Considerations about the Neuropsychiatric Conditions of Quixote of La Mancha

Abstract

Don Quixote of La Mancha, the picturesque character created by Miguel de Cervantes Saavedra in his immortal book The Ingenious Nobleman Sir Quixote of La Mancha, presents several neuropsychiatric conditions, including tremor, sleep disturbances, neuropsychiatric symptoms, syncope, perception disorders and traumatic brain injury.

Throughout the masterpiece, there are episodes where the aforementioned disorders are evident. This paper makes a list of them and analyses them in the light of the current knowledge of those conditions.

Resumen

Don Quijote de la Mancha, el pintoresco personaje creado por Miguel de Cervantes Saavedra en su obra inmortal El Ingenioso Hidalgo Don Quijote de la Mancha, presenta varias condiciones neuropsiquiátricas que incluyen tremor, trastornos del sueño, síntomas neuropsiquiátricos, síncope, trastornos de la percepción y traumatismo craneoencefálico.

A lo largo de la obra, se presentan episodios en los que se hacen evidentes los diferentes trastornos mencionados. El artículo hace un recuento de ellos a través de la novela y un análisis a la luz de los conocimientos actuales sobre dichas condiciones.

Introduction

Alonso Quixano, also known as Don Quixote, a character created by Don Miguel Cervantes Saavedra (Miguel Cervantes) in his immortal work El ingenioso hidalgo Don Quijote de la Mancha [The Ingenious Gentleman Don Quixote of La Mancha],¹ has very particular characteristics that might be thought of as eccentric and amusing but point to several neuropsychiatric conditions that we wish to identify and remark upon here.

García Barreno has indicated that Alonso Quixano would have been born in the late 1540s, which would have made him a contemporary of Cervantes (1547-1616).²

Cervantes characterises Quixano in the first part of the novel as a simple, good man.³ Regarding Quixano's physical appearance, he describes him as having a lean, strong build; a gaunt, dry, sallow face; long, skinny legs covered in hair; and broad veins. He states that he was very much an early riser and slept little. This physical description was associated at the time with a short-tempered, melancholic individual.² Don Alonso's sleep disorders recur throughout the work, and are considered in part the aetiology of his mental changes.³

Melancholy, known since ancient times and closely linked to an imbalance in the four humours, had medical and cultural connotations in 16th-century Europe.²

The neuroscience-related terminology in the book includes at least 12 mentions of Don Alonso Quixano's "brain" or "brains". A few refer to his intelligence; most refer to madness.²

Neuropsychiatric conditions

Juan Mendoza-Vega has observed that the book's two parts describe various conditions from which Don Quixote suffers. The first part cites several types of trauma and how they are treated; the second refers to non-trauma conditions.⁴

Regarding neuropsychiatric conditions, in the first part references to mental conditions and symptoms are more florid, whereas in the second mixing of mental illness and loquacity becomes more obvious.

Palma et al.⁵ cited a number of symptoms which they found in a close reading of the novel. Their article "Neurología y Don Quijote" [Neurology and Don Quixote] classified those symptoms as: tremor, sleep disorders, neuropsychiatric symptoms, dementia, syncope, epilepsy, paralysis (palsy or apoplexy) and head trauma.

Trauma

In some episodes, Don Quixote and Sancho Panza, his squire, cause injury to other people; in others, they are the ones who are wounded. Don Quixote suffers trauma to different parts of his body: his head, his face, his teeth (of which he loses several), his ribs and his extremities. In several cases, he is said to be stunned or to faint, and references are made to treatments, including applying poultices and ingesting the medicines of the time such as Fierabrás' balm.² It is said that the substance originates from no more and no less than the powerful balm that was used to embalm the body of Christ. The precious substance, with miraculous powers that would heal all human ailments, has been stolen by the giant Fierabrás (this word of French origin means literally "brave arm"). In the work, Don Quixote mentions to Sancho Panza that he knows the ingredients for preparing the balm: oil, wine, salt and rosemary (1: I-X). The knight boils them and blesses them with eighty paternosters, eighty ave-marias, eighty salves and eighty credos. On ingesting it, Don Quixote vomits, then falls asleep and wakes up without any pain. In Sancho Panza, it induces severe diarrhoea and does not relieve his pain. Alonso Quixano feels that the balm is healthy for him but a cursed concoction for Sancho Panza. Quixote believes the balm does not have the desired effect in Sancho Panza because he is not a knight-errant.²

Sleep disorders

Sleep disorders are mentioned as of Chapter I-I: "what with little sleep and much reading his brains got dry".¹ It is also noted that he passes sleepless nights ruminating about his beloved Dulcinea. At the end of the book it is stated that he manages to sleep more than six hours and regains his lucidity (1: II-LXXIV).

