fell ill at Newark and was unable to continue. He succumbed to the disease during the night of 18–19 November 1216. Contemporary chroniclers had several alternative theories as to what had killed the monarch, and Shakespeare chose the most colourful when he portrayed the event in King John: he laid the blame on a monk who had poisoned him (see Chapter 8).
Dysentery wasn’t the only disease that worried the military. Soldiers that survived the ‘bloody flux’ might have had the opportunity to contract venereal diseases from the prostitutes who often accompanied the troops. When soldiers returned home from campaigns they often took booty home with them, the spoils of war, and they may also have carried syphilis, which spoiled them in a different way. Playwrights may have been reluctant to portray the horrors of plague or dysentery but they were more than happy to satirise syphilis and its sufferers.
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Victims of disease, and particularly disfiguring diseases such as smallpox or scrofula, were usually seen as objects of pity. But syphilitics, with their characteristic facial deformities, were openly mocked. Syphilis, most commonly referred to as ‘the pox’,9 first appeared in Europe in 1494–5 but its spread was rapid.10 By the time Shakespeare was writing it was such a common disease that his audiences would have easily understood even very subtle references to it in his plays and poetry.
At the time, the cause of the disease was unknown but many theories were offered up. Some believed the disease had been created during the sexual union of a courtesan and a leper. Others thought it a curse from God for illicit sex. Still others laid the blame on anything from cannibalism to American iguanas or the potato. However, some commentators were more perceptive.
In 1546 Girolamo Fracastoro composed a 1,300-line poem about the pox. Hidden within those lines he postulated the existence of tiny invisible living things that could cause the disease: what today we would call germs. Fracastoro was centuries ahead of his time. Germ theory was not widely accepted until the mid-nineteenth century and the germ that causes syphilis was not identified until 1905 by Erich Hoffmann and Fritz Schaudinn.
What Hoffmann and Schaudinn identified was the spirochete, or bacterium, Treponema pallidum. It is a bacterium with a snakelike shape about the size of a red blood cell. The spirochete wriggles its way from one person into another through a break in moist skin or through mucous membranes. The mystery of syphilis has now been made clear, but where it came from is still vague.
The first descriptions of the disease showed it was new, or certainly a much more vigorous and devastating form of an existing disease. When new diseases are introduced into a population they are initially more virulent as there is no previous immunity to defend against them. The symptoms in these initial infections are more exaggerated, and can even differ markedly from the symptoms displayed by patients once the disease has become established in a population.
The first great syphilis epidemic occurred in Naples in 1494–5 during a French invasion. It produced grotesque sores all over the body. The disease swept through the population so dramatically and devastatingly that even lepers protested when syphilitics moved into their neighbourhood. By the end of the sixteenth century milder strains of syphilis had displaced more aggressive forms that killed their host too quickly and they have been with us ever since.11
The first appearance of the disease in Europe came about very shortly after the return of Columbus from the New World on 15 March 1493. For many this is more than mere coincidence. The assumption is that Columbus and his crew brought back the disease from Hispaniola (an island divided between modern-day Haiti and the Dominican Republic). But there is an alternative theory.
Some believe the initial epidemic in Naples was caused by several diseases, one of which was syphilis, combining to cause such devastating results. The theory goes that syphilis was already present in Europe in the form of yaws, a subspecies of the same bacteria that causes syphilis, Treponema pallidum. Yaws was certainly in existence in Europe long before syphilis arrived, and it would have been classified as leprosy by medieval doctors because of its effects on the skin (it causes deep open sores to appear). It is transmitted by direct contact with the skin of an infected person.
The theory states that syphilis is a mutation of the yaws spirochete into a more dangerous form that is transmitted through mucous membranes by sexual contact. It is suggested that the mutation would have been prompted or exacerbated by the mass movement of human populations, such as happened within the slave trade.
Yaws could be caught at any age and was likely to be an early childhood disease that would help the population build up a tolerance to it (childhood symptoms are often milder than if the same disease infects an adult). But syphilis would have infected people when they were older.
Evidence of syphilis has been found in skeletons from the Dominican Republic dating back to pre-Columbian times. This appeared to end the argument once and for all in favour of the Hispaniola/Columbus theory. That held true, until skeletons were excavated from a medieval monastery known as Blackfriars in Hull, England. The bones were dated to between 1300 and 1420, long before Columbus’s return, and appeared to show signs of syphilis. Others claimed the skeletons showed signs of yaws, not syphilis. The debate continues to rage and is only likely to end when a test can be established to distinguish the yaws spirochete from the syphilis one.
