A fundamental question

All’s Well That Ends Well is one of Shakespeare’s so called problem plays. Although normally considered a comedy, it is very nearly a tragedy, so nearly that its real genre is in doubt. Even the supposedly happy ending, which restores it to the realm of comedy, is equivocal and suspiciously perfunctory.

The play also has a medical problem. Indeed the whole plot turns on it; commentaries and introductions to various editions do not dwell on this problem much, but it is likely to preoccupy any doctor who sees or reads the play. It is the question of what kind of fistula, exactly, the king of France suffers from and how it was cured.

Helena is the daughter of a famous physician, now dead, who is part of the household of the countess of Rousillon. She is in love with the countess’s son, Bertram, a somewhat callow youth who is also a fearful snob.

When he goes to Paris, she soon follows, vowing to cure the king’s mortal illness, caused by a fistula, and thus raise her status enough to win Bertram. Indeed the king, initially reluctant to be treated by her, offers her the hand of any man she chooses if she cures him (the king feels he has the right to offer this). She cures him and chooses Bertram, who goes through with the marriage, but rather than consummate it he flies to the wars in Italy, vowing never to be a real husband to her. Eventually, by the usual subterfuges involving mistaken identity, Helena wins him back. The play ends with a less than ringing declaration of faith in the future of the couple by the king:

All yet seems well, and if it end so meet,

The bitter past, more welcome is the sweet.

Why is the king dying from his fistula? There is a subtle dig at the royal physicians, who have “worn me out/With several applications” (that is, their different treatments). Anyone who has read of the way, say, that Philip II of Spain, Charles II of England, or Louis XIV were treated by their physicians will realise that a cure being worse than the disease was no mere figure of speech in those days, as no doubt sometimes it is not even in our own; and perhaps Helena saved the king’s life not because he was dying from fistula but because he was dying from medical treatment, from whose wilder prescriptions she desisted, replacing them with the ineffectual but harmless cure alls, “of rare and proved effects,” bequeathed to her on his deathbed by her father.

Where is the king’s fistula? To proctologists their area of the body is the seat of all happiness, and therefore of all misery, and in Diseases of the Colon and Rectum (1998;41:914-24) the American surgeon Bard C Cosman makes a powerful case for the fistula of the king of France having been anal. Most commentators had hitherto placed it northward in his body, usually in the breast.

There is one argument against what Dr Cosman says. Helena’s treatment has restored sensation in the king’s hand, which his illness had destroyed. It is difficult to see how an anal fistula could have resulted in this—unless, of course, treated with heavy metal medications and unguents (and the father of heavy metal treatments, Paracelsus, is named, though in passing, in the play).

But who can resist this conclusion of Dr Cosman, that his reading of the play “has implications . . . for our view of the place of anal fistulas in cultural history”?