In Chapter I-XXXV, on an adventure involving wineskins (these vessels used in those times were made of cow's leather and sealed before they were filled), a sleeping Don Quixote initiates a battle with a giant in which he brandishes his sword and rips some of the skins. He persists despite being asleep and despite attempts on the part of several people to wake him. When he finally awakens, he mistakes the curate for a princess.¹ This episode has been interpreted as indicative of rapid eye movement sleep behaviour disorder.⁵ Chapter II-XXII presents an episode in the cave of Montesinos in the Sierra Morena. The main character in the story enters the cave alone and is there a little less than two hours. On leaving, "Don Quixote answered not a word, and drawing him out entirely they perceived he had his eyes shut and every appearance of being fast asleep".¹

Quixote tells Sancho Panza and others that he was in the cave for three days and encountered Montesinos, other characters in chivalry stories and the enchanted Dulcinea. This very likely reflects the same condition as the episode with the wineskins.⁶

Tremor

This is mentioned metaphorically as Sancho Panza suffers from it, and Don Quixote experiences it due to anger and other emotional conditions such as fear.^4,5 At the time, there was debate between the cardiocentric and the cerebrocentric theory. In the former theory, the heart was the centre of the mind and emotions and, in an emotional situation, a rapid heart rate "spread" to the extremities and caused tremor.⁵

Psychiatric conditions

Regarding his psychiatric conditions, the ingenious gentleman ends his days in his home, without having visited his era's equivalent of a psychiatric clinic. However, throughout the work it is clear that Don Quixote suffers from problems that form part of a condition then called "madness". For the purposes of this publication, his condition is analysed by symptoms using current terminology.

Alterations in perception

On several occasions, there are delusions. The best-known episode involves windmills which Don Quixote describes as follows: "thirty or more monstrous giants present themselves, all of whom I mean to engage in battle and slay" (1: I-VIII). This event culminates with Don Quixote recognising that the windmills are merely windmills. Faced with this reality, he believes himself to be the victim of a spell by the magician Friston (1: I-VIII).

However, throughout the work, Don Quixote presents alterations in perception that are sometimes cases of delusion and other times cases of false recognition.⁷ At the start of the work, he mistakes an inn for a castle and the people therein, including some prostitutes, for princesses (1: I-II). In Chapter I-VII, Don Quixote meets a humble priest whom he takes for the Archbishop Turpin; he also mistakes a couple of priests for two sorcerers who attack him (1: I-VIII). On another occasion, he faces a flock of sheep, but he sees and hears an army of great heroes of chivalry (1: I-XVIII).

Another case of false recognition occurs when he mistakes a barber travelling on a donkey for a warrior. He decides to engage in battle with the barber as he sees that he is wearing a golden helmet (1: I-XX). In reality, the helmet is a shaving bowl (a metal container used by barbers to soak the beard). This false recognition as a helmet is repeated throughout the work (1: I-XLV, I-XLIX). Quixote also attacks a procession of supplicants carrying an image of the Virgin Mary, as he sees a kidnapped princess (1: I-LII).

The episode in the cave of Montesinos features not only hallucinations, but also an altered perception of time. When leaving the cave, Sancho is aware that one hour has passed; in the main protagonist's mind, three days have elapsed (1: II-XXII).

Certain characters appearing in the novel take advantage of some of Don Quixote's delusions and false representations. For example, the curate, with Dorotea's help, convinces him that she is the Princess Micomicona seeking his services as a knight to rescue her kingdom from a giant (1: I-XXIX). In another instance, the curate convinces Don Quixote to allow himself to be taken home in a cage (1: I-XLVI). Sancho Panza acts similarly when attempting to convince Don Quixote that a country woman is Dulcinea; since he sees her as such, Sancho tells him that the woman is the enchanted Dulcinea (1: II-X). The idea of the enchanted Dulcinea is constantly repeated in the second part of the novel.

There are intervals between lucid episodes and episodes of various types of disturbance, including behavioural disturbance. In the work, Don Quixote makes very lucid speeches full of common sense such as his speech to Dorotea (1: I-XXX), his speech on arms and letters (1: I-XXXII), his speech to children (1: II-XVI), and his speech to Sancho Panza on the government when Sancho is preparing to go to govern the island of Barataria (1: II-XLIII): "'But another strange thing about it', said the curate, 'is that, apart from the silly things which this worthy gentleman says in connection with his craze, when other subjects are dealt with, he can discuss them in a perfectly rational manner, showing that his mind is quite clear and composed; so that, provided his chivalry is not touched upon, no one would take him to be anything but a man of thoroughly sound understanding" (1: I-XXX).

Adolfo de Francisco Zea has noted that most of Quixote's actions are marked by sanity, prudence and good judgement.³ Martín-Araguz et al.⁸ indicated that, in the prologue to the second part, Cervantes refers to Quixote as a sort of measured madman, or, in today's language, sane, sensible and prudent.