Whatever the origins of the disease, the outbreak in Naples in 1494/5 marked a turning point. It quickly developed into a global epidemic. The new, more active, form of Treponema pallidum spread astonishingly quickly. It was undoubtedly helped by war, with disbanded soldiers carrying the infection far and wide. By 1498 the disease had reached India. From there it moved to China where it was known as the ‘Canton rash’. By 1512 it had arrived in Japan under the name of the ‘Chinese ulcer’. As the contagion spread, each country blamed its neighbour. The Russians blamed the Poles, the Poles blamed the Germans, the Germans blamed the Spanish. The French and Italians blamed each other, as did the Christians and Muslims.
By the time Shakespeare was making satirical references to the disease in his plays and poems, the pox was responsible for up to half of all hospital admissions, according to the surgeon William Clowes.12 Prostitutes were blamed for incubating the disease but few blamed their clients for the spread of the infection. Falstaff voices the common belief when he tells the prostitute Doll Tearsheet, ‘If the cook help to make the gluttony, you help to make the diseases, Doll. We catch of you, Doll, we catch of you’ (Henry IV Part II). There were thousands of women selling sex in England’s capital and other major towns, to eke out a living in difficult economic times. Certain districts became well known for their brothels, and the South Bank was home to some of the most notorious brothels or ‘stews’ as they were known.
The South Bank was also home to Shakespeare’s Globe theatre and the site of the Bishop of Winchester’s palace. Many of the South Bank brothels were formerly controlled by the Bishop of Winchester, until the law changed and there was a crackdown on prostitution in Henry VIII’s time, so prostitutes gained the nickname of Winchester geese. A Winchester goose might also be someone who had contracted syphilis from a prostitute. In Henry VI Part I the Duke of Gloucester calls the Bishop of Winchester a ‘Winchester goose’, which is a much greater insult than it may appear. The same phrase is used in Troilus and Cressida, which contains so many references to syphilis that it has become known as the ‘pox play’.
The play was inspired by Homer’s Iliad and Chaucer’s Troilus and Criseyde.13 The two named in the title of the play are lovers brought together by Cressida’s lecherous uncle, Pandarus (the name gave rise to the Elizabethan slang ‘pander’ for a bawd or pimp). If the play’s setting of war, and Pandarus’s arranging illicit sexual meetings between the lovers, wasn’t enough to associate the play with syphilis, there is more.
The lovers are separated when Cressida is handed over to the Greek side in exchange for a Trojan prisoner. Despite swearing to be faithful to Troilus, Cressida is wooed by Diomedes, showing women’s perceived unfaithfulness. Another Greek character, Thersites, plays the part of the fool hurling insults at everyone, usually laced with references to disease. One particular insult, directed at Patroclus, lists the symptoms of syphilis:
Why, his masculine whore. Now, the rotten diseases of the south, the guts-griping, ruptures, catarrhs, loads o’ gravel i’ the back, lethargies, cold palsies, raw eyes, dirt-rotten livers, wheezing lungs, bladders full of imposthume, sciaticas, limekilns i’ the palm, incurable bone-ache …
The list is a long one, and such detailed knowledge of the disease might not be expected from a writer with no medical training, but Shakespeare potentially had access to a number of other sources (see Chapter 2). Apart from consulting doctors, there were many treatises and commentaries written about the disease that he could have learned from. For example, Phillip Stubbes wrote in his 1583 Anatomie of Abuses:
On whoredom […] besides that it bringeth everlasting damnation to all that live therein […] it also bringeth these inconveniences, with many more, videlicet [viz], it dimmeth the sight, it impaireth the hearing, it infirmeth the sinews, it weakeneth the joints, it exhausteth the marrow, consumeth the moisture and supplement of the body, it revileth the face, appalleth the countenance, it dulleth the spirits, it hurteth the memory, it weakeneth the whole body, it bringeth consumption, it causeth ulceration, scab, scurf, blaine, blotch, pockes and biles, it maketh hoare haires, bald pates, induceth old age, and, in fine, bringeth death before nature urge it, malady enforce it, or age constrain it.
Stubbes may have conflated syphilis with more than one other disease, but you get the general idea.
The list could be even longer if all the possible symptoms of the disease are listed. As John Stokes, a twentieth-century specialist in syphilis, put it, ‘Almost anything might be expected at any time.’ The symptoms mimic so many other diseases in the later stages that people were often misdiagnosed. Syphilis became known as ‘the great imitator’. The crucial initial symptom of diagnosis, a chancre on the genitals, may have healed years before and long been forgotten.
The initial often painless chancre, or sore, usually appears on the genitals around three weeks after infection; it is followed by fever, rash and a feeling of malaise. This stage is known as primary syphilis. The sore will disappear after about six weeks but the spirochete has already moved into the rest of the body, through the bloodstream, where it settles down for a prolonged stay. The body’s immune system may put up a valiant fight, destroying millions of bacteria, but a few of the spirochetes will evade the onslaught and go on to reproduce. All tissues are likely to suffer over the following years and decades, with nerves and blood vessels being particularly susceptible to attack.
