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PART OF the genius of William Shakespeare lies in his accurate depictions
of most vocations and walks of life. His understanding of the courts of
law and legal intricacies are uncanny; he appeared to comprehend the lives
and duties of soldiers, sailors, botanists, farmers, cobblers, butchers,
innkeepers, merchants, weavers and witches. He described the customs and
ways of the royal courts, aristocratic and diplomatic societies, as well
as the humble knowledge of the lowly and ignorant. His knowledge of the
Bible and mythology was prodigious.

Should one be astounded that most of the medical specialities have claimed
him as one of their own? Shakespeare’s 37 plays and poetry contain more
than 700 references to medicine and psychiatry. Modern medical literature
contains papers describing the Bard’s accurate descriptions of symptoms
and diseases by rheumatologists, obstetricians, paediatricians, ear nose
and throat specialists, dentists, orthopaedists and specialists in the diseases
of the elderly. Psychiatrists and psychol-ogists have documented Shakespeare’s
extraordinary depth and insight in volumes that would fill the shelves of
libraries.

We can only speculate on how Shakespeare’s mind absorbed and contained
as much, and how he came by this knowledge. We know virtually nothing about
the man and none of his personal papers survived. Hard facts are limited
to public records that show he was a taxpayer and a property owner who made
a will. Those of his plays that survive – the quartos and the folios – were
transcribed by colleagues. His medical knowledge is beyond the ken of the
well-educated layman, even in 1990. Some scholars believe he derived his
medical insights from his son-in-law, Dr John Hall, but others argue against
this because Hall moved to Stratford in 1601, and married Shakespeare’s
daughter, Susana, in 1607, when most of Shakespeare’s writing was behind
him. In his dramas the important medical insights, diagnoses and pronouncements
are made not by physicians, but by lay people.

During Shakespeare’s lifetime, William Harvey had not yet established
the role of the heart and the circulation of the blood. The residence of
the soul, in the brain, in the heart or in the liver, was still debated.
People often used amulets, potions and magic to ward off plague and disease.
Yet the Bard promoted reasoned physiological and scientific facets of medical
knowledge. We know he had access to the works of Galen, the champion of
the ancient and traditional in medical practice, alive in the 2nd century,
and to the writings of Paracelsus, forerunner of modern healing practice
with drugs and chemicals who worked in the 15th century, because characters
in his works directly refer to them.

Shakespeare reveals his knowledge of the anatomy of the brain in his
reference to the pia mater, a thin transparent covering of the brain, in
Twelfth Night, among others. In Love’s Labour’s Lost Holofernes says: ‘these
are begot in the ventricle of memory, nourished in the womb of pia mater.
. .’ Even today very few lay people know that the brain has four major fluid-filled
chambers, or ventricles, within it. Four hundred years later, contemporary
physicians cannot localise memory much more precisely. Benjamin Richardson,
a 19th-century English physician and bardolater, speculated that Shakespeare
learnt from an anatomy tome written and illustrated by Helkiah Crooke; it
was published in 1615 by W. Jaggard of the Barbican in London. Jaggard was
Shakespeare’s publisher, so perhaps the Bard studied Crooke’s drawings at
Jaggard’s publishing house.

Leg cramps and pain must have been as common in the Renaissance as they
are now, as Timon in Timon of Athens admonishes: ‘Thou cold sciatica, cripple
our senators, that their limbs may halt as lamely as their manners!’ And
Prospero, in The Tempest, instructs: ‘shorten up their sinews with aged
cramps’. Modern physicians would do well to produce such succinct clinical
descriptions. Those who are prone to migraines can readily identify with
the nurse in Romeo & Juliet, as she complains: ‘Lord, how my head aches;
what a head have I! It beats as it would fall in twenty pieces.’ And Othello
tells Desdemona ‘I have a pain upon my forehead, here.’ Desdemona says:
‘let me but bind it hard, within this hour it will be well.’ Shakespeare
effectivelylinks the sense of smell with the autonomic nervous system(which
reacts by reflex to various stimuli) in All’s WellThat Ends Well; Lafeu
observes: ‘Mine eyes smell onions;I shall weep anon.’

