Congenital Neurosyphilis as Portrayed in Henrik Ibsen's Ghosts

Leonard J. Hoenig
Dermanities, October 25, 2009; 6¹

In 1881, Henrik Ibsen's play, Ghosts, created a sensation in the theatrical world by bringing to center stage the taboo topic of venereal disease. Although syphilis is not mentioned by name in the play, it is clear that a major character, Oswald Alving, is suffering from congenital neurosyphilis. When Ibsen wrote Ghosts nearly 130 years ago, syphilis was widespread. Nowadays, many readers have rarely, if ever, seen a case of late congenital neurosyphilis due to effective prenatal screening and treatment of infected mothers. It may therefore be interesting to take a fresh medical look at Ghosts, not only to better appreciate Ibsen's play but also to remind ourselves of the devastating clinical manifestations that syphilis once had on the lives of its victims.

Case Presentation

Oswald Alving is an approximately twenty seven year old artist who suffered from long standing headaches while growing up. Around age twenty-five these headaches intensified: "I began to feel the most violent pains in my head—mostly at the back, I think. It was as if a tight band of iron was pressing on me from my neck upwards" (p. 108)¹.

These severe headaches were accompanied by difficulty concentrating: "I soon saw that I couldn't work any longer. I would try and start some big picture; but it seemed as if all my faculties had forsaken me, as if all my strength were paralysed. I couldn't manage to collect my thoughts; my head seemed to swim" (p.108) ¹. Oswald also suffered from a transient attack of altered mental status rendering him temporarily an invalid. He sought medical attention and is told by the doctor that he is suffering from congenital syphilis; "He was one of the best doctors there. He made me describe what I felt, and then he began to ask me a whole heap of questions which seemed to me to have nothing to do with the matter. I couldn't see what he was driving at …At last he said: 'You have had the canker of disease in you practically from your birth'—the actual word he used was ' vermoulu' " (p. 108) ¹.

At the play's end, Oswald again suffers an attack of altered mental status and becomes permanently handicapped: "Oswald seems to shrink up in the chair; all his muscles relax; his face loses its expression, and his eyes stare stupidly". (p. 128) ¹. Oswald is seen repeating in an expressionless voice: "The sun-the sun" (p.128) ¹.

Discussion

It is challenging to medically evaluate the illness of a fictional character such as Oswald Alving, because the playwright, while seeking to be "realistic" in his clinical descriptions, may also take poetic liberty with the symptoms and alter them to achieve a dramatic impact on the audience. Despite this limitation, I think that Henrik Ibsen's Ghosts captures some of the clinical features of late congenital neurosyphilis.

In the play, Oswald Alving is diagnosed by one of the "best" doctors as having congenital syphilis. Ibsen indicates that Oswald's father, Captain Alving, was the source of the infection which he acquired through risky sexual behavior and then passed on to his son. Ibsen doesn't specify exactly how this transmission occurred although the favored late 19th Century medical view held that congenital syphilis was passed on in an hereditary fashion directly by the father to the offspring at the time of conception². By contrast, current understanding of syphilis transmission would explain that Captain Alving first infected his wife, who then transmitted the spirochete to her unborn son, via the placenta, during pregnancy. Mrs. Alving is clinically asymptomatic in the play, suggesting that she is in the latent stage of syphilis, although Ibsen himself may not have entertained this medical scenario.

Oswald became seriously symptomatic from late congenital neurosyphilis during his mid twenties, an age somewhat beyond the typical textbook presentation for juvenile paresis which tends to occur earlier, usually from the ninth to fifteenth years³. Clinical onset of juvenile paresis, however, can occur in the early twenties⁴. It is also possible that Oswald had symptomatic neurosyphilis earlier in his life since he suffered from headaches while growing up.

The diagnosis of congenital syphilis back in the 19th Century was made on clinical grounds as there were no serological tests for syphilis available at the time and because the spirochete had not as yet been identified as the causative agent. Oswald's physician probably made the diagnosis of congenital neurosyphilis based on the case history and perhaps by finding in Oswald some of the typical stigmata of congenital syphilis as described by Jonathan Hutchinson during the 1850's and 1860's (e.g. dental deformities)². The differential diagnosis would include acquired neurosyphilis, as Ibsen himself suggested in the play, as well as other disorders of the central nervous system⁵.

Clinically, Oswald appears to exhibit symptoms that overlap meningiovascular syphilis and general paresis. Oswald's headaches and neck stiffness are indicative of the chronic meningitis that occurs in neurosyphilis. His difficulties with organizing his thoughts and inability to work suggest that Oswald has brain parenchymal disease (meningoencephalitis) as occurs in general paresis.

Oswald's sudden episodes of altered mental status and weakness may have been caused by cerebrovascular accidents that can occur in meningiovascular syphilis due to arterial inflammation and occlusion. Alternately, Ibsen's description of Oswald's final deteriorated state seems to fit the picture of end stage dementia and paralysis typical of paretic syphilis. If that is the case, then Ibsen here may have taken some dramatic liberty by portraying end stage paresis as occurring suddenly in Oswald rather than as a progressive mental and physical decline with associated neurological features such as seizures, behavioral abnormalities, twitches, action tremors, impaired speech etc…³.

It is interesting that Ibsen, in Ghosts, uses the French word "vermoulu" or "worm-eaten" to describe the clinical diagnosis of congenital syphilis in Oswald. I couldn't identify the source from where Ibsen got this term, although a similar term called "Etat Vermoulu" was used by the noted French neurologist Pierre Marie to describe the cortical degeneration that can occur in senile brains⁶.

Ghosts was written when syphilis wreaked havoc on people's lives causing much suffering and death. Although Ibsen was not a physician, he seems to have been quite knowledgeable for his time about congenital syphilis, especially since the association of congenital syphilis with late neurological events, such as general paresis, was still in the process of being reported and described⁷. Despite the limited clinical details presented in Ghosts, Ibsen's play nonetheless has captured for audiences the sad outcome of congenital neurosyphilis.

Today, Henrik Ibsen's Ghosts remains a theatrical masterpiece enjoyed by audiences around the world. Ghosts is also a masterful example of how a medical disease can be woven into the major themes of a drama and how an illness's disastrous clinical consequences become the play's tragic climax.

References