After the initial stage the symptoms subside for an indeterminate length of time, from a few months to many years, but averaging seven years. During this period many would have thought their initial treatment had been successful. But the spirochete was still there, multiplying and causing a slow progressive inflammatory reaction. This symptom-free time was most dangerous, as syphilitics could still pass on the infection to others. The disease is very infectious for the first two years, less so after that and rarely contagious after five years.
After the period of latency, the disease re-emerges as an all-over rash of pustules, much like chicken pox. References to ‘lazar-like’ eruptions of the skin in Shakespeare’s plays may show his knowledge of this later development of symptoms. This stage is known as secondary syphilis.
The disease will disappear from view again but leave the victim feeling dreadfully unwell. Patients often went from doctor to doctor to describe mysterious fevers and aches and pains with no apparent cause. This is the third stage of the disease, tertiary syphilis, when the inner structures of the body are attacked. The spirochete can create symptoms that look like anything but syphilis. Before a clinical test was developed, people were diagnosed with anything from rheumatism to gout, eczema, epilepsy, jaundice, schizophrenia or just plain ‘nerves’. In the final stages, tertiary syphilis develops into a hideously disfiguring and agonising disease.
One of the characteristic disfigurements of tertiary syphilis is a collapsed or ‘saddle’ nose, caused when the cartilage of the nose is eaten away.14 Sir William Davenant, poet, playwright, godson and (he claimed) actual son of William Shakespeare, ‘got a terrible clap of a Black handsome wench that lay in Ale-yard, Westminster […] which cost him his Nose.’
Portrait of Sir William Davenant by John Greenhill.
In the past corks were stuffed into nostrils to give a more normal appearance to the nose. Quills were then inserted to allow the individual to breathe. Some attempted to cover up the deformity by wearing a false nose made of copper. In Troilus and Cressida, Cressida, resistant to her uncle’s attempts to persuade her to like Troilus, commended him ‘for a copper nose’.
Finally death would arrive after years or decades of poor health. This could be a slow protracted death, writhing in a bed raving about God (from the spirochete attacking the brain), or a very sudden event when an aortic aneurysm, caused by the spirochete attacking the blood vessel’s walls, suddenly gave way.
Some took precautions against infection by wearing ‘venus gloves’ or condoms (in Troilus and Cressida apparently Menelaus’s ex-wife swears by them). It is doubtful these early condoms were as effective as modern versions in preventing transmission, but they were considerably better than other preventative measures that were taken. Some who engaged in risky activity took the precaution of wrapping their endangered organ in a piece of cloth soaked in wine, shavings of Guaiac (tree resin), flakes of copper, mercury compounds, gentian root, red coral, ash of ivory and burnt horn of deer. Stewed prunes were thought to be an effective cure and were often served in brothels. ‘Hard pissing’ was thought to flush out the disease and so brothel owners often placed two chamber pots under each bed for their clients.15 At a time when all diseases were thought to be due to an imbalance of humours, removing the ‘corruption’ by bleeding, vomiting, sweating, defecation or urination was thought a reasonable treatment, but they were wrong.
A burning sensation during urination is a typical symptom of venereal disease, but of gonorrhoea rather than syphilis. In Elizabethan England it was often conflated with syphilis under the general term ‘pox’, though it was likely that both infections were often contracted simultaneously. Some thought the burning sensations of gonorrhoea were just the prelude to syphilis and they were different stages of the same disease. It also gave an opportunity for Shakespeare to add in a few knowing jokes and an alternative interpretation to phrases such as ‘I burn with thy desire’ (Henry VI Part I) and ‘Love’s fire took heat perpetual’ (Sonnet 154).
If preventative measures failed, and a chancre did appear, early treatment might be sought. But there was a problem. The pre-eminent medical authority of the time was Galen, a second-century Greek physician who ministered to gladiators and emperors in the Roman empire. Galen had no treatment for pox as the disease was unknown in his lifetime, so sixteenth-century medical men improvised. One treatment involved covering the sore with a spider’s web (an adaptation of a treatment also used to heal cuts). A more drastic remedy would be to attempt to remove the sore. If that didn’t work, binding the base of the penis was thought to prevent the infection spreading to the rest of the body. None of these treatments would have helped and as the disease progressed, symptoms got worse.
New and virulent diseases demanded new and stronger treatments. One of the most common treatments for pox was mercury, leading to the phrase ‘A night with Venus, a lifetime with Mercury’. Mercury had long been used in Arabic medicine to treat skin disorders such as leprosy, and it was easy to make the link with the skin lesions that appeared with syphilis infections.
