Eleanor J. Molloy
Gerard De Lairesse suffered from congenital syphilis. Image: Portrait of Gerard de Lairesse. Rembrandt van Rijn. 1665–67. The Metropolitan Museum of Art. Public Domain.
Syphilis was endemic in Elizabethan England and it was estimated that nearly 20% of the population of London were infected.1 The signs and symptoms were commonly known to the average person and would be potentially recognizable to the audience in Shakespeare’s plays. Shakespeare mentions syphilis more times than any other disease, referring to it as: “the infinite malady,” “hoar leprosy,” and the “malady of France.” It has also been suggested that Shakespeare himself may have suffered from syphilis as there are multiple references to both syphilis and symptoms of syphilis in his works.2 In the pre-antibiotic era, syphilis presentations would have included the full spectrum of disease, from high fevers also known as “burnt blood,” pustular rash, meningitis, aortic regurgitation, severe body pain, malaise, mental health issues, and blindness.3
Elizabethans had many names for syphilis including: the French pox, the Spanish sickness, the great pox, and simply, the pox. The term “syphilis” was first mentioned by Girolamo Fracastoro from Verona in 1530 in his work “Syphilis sive Morbus Gallicus.”4 In Edmund Spenser’s the Faerie Queene there is evidence of pestilence and a syphilitic apocalypse is suggested.2 Syphilis spread rapidly throughout Europe in the fifteenth century. Several theories exist regarding these outbreaks, such as that it originated with Spaniards carrying the disease home from the Americas in 1493. Another early description of a syphilis epidemic in Europe related to the invasion of Rome by the French forces in Naples.4 In 1585 William Clowes, a famous Elizabethan barber-surgeon, commented that the numbers of syphilis patients were so vast that London hospitals had insufficient space for the “infinite multitude,” describing it as syphilitic apocalypse.2 It would be several hundred years until a definitive treatment for syphilis was established with the discovery of penicillin.
The presentation of psychiatric symptoms due to neurosyphilis may mimic psychiatric presentations associated with any other etiology, and any psychiatric symptom can be present in neurosyphilis. It may be possible that Shakespeare was implying that Macbeth had syphilis. It is estimated that in sub-Saharan Africa more than 1% of all psychiatric admissions are related to neurosyphilis.5 Patients may present with delusions of grandeur, hallucinations, emotional lability, and inappropriate behaviors.
The progression of untreated syphilis is often slow with insidious symptoms and varying presentations so that it is called the “great imitator.” Caused by the spirochete Treponema pallidum, the primary manifestation of a chancre may progress to secondary and finally tertiary syphilis over years. Tertiary, or late-stage disease, is evident in approximately 15% of people infected if not treated.6 Inflammatory lesions may develop affecting multiple organ systems, and neurosyphilis can develop at any stage.6 Congenital syphilis also has a wide variety of presentations that may include pregnancy loss, optic atrophy, blindness, progressive sensorineural deafness, neurosyphilis, juvenile paresis, and dental and skeletal abnormalities.7
“And nothing is, but what is not” – Act 1, scene 3
Syphilis would have been more common for a career soldier such as Macbeth, an occupation which carried a high risk for sexually transmitted diseases (STDs). War has long been associated with the spread of syphilis. In the Thirty Years’ War, the recruitment of mercenaries from all over Europe and the long duration of the conflict allowed the spread of the disease throughout Europe.3 Macbeth’s childlessness is an important part of the play. Although he is king, he will not “beget kings unlike Banquo.” The striking number of male children in Macbeth, including sons of Banquo, Macduff, Duncan, and Siward highlights Macbeth’s childlessness and lack of an heir. These children play important roles and are ruthlessly pursued by Macbeth, as in Act 3 scene 1: “Upon my head they placed a fruitless crown, And put a barren sceptre in my grip, . . . no son of mine succeeding.”
