menuPaper: Don Quixote's diagnoses: an historical approach
07 November, 2003
Observatory of Scientific Communication,
Universitat Pompeu Fabra
(Barcelona, Spain)
INTRODUCTION
Was Don Quixote mad? In other words, should he really be considered a mental patient? I realise that the character, Alonso Quijano, and particularly his alter ego, Don Quixote, has been regarded as a model of illness, is a suitable subject for scientific study.
In the opinion of Thomas Sydenham (1624-1689), known as the “English Hippocrates”, Don Quixote was the best treatise from which to learn about medicine. In the history of medicine since the XVIII century, and especially when psychiatry appeared as a speciality, different mental-health theories have been projected onto Don Quixote as though he were indeed a medical patient. Several attempts at a diagnosis of Don Quixote will be discussed in this paper, starting with the humoral theory, and followed by others such as; anatomical, neuropsychological, or psychosomatic approaches. Many doctors, from several countries (France, Italy, Germany, Spain) wrote about Don Quixote trying to establish a diagnosis. These erudite people, surgeons, doctors and, later, psychiatrists, all published works on Don Quixote’s pathology. In Spain, well-known doctors were called “cervantists”, because they were learned doctors in Cervantes’ work.
For instance, in Spain the first doctor who wrote a clinical history about Don Quixote’s illness was Antonio Hernández Morejón, an historian and surgeon belonging to the Colegio San Carlos in Madrid. In his work Bellezas de medicina práctica descubiertas en el Ingenioso Caballero Don Quijote de la Mancha (1836)[1], he presents a complete clinical history of Don Quixote. The important thing to bear in mind now is how Don Quixote is considered by this author. Hernandez Morejón describes him as choleric and melancholic, a description that introduces the first approach in character diagnosis.
A humoral approach
Hippocrates de Cos (460-370 BC) said that personality and illness are dependent upon four humours that usually lie in the body. Any imbalance in these humours resulted in personality problems or illness. It was grounded in the Empedoclean principle of the four supposed elements: water, air, fire, and earth. The four constituent elements, or humours, in man were identified analogously as phlegm, blood, yellow bile and black bile, all of which had to be in correct proportion to one another. The doctrine of the Four Humours endured for many centuries and remained fundamental in European medicine for over two millennia.
The hippocratic influence was decisive in Galen’s medical philosophy. He had the feeling that the fluids first make all the tissues and then the different organs of the human body. Galen’s theory was the prevalent one in the Middle Ages. However, during the Renaissance, several thinkers, for instance Marsilio Ficino (1433-1499), believed that melancholia gave the power of life required in all the creative processes, an idea which was taken up again by the romantics in the XIX century. But in the time when Don Quixote was written, in the baroque period, melancholia was considered an “occult drama”, a stigma.
The four basic temperaments: phlegmatic, sanguine, melancholic and choleric, were each caused by a predominance of one of the four humours. The humours and their corresponding temperaments were closely allied with the four elements and the dualities hot/cold, wet/dry. The choleric or bilious temperament is a result of too much choler, or yellow bile in the system. Associated with fire, heat and dryness, it has as its characteristics violence, vengefulness, and irritability. The melancholic is an abnormal state attributed to an excess of black bile and exhibits irascibility or depression associated with earth. Cold and dry circumstances to lead to a lowering of spirits. Don Quixote is characterised as “The nobleman who has a sad figure”.
Each humour was thought to give off vapours which ascended to the brain; an individual’s personal characteristics (physical, mental, moral) were explained by their temperament. The perfect temperament resulted when no one of these humours dominated.
According to the theory of Four Humours, the choleric and melancholic temperaments have been recognised in the character of Don Quixote. Several factors could have produced in him an acquired melancholy: diet, insomnia and his compulsive addiction to reading chivalry books. An enormous cholera lead to a feverish condition. Then, as a consequence of humour combustion, the yellow bile is turned into black bile and Don Quixote falls into illness and helpless physical disability.