In any case, Don Quixote's judgement is altered, as in the episodes in which he attacks clerics (1:I-VIII) and religious processions (1: I-LII). The episode in which the character's poor judgement is most notable is probably the one in which he decides to free a group of prisoners transported bound by chains (1: I-XXII). Don Quixote is nearly arrested by the Holy Brotherhood, a police authority at the time, but released given his mental state (1: I-XLV).

From the start of the work, in the preliminary text¹, some poems, such as Urganda's verses, describe Don Quixote as a madman. Throughout the work, he alternates between delirium and lucidity. In the first part, his delusions and false recognitions, as well as his unstable mind and tendency towards aggression, are most striking. In the second part, the idea that Dulcinea is enchanted becomes more recurrent and consumes the protagonist's thoughts.

According to Francisco Alonso Fernández, using the names of the time, Don Quixote would have suffered from an expansive delusion classified as a delusion of autometamorphosis of global greatness (megalomania). The same author has pointed out that delirium leads him not only to assume a new identity as a knight-errant, but also to perceive himself differently. At that time, Alonso Quixano is 50 years old, the equivalent of being 90 years old today. He projects himself as a heroic and courageous subject endowed with great physical and mental capacities. He also presents psychomotor agitation; believing that he no longer needs to sleep, he enters a state of delusional hypomania. His delirium has a very marked megalomaniac component; his sense of duty to right wrongs is stimulated by a narcissistic desire for universal fame and glory.⁶

A shift in affect is also noted, with terms such as disillusion and melancholy clearly alluding to a depressive condition.^4,7 At a certain point he decides to do a penance consisting of doing pirouettes naked in the forest. He does all this to convince Dulcinea of his love.

He voluntarily enters a state of madness and debates whether to imitate the madness of Roland or that of Amadis. Ultimately, he chooses melancholic madness and carries on with his penance in the forest, where he constantly perceives the presence of supernatural beings (1: I-XXV): "And though I have no intention of imitating Roland, or Orlando or Rotolando (for he went by all these names), step by step in all the mad things he did, said, and thought, I will make a rough copy to the best of my power of all that seems to me most essential; but perhaps I shall content myself with the simple imitation of Amadis, who without giving way to any mischievous madness but merely to tears and sorrow, gained as much fame as the most famous" (1: I-XXV).

In the second part, the barber tells Don Quixote a story about a madman and he takes the hint. Furthermore, Sancho Panza understands that Don Quixote is mad (1: II-II), and they discuss whether to persist in madness or seek holiness (1: II-VIII).

Quixote's death

Don Quixote returns to his town frustrated as he is unable to disenchant Dulcinea. When he arrives at his home, he sleeps for six hours. When he wakes up, he recognises that he is Alonso Quixano and that his madness stemmed from reading chivalry books. With his judgement restored, he dictates his will, says goodbye to everybody, especially Sancho Panza, and dies after three days (1: II-LXXIV). "My reason is now free and clear, rid of the dark shadows of ignorance that my unhappy constant study of those detestable books of chivalry cast over it. Now I see through their absurdities and deceptions, and it only grieves me that this destruction of my illusions has come so late that it leaves me no time to make some amends by reading other books that might be a light to my soul" (1: II-LXXIV). "Forgive me, my friend, that I led thee to seem as mad as myself, making thee fall into the same error I myself fell into, that there were and still are knights-errant in the world" (1: II-LXXIV).

Although Miguel de Cervantes was a great-grandson and son of surgeons, there are very few references to physicians in the novel.⁸ His great-grandfather, Juan Diaz de Torreblanca, was a scholar, physician, and surgeon, and his father, Rodrigo Cervantes, was a blood-letting surgeon.⁹ One such reference occurs in the protagonist's last moments, when he is visited by a physician. After examining the patient, the physician concludes that "melancholy and depression were bringing him to his end" (1: II-LXXIV).

The influence of the medical knowledge of the time, especially the work of Don Juan Huarte de San Juan, is clear in the work.¹⁰

Final remarks

Alonso Quixano, a character created by Miguel Cervantes, is extraordinary in many ways. This text has dealt solely with his neuropsychiatric afflictions, but the literature review revealed that the medicine of the time is well described, in him and in other characters, particularly his squire Sancho Panza. The work also reflects the scientific tensions of the time, recognising that the brain is the organ affected in mental illness (cerebrocentric theory), but that tremor results from an increase in heart rate due to emotions lodged in the heart (cardiocentric theory).

Miguel de Cervantes's characterisation of Don Quixote seems so real, so flesh-and-blood, that it inspires some of us to see him as a patient and sift through his story in search of signs and symptoms offering insight into this wonderful character.

Conflicts of interest

The authors declare that they have no conflicts of interest.