BMJ 2001;323:1475-1477 ( 22-29 December )
Looking back...
One of the oldest cases of schizophrenia in Gogol's
Diary of a Madman
Eric Lewin Altschuler, assistant director. Brain and Perception
Laboratory, University of California, San Diego, 9500 Gilman
Drive, 0109, La Jolla, CA 92093-0109, USA
ealtschuler{at}ucsd.edu
Besides intrinsic historical and literary interest and
clinical usefulness by providing good exemplar cases, the study of the
history of a disease can provide clues to its pathogenesis
it is
necessary, but not sufficient, that the cause of a disease be at least
as old as the disease itself. Here I note one of the oldest and most
complete descriptions of schizophrenia, in Nicolai Gogol's classic
short story Diary of a Madman (1834).1
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Summary points
Nicolai Gogol's classic short story Diary of a
Madman (1834) contains one of the earliest, and most complete,
descriptions of schizophrenia
Beyond intrinsic and historical interest, this case is important
because it has implications for the antiquity, and possibly the
aetiology, of schizophrenia
From a literary point of view, the story can be appreciated as a
sketchalbeit a most brilliant oneof the disease
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History of schizophrenia |
It might seem unnecessary to need to prove that schizophrenia is
an old disease because "every town had a fool." However, the only
case of schizophrenia that possibly meets the diagnostic criteria for
the disease (see box) much before 1800 is that of Edgar or Poor Tom in
Shakespeare's King Lear.3-5 This has led to
the tentative suggestion that some factora virus, environmental toxin, or perhaps "modernity itself"in play since 1800 has
greatly increased the incidence of schizophrenia.3 As the
signs of schizophrenia can be noticed without any laboratory test or
even specialised training, the extreme dearth of old cases of
schizophrenia cannot trivially be due to lack of advanced diagnostic
equipment or medical education in days of yore. The "mad" ravings
of a local town "fool" could have been secondary to mania, temporal
lobe epilepsy,6 substance misuse or withdrawal, vitamin
deficiencies, or heavy metal poisoning.
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Diagnostic criteria for schizophrenia (according to
Diagnostic and Statistical Manual, third
edition2)
- The person must have at least two out of five symptoms(i)
delusions, (ii) hallucinations, (iii) disorganised speech, (iv)
grossly disorganised or catatonic behaviour, or (v) negative symptoms
(such as alogia, avolition, etc)for a substantial portion of a
one month period
- Continuous signs of disturbance must continue for at least six
months
- Since the onset of disturbance, the person must have substantial
social or occupational dysfunction
- Required exclusion criteria are substance misuse or dependence,
general medical condition, mood disorder, and pervasive developmental
disorder
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Nicolai Gogol |
Nicolai Gogol was born in the Ukraine in 1809. He moved to St
Petersburg in 1829 and got a job through a friend at a government ministry. From 1834 to 1842 he published five tales about the Ukraine,
including Diary of a Madman (1834), The Nose
(1836), and The Overcoat (1842). During this time he
also wrote numerous other stories, plays, and essays. In 1842 he
published part one of his great novels, Dead Souls.
Gogol spent much of his later years outside of Russia. In
1848 he made a pilgrimage to Jerusalem and apparently had increasing religious mania in his final years. He completed part two of Dead Souls in 1852 but then burnt the manuscript on 10-11 February of
that year and died on 21 February, perhaps from self
starvation.1 Gogol is one of the greatest Russian writers
and served as an inspiration to later writers such as Nabokov and
Dostoevsky.1
 | | (Credit: BRIDGEMAN ART LIBRARY) |
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Nikolai Vasilievich Gogol (1809-52)
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Diary of a Madman and diagnosis of
Poprishchin |
Diary of a Madman is in the form of the diary of
Axenty Ivanovich Poprishchin, a Ukrainian civil servant in his 40s. The
story starts with an entry for 3 October (year 1). (The story does
not list years. I use them as a chronological aid in discussing the story.) The day does not start well for Poprishchin, who gets up late
and is late for work. Poprishchin notes in his diary that later that
day he thinks he hears two dogs talking to each other in Russian. He
further notes: "`It can't be true, I must be drunk.' But I hardly
ever drink." Things go downhill quickly: Poprishchin has increased
trouble at work, and on 13 November (year 1) he notes that he reads
letters from the dogs to each other.