In 1621 Robert Burton (1577-1640), theologist, Anglican preacher, librarian at Oxford, published The Anatomy of Melancholy, a treatise which contains definition, the type of melancholia, definition, causes, symptoms, and cure and. Burton defined himself as a melancholic who looked for the cure through study, believing that leisure was a great cause of melancholia. Only remember now that the sudden changes in Don Quixote begin when he want nothing to do with his property and he compulsively devotes himself to reading chivalry books. The physical condition of the body, its humoral balances and symptoms, are considered in terms of their effect on the passions and emotions, and the passions are important because of the misery they cause when they overrule reason.
An anatomical approach
The analysis of the Anatomy of Melancholy is not the aim of this paper but I would like to emphasise now the term “Anatomy”. Later on, in the XVIII century after Harvey had described, for the first time, blood circulation in the human body, or after Vesalius’ descriptive anatomy work, the humoral theory persisted but, faced with these facts, was more and more questionable. A new way of understanding medicine was gaining ground, a new experimental medicine based on observation. From this point of view the disease had to be correlated with some kind of signal in the body. In 1761 Giovanni Battista Morgagni carried out many autopsies on mental patients.
When Hernández Morejón in his work Bellezas made the following comment, it was without doubt in this context :
Una cosa falta en mi concepto en la obra de Cervantes para el complemento de la historia; a saber: la abertura del cadáver de Don Quijote[2].
Why is that, wonders the author immediately. Probably, because of a poor knowledge of anatomy at that time or maybe because Don Quixote was healed just before he died, then the autopsy was not appropriate.
Before Hernandez Morejón, other surgeons, for instance Antoni Gimbernat (1734-1816), first surgeon to the king Carlos III and founder of Colegio San Carlos in 1787, had been looking for the aethiology of mental diseases in the brain of the dead body without success - evidence was impossible to find. Said his friend Joseph Townsend, “after having dissected more than six hundred heads of wise men, fools, and madmen, he assures me that he was never able to discover anything remarkable in either texture or colour to distinguish them.”[3]
A Neuropsycological approach
Only since the XVIII century has it been possible “to get nervous”. The autopsies performed on mental patients by Giovanni Baptiste Morgagni (1708-1771) published in his work De sedibus in 1771, and the experiences in the nervous system and in reflex action of Albrecht von Haller (1708-1777), lead to the lesion giving the benefit of epistemological value, in other words, through the study of the lesion medical knowledge about the illness could increase. Moreover, Wilheim Griesinger (1817-1868) insisted that all psychiatric conditions are products of organic diseases which either directly or indirectly impair brain function.
On the other hand, when Rene Descartes (1596-1650) make a distinction between res cogitans and res extensa so, it was possible to think about mental illnesses. In this century melancholia was defined in terms of a “weak nervous system”. Also, having established circularity, this implied that the disease of the soul could originate in the nervous system and, in turn, the melancholic state could be as a consequence of psychic suffering.
All the above introduces the neuropsychological approach. In the psychiatric treatises of the XVIII century are allusions to Quixote as a model of symptoms for a new term in clinical assessment - monomania.
From the French school, Philippe Pinel (1745-1826), published the Traité médico-philosphique sur l’alienation mentale ou la manie in 1801, where he describes the monomania affectation. Pinel was the founder of the scientific psychiatry as well as being the first to refer to the type of patient care “moral treatment”. Pinel defined Don Quixote’s disturbance as “une description admirable de la monomania” characterised by obsessive, fixed and illusory ideas. The term melancholy is now referred to a mind which could develop mania. He was fascinated by the “follie raisonnante”, i.e, mania without intellectual disorder. In his diagnoses Jean Ettienne Esquirol (1772-1840), who was a Pinel’s successor, differentiated between illusions and hallucinations, and thought that Don Quixote was a very good example of the prevailing monomania after the Crusades in Europe.