A neurologist can marvel at the Bard’s depth of knowledge and understanding
of the visual apparatus four centuries ago; he was acquainted with the muscles
and nerves that move and direct the eyeballs, and which mediate vision.
In Cymbeline, Imogen states that she would have ‘. . . broke mine eyestrings,
cracked them, but to look upon him’. Hermia, in A Midsummer Night’s Dream,
says: ‘Methinks I see these things with parted eye, when everything seems
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Shakespeare often employs the convention that things are not always
as they appear. One example of his exploration of appearance versus reality
is that foolish and imperceptive characters in his plays, who are blinded
and lose their sight, then gain a greater insight and more acute perception
of persons and events around them. Gloucester, in King Lear, is easily duped
by Cornwall, his false, illegitimate son, who lies and cheats and convinces
Gloucester to renounce his stepbrother, the sincere and devoted son. But
after Gloucester is blinded, he comes to ‘see’ the true feelings of his
two sons towards him. Shakespeare again demonstrates the anatomical knowledge
in the scene where Cornwall brutally gougesout Gloucester’s eyes, exclaiming:
‘Out vile jelly! Where is thy lustre now?’ The vitreous humour is a black
gelatinous matter which fills the eyeball – but how many lay people know
this today? In beautiful language, Shakespeare imparts his awareness that
when one sense is compromised, the nervous system will compensate by augmenting
the function of another. In A Midsummer Night’s Dream Hermia reveals: ‘Dark
night, that from the eye his function takes, the ear more quick of apprehension
makes. Wherein it doth impair the seeing sense, it pays the hearing double
recompense. Thou art not by mine eye, Lysander, found; mine ear, I thank
it, brought meto thy sound.’

Hundreds of years before the physiological explanations for stroke were
appreciated, Shakespeare’s genius perceptively hits close to the mark when
he has Falstaff, in The Second Part of King Henry IV, say: ‘This apoplexy
is, as I take it, a kind of lethargy . . . a kind of sleeping in the blood,
a whoreson tingling.’ He adds: ‘It hath its original from much grief, from
study and perturbation of the brain.’ Modern clinicians describe the mechanism
of stroke with just this same understanding: apoplexy is a sudden cessation
of sense and motion – a modern stroke; the lethargy, or sleeping in the
blood, correlates with obstructed arteries in the brain, which interferes
with the brain’s circulation resulting in a terrible tingling or numbness
that justified the adjective ‘whoreson’ – vile or hateful.

Patients and their families typically ask the physician if the stroke
could have occurred from too much stress. As Falstaff puts it, ‘from grief
. . . and perturbation of the brain . . .’. The Bard’s intuitive understanding
of this neurological process 400 years ago is remarkable.

Richard III was born breech, meaning his feet were delivered before
his head – which increases the risks of complications and fetal injury.
Holinshead, who chronicled the history of the British Isles in 1577, cites
that Richard III had a ‘. . . weerish withered arm, and small’. Modern physicians
know this condition of an underdeveloped arm as an Erb’s palsy, caused by
stretch injury to the nerves of the arm as they course from the spinal cord
through the neck and shoulder. Richard’s humped back may also have increased
the pressure on the spinal cord, which in turn could have caused his limping
gait.

‘O sleep! O gentle sleep! Nature’s soft nurse . . .’ – a description
by Henry IV that we can easily warm to. Yet towards the close of this century,
medical science still understands very little about the physiological phenomenon
we know as sleep. ÐÓ°ÉÔ­´´s do not know why we sleep nor why the brain
remains very active during sleep. Electrophysiological studies with the
electroencephalogram have revealed five different stages of the sleep cycle.
Lady Macbeth walks and talks in the famous scene of the fifthact in Macbeth
in her somniloquy: ‘Out, damned spot!’ Literary neuroscientists have believed
that Lady Macbeth was sleep-walking in stage IV of sleep, as has been documented
in actual patients, but these people rarely talk during their sleepwalking.
Specialists in sleep and its disorders, on the other hand, argue that because
Lady Macbeth speaks out angrily, she is actually suffering from a different
sleep disorder, one known as the rapid eye movement sleep behaviour disorder
syndrome. The point here is that the great poet created this dramatic figure
so accurately, and makes her so believable, in the human sense, that four
centuries later scientific experts have enough evidence to engage all of
their experimental knowledge in order for each side to argue about a fictitious
character dwelling in Shakespeare’s imagination! Epilepsy afflicts several
of the monumental characters in Shakespeare’s dramas. Julius Caesar and
Othello experience convulsions in the plays, and Macbeth may also be epileptic,
with his altered perceptions and mental functions, and he alludes to these
as ‘Then comes my fit again.’

The loss of intellectual powers is known to physicians, psychiatrists
and psychologists as dementia; senility is the vernacular for the condition
in the elderly. Alzheimer’s disease is the usual cause of senility. Shakespeare
shows us that it was very common in the elderly during the Renaissance.
The King, in The Life of King Henry V, says: ‘Old men forget’; Dogberry
concisely describes this, in Much Ado About Nothing: ‘When the age is in,
the wit is out.’