The first descriptions of mental health issues are visual and auditory hallucinations. Macbeth’s first visual hallucination involved the dagger: “Is this a dagger I see before me . . . come let me clutch thee: I have thee not yet I see thee still.” He describes it as a “fatal vision” and a possible “dagger of the mind, false creation. Proceeding from the heat-oppressed brain?” “Mine eyes have made fools o’th’other senses, Or else worth all the rest.” He describes a “strange uniformity which is nothing to those who know me.” Lady Macbeth ascribes this episode to a childhood malady and describes him as “brainsickly.” Macbeth’s deteriorating mental health is evident in his visual hallucinations of the ghost of Duncan: “hence horrible shadow!” and“ Oh full of scorpions is my mind.”
He also suffers from insomnia: “Macbeth shall sleep no more.” He is concerned that “wicked dreams abuse The curtained sleep,” and in Act 2, scene 2: “Sleep no more Macbeth does murder sleep: the innocent sleep, Sleep that knots up the ravelled sleeve of care, the death of each days life, sore labour’s bath, Balm of hurt minds, great nature’s second course, chief nourisher at lifes feast.” Depression is evident in several passages, such as his famous nihilistic speech upon hearing of the death of Lady Macbeth: “. . . tomorrow and tomorrow and tomorrow creep at this petty pace from day to day. . . .”
There are other miscellaneous features that can be ascribed to the “great imitator” syphilis such as hyperacusis9: “every noise appals me?” There may also have been cardiovascular symptoms in “make my seated heart knock at my ribs Against the use of nature?”
Macbeth has a dramatic personality change during the course of the play. He is first introduced as a brave hero referred to by Duncan as a “valiant cousin, worthy gentleman?” and “noble Macbeth” (Act 1 scene 1). Later Malcolm describes Macbeth as “This tyrant whose sole names blisters our tongues was once thought honest.” The negative impact on Scotland owing to Macbeth’s reign is described as: “Each new morn, new widows howl, new orphans cry, new sorrows strike heaven in the face.” He is repeatedly described as “steeped in blood” and “a tryrant,” “black Macbeth,” “. . . not in the legions of hell can come a devil more damned in evils to top Macbeth,” and “devilish Macbeth.”
Symptoms of tertiary syphilis typically begin ten to fifteen years after the initial infection and include memory loss, impaired concentration and ability to learn, irritability, mania, depression, and psychosis. Macbeth had personality changes, depression, seizures, loss of empathy, delusions of grandeur, and impaired judgment. In tertiary syphilis patients can be irritable, moody, delusional, unempathetic, demanding, raging, and grandiose. They can vary from obsessive-compulsive, detail-oriented behavior to manic impulsiveness. They may exhibit disorganized thinking, transient false beliefs, mental rigidity, and repetitive behaviors. Macbeth orders the murder of entire families and causes generalized misery in Scotland. Late psychiatric symptoms are predominated by a dementia indistinguishable from other forms of dementia, including impaired judgment, confusion, and lack of insight.10 This may be reflected in the lack of insight into the progress of Birnam Wood to Dulsinane, and the false confidence that “no man of woman born” could exist to kill him according to the prophecy.
Lady Macbeth’s journey from a position of strength and control to depression, somnambulism, and probable suicide is clearly outlined in the play.
She appears to have experienced a neonatal death, which may be attributed to congenital syphilis. There is no mention of other children or the possibility of a pregnancy in the future, potentially pointing to infertility or avoidance of pregnancy due to syphilis. Lady Macbeth describes breastfeeding a newborn “giving suck” and a neonatal death is assumed. “I have given suck and know, How tender tis to love the babe that milks me.” This would fit with a diagnosis of congenital syphilis resulting in neonatal death, and would explain Macbeth’s attention to Lady Macbeth and potential guilt reflected in this relationship, culminating in her ability to persuade him to commit regicide. In this persuasion she mentions the baby, saying: “I would while it was smiling in my face, Have plucked my nipple from his boneless gums, and Dashed the brains out, had I so sworn As you have done to this” (Act 1 scene 6). Although she incites Macbeth to regicide she does not condone his further murderous behavior and could not kill Duncan: “Had he not resembled my father as he slept, I had done’t.”