Don Quixote, after fighting with the White Moon Knight in Barcelona, which is another allusion to melancholy by the author, comes back home defeated, and there his friends, the priest and the barber, with a moral based treatment, were able to listen to reason. Hernandez Morejón, the author of Bellezas, said that Cervantes anticipates Pinel by two centuries when, in his work, he prescribes a moral treatment for the alienation of Don Quixote. The moral treatment was a therapy based on humanitarian treatment which avoided any repressive measures.
E. Pi i Molist (1824-1892), Catalan psychiatrist in charge of the Mental Institute in the Hospital Santa Creu i Sant Pau in Barcelona, is the author of the work about Don Quixote entitled : Primores de Don Quijote en el concepto médico-psicológico y consideraciones generales sobre la locura para un nuevo comentario de la inmortal novela(1886)[4]. Pi i Molist begins his work with a review of the Hernandez Morejón assessment. He had his own diagnosis of the character as delirious monomania and sensory illusions: optical, acoustic, olfactory and tactile, and moreover a constant lesion in his affective sensibility manifested as an erotomania. In the opinion of this author, Cervantes should be remembered with Esquirol in medical and psychological memorials.
Since Pinel, the desire to have a systematic understanding of the diseases was to culminate in Emile Kraepelin (1856-1926) who conducted descriptive psychiatry and was known for two very important contributions; his descriptions of the behaviour and course of illness in psychotic patients, and his classification scheme. He was the first to bring together catatonia, hebephrenia and paranoia into the category “dementia praecox”, later changed to “schizophrenia”. He was also influential in keeping alive the theory of the organic cause of psychiatric conditions, and his statement that every type of psychosis can be shown to have specific brain lesions. Kraepelin named the psychosis primaria paranoia. When the 300th anniversary of the first edition of Don Quixote was celebrated in 1905, Dr. Ricardo Royo Villanova presented a new clinical history analysing the precedents, signs and symptoms, both morphological and physical and the progress of illness, arriving at the following diagnosis:
... paranoia crónica o delirio sistematizado o parcial de tipo expansivo, forma megalómana y variedad filantrópica[5].
A Psychosomatic approach
Heavily influenced by the psychoanalysis of Sigmund Freud (1856-1939), this point of view denied the epistemological value of the mental disease description and systematic classification in order to be able to achieve knowledge. The most important thing will be now the understanding of the illness.
Ernst Krestchmer (1888-1964) have been correlated build and physical constitution with personality characteristics and mental illness. Kretschmer posited three chief constitutional groups:
· the tall, thin asthenic type
· the more muscular athletic type, and
· the rotund pyknic type.
He suggested that the lanky asthenic and to a lesser degree the athletic types, were more prone to schizophrenia, while the pyknic types were more likely to develop maniac-depressive disorders. His work was criticised because his thinner, schizophrenic patients were younger than his pyknic, manic-depressive subjects, so the differences in body type could be explained by differences in age. Nevertheless, Kretschmer’s ideas to some extent entered into popular culture and generated further psychological research.
In this context, José Goyanes wrote his work entitled Tipología del Quijote. Ensayo sobre la estructura psicosomática de los personajes de la novela (1932)[6]. This author, following an psychosomatic approach and taking in account the Kretschmer biotopology theory, believes that the behaviour of people is defined all together by two components, biological and psychological. In accordance with this belief he has the following definition of Don Quixote:
è from biological component was a
leptosomatic, i.e, athletic constitution, idealist, tendency to sublimate his instincts, hyperthyroidism (with increased catabolism), characterised by sparkling eyes, smooth skin, good reflexes, heart arrhythmia.
è from psichological component was an
schizothymic, i.e, introverted according to psychoanalysis or having a delirium of interpretation or paranoia in psychiatry.
In summary, the Don Quixote’s biotypology predisposes him to madness, the constant repression of libido is the cause of his pathology, and lastly, the compulsive reading of chivalry books lead him to manifest the illness.