Upon reading what Polixenes has to say about a demented old man in The
Winter’s Tale, it is clear that Shakespeare perceived those around him with
great perspicacity. ‘Is not your father grown incapable of reasonable affairs?
Is he not stupid with age and altering rheums? Can he speak? hear? know
man from man? dispute his own estate? Lies he not bed-rid? and again does
nothing but what he did being childish?’ This demented elderly man thus
could not recognise even his own relatives, had rheumatism and aches, was
unable to walk and needed others to care for him, like a young child.

Homes for chronic care for the aged and frail must have been a social
need four centuries ago just as today. Feeble, old Bedford sits in a chair
observing a battle in The First Part of King Henry VI, and Talbot says to
him: ‘Come my lord, we will bestow you in some better place, fitter for
sickness and for crazy age.’

Over the past 100 years King Lear has been the subject of many scholarly
studies. Lear loses his judgment, and this loss is followed by betrayal
by his loved ones, loss of almost all his friends, and the physical assault
of a severe storm. He develops a psychosis, or loss of contact with reality,
as a result of these tremendous emotional and physical stresses. Lear begins
to hallucinate and he ‘sees’ his egregious daughters before him on the heath.
Lear has a physical, or organic cause for his confusion, rather than a purely
psychological disorder. People who are psychotic due to physical illness
tend to have visual hallucinations, like Lear; people who are psychotic
due to purely psychiatric illness tend to have auditory hallucinations,
such as hearing voices. What is amazing is that Shakespeare described Lear
so astutely and correctly. This is another Shakespearian character to which
modern psychiatric diagnostic techniques can be applied. A temporary organic
psychosis, or delirium, is probably Lear’s difficulty, as he regains his
mental abilities at the conclusion of the tragic tale. Dementias rarely
revert back to normal, so Lear is probably not demented.

Alcoholics, such as the chronic drinkers Sir Toby Belch and Sir Andrew
Aguecheek in Twelfth Night, do not escape the clinical observations of the
Bard. Chronic ingestion of large amounts of alcohol can damage the liver
and make it small, hard, scarred and thus relatively bloodless. The liver,
which normally functions to lower the bloodstream’s protein toxins, can
no longer remove them and so toxins accumulate and assault the brain, causing
confusion, and even coma. Shakespeare knew this. He has Sir Toby Belch say:
‘For Andrew, if he were opened, and you find so much blood in his liver
as will clog the foot of a flea, I’ll eat the rest of his anatomy.’ And
Aguecheek confesses: ‘I am a great eater of beef, and I believe that does
harm to my wit.’

Alcohol’s other effects include lowering one’s inhibitions and then
inducing sleep, increasing urination and, after chronic use, causing a permanent
increase in unsightly blood vessels at the tip of the nose known as rhinophyma.
It can produce lechery but also causes impotence. The porter in Macbeth
attests to these facts: ‘drink, sir, is a great provoker of three things
. . . nose painting, sleep, and urine. Lechery, sir, it provokes and unprovokes;
it provokes the desire but it takes away the performance.’

Shakespeare clearly outlines the neurological effects of syphilis, where
there is paralysis of a vocal chord as a syphilitic swollen blood vessel
compresses its nerve and can cause a hoarse voice; syphilis can also inflame
the vocal cords. In Timon of Athens, Timon directs two prostitutes to give
their disease to the men of the city to ‘crackthe lawyer’s voice’. Theunique,
sharp-shooting painson the shins, and impotency, both due to syphiliticdamage
of the spinalcord called tabes dorsalis,were known to Shakespeare. Again
he has Timonsay: ‘strike their sharp shins . . . and quell the source of
all erection.’ Incontinence, the loss ofthe ability to control theurine,
can also be causedby syphilitic tabes dorsalis. In The Merchant of Venice,
Shylock says: ‘. . . and others . . . cannot contain their urine’.

Elizabethan physicians knew about plants, herbs and poisons, and so
did Shakespeare; many scholarly studies are devoted to the Bard’s botanical
knowledge. In Hamlet, the King was poisoned by his brother who poured henbane,
a scopolamine drug, into his ear. Is this fanciful poetic licence? Scholars
argue to the contrary. A murderer could easily drop a liquid poison, warmed
to body temperature, into a sleeper’s ear. If the victim had a hole in his
eardrum – and perforated eardrums following ear infections, before the use
of antibiotics, must have been common – the liquid would pass from the outer
ear canal, through the perforation, into the middle ear chamber and then
directly pass down the eustachian tube into the throat, to be swallowed.
Again, we ask ourselves, how did Shakespeare know that this anatomical pathway
was so accessible? William Shakespeare was remarkable not only for his specific
vast knowledge, but also for the wisdom and insight with which he illuminated
the human condition. For what it is worth, I was not discouraged, even after
reading Kent’s advice in King Lear: ‘Kill thy physician, and the fee bestow
upon the foul disease.’

Dr Lance Fogan is a neurologist working in Panorama City, California.