Macbeth’s mental health deteriorates throughout the play, losing empathy especially when he hears of the death of Lady Macbeth. She develops a nocturnal obsession with handwashing, which has been ascribed to guilt relating to Duncan’s death and the removal of blood stains. However it is unusually referred to as a “spot” (“out, out damned Spot . . .”), which may also be describing the palmar lesions of secondary syphilis. This also fits with obsessive-compulsive traits and disorganized thinking attributable to tertiary syphilis. She is initially very certain of her actions and philosophical about the outcomes: “Things without all remedy Should be without regard: what’s done is done” (Act 3,scene 2). However her deteriorating mental health may point to syphilis as an underlying cause rather than simply guilt about her involvement in the death of Duncan.
There are several references to Lady Macbeth’s “infected brain.” The physician observes her somnambulism and hand-washing and suggests she has an “infected mind.” And she has a “mind diseased” according to Macbeth, who asked the physician to “find her disease and purge it to a sound and pristine health.” These were often used in Elizabethan literature to describe syphilis.1
There is much superstition associated with the play Macbeth, including the bad luck associated with saying the name Macbeth aloud. Maybe the curse of the Scottish play is related to the association with the taboo subject of syphilis and the purging rituals required relate to disease.26 A high index of suspicion for syphilis is still needed in patients presenting with a history and symptoms similar to those of the Macbeths.
- Fabricius J. Syphilis in Shakespeare’s England. London. Jessica Kingsley, 1894.xvi+296 pp. III.
- Ross JJ. Shakespeare’s Chancre: Did the Bard Have Syphilis? Clinical Infectious Diseases, Volume 40, Issue 3, 1 February 2005, Pages 399–404,
- Colin Milburn Syphilis in Faerie Land: Edmund Spenser and the Syphilography of Elizabethan England. Criticism; Volume 46, Number 4, Fall 2004 pp. 597-632 | 10.1353/crt.2005.0017Criticism 46.4 (2004) 597-632
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- Ha T, Tadi P, Dubensky L. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-2019 May 11
- Roberts MC, Emsley RA, Jordaan GP. Screening for syphilis and neurosyphilis in acute psychiatric admissions. S Afr Med J. 1992 Jul;82(1):16-8.
- Molloy EJ, Owoeye C, Knowles S. Is antenatal screening for syphilis still necessary? Ir Med J. 2012 Feb;105(2):37-8.
- Craig M. Psychological Medicine, First Edition. London: Churchill. 1905
- Gordon and 2000 and hyperacuisis
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- Lishman WA, Jacobson RR, Acker C. Brain damage in alcoholism: current concepts. Acta Med Scand Suppl. 1987;717:5-17.
- Ortego NJ, Miller BL, Mena I, Palmer BW. SPECT in neurosyphilis. Clin Nucl Med. 1995 Mar;20(3):272.
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- Hotson JR. Modern neurosyphilis: a partially treated chronic meningitis. West J Med. 1981 Sep;135(3):191-200.
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- Gordon SM, Eaton ME, George R, Larsen S, Lukehart SA, Kuypers J, Marra CM, Thompson S. The response of symptomatic neurosyphilis to high-dose intravenous penicillin G in patients with human immunodeficiency virus infection. N Engl J Med. 1994 Dec 1;331(22):1469-73.
- Tichonova L , Borisenko K, Ward H, et al. Epidemics of syphilis in the Russian Federation: trends, origins, and priorities for control. Lancet 1997;350:210–13
- Umapathi KK, Thavamani A, Chotikanatis K. Incidence Trends, Risk Factors, Mortality and Healthcare Utilization in Congenital Syphilis-related Hospitalizations in the United States: A Nationwide Population Analysis. Pediatr Infect Dis J. 2019 Nov;38(11):1126-1130.
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- The curse of the Scottish play. Accessed 8th November 2019: https://www.rsc.org.uk/macbeth/about-the-play/the-scottish-play
ELEANOR J. MOLLOY is a Consultant Neonatologist & Paediatrician in the Department of Paediatrics, at Trinity Centre for Health Sciences, Tallaght University Hospital.