Discussion
From Hernandez Morejón until modern times, Don Quixote has being regarded as a patient and his clinical history have been a good explanatory tool. The most recently published work that I know is The clinical history of Don Quixote, by Bailón-Blancas in 1993.
But other possible interpretation have been made by, for instance José Goyanes. From what he says, we are witnesses to character metamorphosis, a transformation, from the first chapter of the novel. The changes in Don Quixote’s personality have the aim of devoting himself to the world of the action and justice. Under this point of view there isn’t anything could be qualified as insanity, i.e. a permanent disorder of the mind.
Because other authors consider Don Quixote to be alienated, strange, conventional, more literary than scientific, a cultural event or a cultural icon, a literary resource, all of this allowed Cervantes to talk freely through Don Quixote without any difficulty.
Miguel de Unamuno (1864-1936), Spanish author and philosopher, predecessor of Existentialist philosophy with Søren Kierkegaard, educator, whose essays had great influence in early 20th-century Spain, criticised the “cervantist” in this sentence:
De cuantos comentadores caen sobre El Quijote, no los hay más terribles que los médicos. Al punto se meten a escrudiñar de qué especie era la locura de don Quijote, su etiología, su sintomatología y hasta su terapéutica.[7]
Conclusions
When Don Quixote was written, in the beginnings of XVII century, the Hippocratic theory of the Four Humours, take up again by Galeno, was the prevailing medical paradigm.
After the XVIII century, the paradigm began to change and Don Quixote was considered as an explanatory model to show the main medical theories has been developing with time. Physicians, doctors, psychiatrist have all projected their points of view onto the main character of the novel by means of the analysis, making a clinical history of Alonso Quijano, the real person.
There remains a reasonable doubt whether Don Quixote’s illness really exists or if it has been instrumentalized, i.e. used as a tool, or if one possible human condition has only been understood as belonging specifically to medical science.
Bibliography
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BAILÓN-BLANCAS, Historia Clínica del Caballero don Quijote, Madrid, Ed. Entonio Fernández Heliodoro, 1993.
BURTON, R., Anatomia de la melancolía, Madrid, Asociación Española de Neuropsiquiatría, 1997.
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DE CERVANTES, M., El ingenioso hidalgo Don Quijote de la Mancha, Madrid, Aguilar, 1973.
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FÖLDÉNY, LÁSZLÓ F., Melancolía, Barcelona, Círculo de Lectores, Galaxia Gutenberg, DL 1996.
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GOYANES-CAPDEVILA, J., De la biotypologie de Don Quichotte et de Sancho Panza, París, L’Expansion Scientifique Francaise, 1935.
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PI i MOLIST, E., Primores de don Quijote en el concepto médico-psicológico y consideraciones generales sobre la locura para un nuevo comentario de la inmortal novela. Imprenta Barcelonesa, 1886.
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[1] Beauties of practical medicine discovered in the ingenious knight Don Quixote de la Mancha.
[2] Only one thing is missing in the Cervantes’ work , as complement to history, namely, Don Quixote’s autopsy.
[3] J. Twonsend, A Guide to Health being cautions and directions in the treatment of diseases designed chiefly for the use of students, London, Cox, 1796, Vol. 2, p. 110.
[4] Beauties of Don Quixote in the medico-psychological concept and general rules about the madness for a new comment of the immortal novel.
[5] ... chronic paranoia, or systematic or partial delirium with an expansive style, delusions of grandeur, and philanthropic variety...
[6] Don Quixote’s typologie. Assay about the psychosomatic structure of the characters of the novel. Lecture presented in a Conference at Medicine University of Paris in 19-10-1934, III Congres de la Presse medicale latine.
[7]The physicians are the most awful Don Quixote’s commentators. All of them tried to scrutinise what is the nature of Don Quixote’s madness, the aethiology, the symptoms, even the therapy.
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