Mercury, or a mercury compound, could be applied directly to the affected area, delivered by mouth or used as a fumigant. Patients would be seated in a tent-like structure with their head emerging from the top. Under their seat would be a heated pan of mercury. In Henry V, when Pistol is speaking about the fate of his ‘Doll’,16 he talks of her treatment in the ‘powdering tub of infamy’, a direct reference to the fumigant method. The fragment from Sonnet 153, ‘seething bath, which yet men prove / Against strange maladies a sovereign cure’ may be another reference to mercury vapour treatment. In fact, there are so many Shakespearean references to venereal disease and its remedies that some have suggested the playwright may have been writing from personal experience.
Mercury might have been successful in treating the initial symptoms of syphilis and the lesions that appear in the tertiary phase of the disease, but it would have had no beneficial impact on secondary syphilis and the risk of poisoning was significant. The side effects of mercury treatment included a sore mouth and throat, sometimes involving ulceration, copious salivation (producing three pints of saliva was often considered a good sign), nausea and frequent bowel movements. In extreme cases it was the treatment that killed rather than the disease (see Chapter 3).
A milder but no more effective treatment came from a tree found growing in Hispaniola, the supposed origin of the disease: Guaiac wood. Guaiac wood was easily confused with ebony, hence ‘the juice of cursed ebony’ in Hamlet, which gives a very different interpretation to what killed Old Hamlet (see Chapter 8).
Most cures focused on the male sufferers and little comfort or care was offered to the women. Some even thought that women couldn’t contract syphilis, but this was patently false as many women died of the disease. Thomas Nashe estimated that prostitutes were syphilitic by the time they were 20, and before they were 40 they were skeletally thin. Women that survived their time as prostitutes often went on to run their own establishment, as does Mistress Overdone in Shakespeare’s Measure for Measure. Once a ‘fresh whore’, she has become a ‘powdered bawd’.
One of Shakespeare’s most memorable victims of syphilis is Pandarus. At the end of Troilus and Cressida it becomes clear that he has been infected with disease and doesn’t have much time left. With only two months to live he appeals to his fellows in the sex trade (implying the audience):
Good traders in the flesh, set this in your painted cloths.
As many as be here of pander’s hall,
Your eyes, half out, weep out at Pandar’s fall;
Or if you cannot weep, yet give some groans,
Though not for me, yet for your aching bones.
rBethren and sisters of the hold-door trade,
Some two months hence my will shall here be made:
It should be now, but that my fear is this,
Some galled goose of Winchester would hiss:
Till then I’ll sweat and seek about for eases,
And at that time bequeath you my diseases.
He will spend his final weeks trying treatments to ease his pain, but he knows he will die. In his last line he bequeaths his fatal illness to the audience.
Notes
1 The bark of several species of cinchona tree contain quinine, the first known effective drug for the treatment of malaria.
2 Other factors also contributed to a reduction in malaria cases, but it didn’t disappear from Europe until the twentieth century and the invention of DDT.
3 Plague eventually died out in Europe, not owing to a natural build-up of resistance, but because there is no native species of burrowing rodent that can allow the plague bacteria to survive the cold winters.
4 Not all flea species form blockages and it isn’t necessary for plague to be transmitted from one host to another, but it most certainly speeds up the process.
5 This could also be interpreted as a reference to a syphilitic sore, which we will discuss later in the chapter.
6 Although this theory is accepted by experts in France and Russia, it remains controversial in the US.
7 At the time King Edward III was on the throne in England, but when Shakespeare collaborated with Thomas Kyd to write a play about the King they made no mention of plague at all. Instead the play focuses on Edward’s successes fighting the French and completely ignores the devastation from pestilence.
8 Contemporary chroniclers, who were not there in person and wished to promote Henry V’s achievements against all the odds, probably exaggerated the devastation caused by disease, or were merely confused by those that were sent home sick.
9 Not be confused with smallpox, which is a completely different disease.
10 Confusion with other skin diseases has caused some doubt about the exact date.
11 Over the 500 years from its first appearance in Europe, syphilis may have been responsible for 10 million deaths in Europe alone.
12 Clowes may have been exaggerating in order to promote his medical work as well as the book he had published, A Short and Profitable Treatise Touching the Cure of the Disease Called Morbus Gallicus.
13 In the Iliad, Troilus is a brave soldier without the taint of sexually transmitted disease about him, but then it was written centuries before the disease appeared in Europe. Chaucer added the romance with Cressida and Shakespeare then embellished it with disease.
14 This is rarely seen today as syphilis can be treated effectively early on with a course of antibiotics.
15 Urinating was also erroneously thought to act as a contraceptive.
16 Some versions of the text have ‘Nell’ instead of Doll. See also Chapter 3.