On 5 December (year 1) Poprishchin records that he read in the
newspaper about the dispute of the succession of King Ferdinand VII of
Spain (1833). On a date written "April 43rd, 2000" (April of year
2?) he writes: "Today is a day of great triumph. There is a king of
Spain. He has been found at last. That king is me. I only discovered
this today." The date for the next entry in the diary is "86th
Martober, between day and night" (October of year 2?). Poprishchin
goes to work after a three week absence and then proceeds to greatly
offend his boss and coworkers. Later, in an entry dated as "No
date," Poprishchin writes that he had been in a large crowd but
"did not reveal [his] identity [as King Ferdinand VIII]" The
date of the last entry of the diary is
(February of year 3?).
Poprishchin notes that people are pouring cold water over his head, his
head is spinning, the sky whirls.
Diagnosis of Poprishchin
Starting in possibly April of year 2, Poprishchin has the
persistent delusion that he is King of Spain. This delusion continues
for the rest of the story, a period of at least three weeks (that he
did not go to work) and probably months or longer. His condition
worsens progressively, and throughout this time he shows disorganised
behaviour by not going to work and then acting bizarrely when he does.
This is also occupational dysfunction. Before the start of his delusion
that he is King of Spain (probably not coincidentally the diary entry
with a bizarre date "April 43, 2000"), Poprishchin experiences a
"prodromal" period, which includes the hallucinations that dogs are
speaking to each other in a human language and the hallucination or
delusion that the dogs are writing letters to each other. The text of
the diary indicates that Poprishchin's speech is becoming increasingly
disordered, the date of the final entry of the diary being only one
example. When Poprishchin reads about the trouble with the succession
of the King of Spain, he seems to take the problem personally (which is
ridiculous because he is not even a citizen of Spain). This is an
example of the sign of "ideas of reference" (perhaps the oldest
such example), which is often seen in schizophrenia.2 In
modern times ideas of reference commonly manifest as the notion that a
television newscaster or other television personality is speaking
directly to the schizophrenic patient.
There is no evidence for pervasive developmental disorder, major
depression, temporal lobe epilepsy, or a general medical condition in
Poprishchin. He does not demonstrate any of the typical behavioural
signs of mania such as going without sleep, hypersexuality, or
profligate spending. Mania can produce delusions such as that one is a
king. However, we might expect such a delusion to manifest itself
differently in a manic patient than it does in Poprishchin. Indeed, in
the diary entry dated "No date," Poprishchin says that he was in a
crowd but did not point out to anyone that they were in the presence of
a king. A manic patient would perhaps take such an opportunity to make
a grand pronouncement. There is no evidence of substance misuse or
dependence by Poprishchin, and alcoholism is explicitly ruled out:
"But I hardly ever drink" (3 October (year 1)). This exclusion is
important as alcohol misuse or dependence is not uncommon in Gogol's
writings. The fifth decade of life is an old but certainly not unheard
of age for a psychotic break.7
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Context of Gogol's story |
Gogol's story thus contains one of the oldest and the most
extensive description of schizophrenia. Given that the story contains all the inclusion and exclusion criteria for schizophrenia, and the
story's unity and title, it suggests there must have been a case(s) in
the Ukraine or Russia that Gogol observed. However, it cannot be ruled
out that Poprishchin is a montage constructed from pathological
features that Gogol observed in various individuals or in literary
characters such as Kapellemeister Kreisler, a creation of German writer
E T A Hoffmann (1776-1822). Indeed, the original title of Gogol's
story apparently was "The Diary of a Mad Musician"8a clear reference to Hoffmann. Hoffmann's works are extensive and complex, and contain many curious characters. In them I have not yet
found a case of schizophrenia, and certainly no descriptions laid out
with the clarity and unequivocal manner of Gogol's case. Gogol may
have been inspired by reports in newspapers such as The Northern
Bee (which Gogol ridiculed and satirised in Diary of a
Madman) of inmates at insane asylums.8 Further study
of these reports and the works of Hoffmann for cases of schizophrenia might be warranted. Gogol's apparent case of schizophrenia in the
Ukraine or Russia (or Germany) no later than 1834, taken in conjunction
with other cases in England and France in 1809,
9 10
show
that schizophrenia was already widely disseminated in Europe by early
in the 19th century, making it increasingly unlikely, though not
impossible, that schizophrenia was largely unheard of before 1800.
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Discussion |
If schizophrenia is an old disease then why are there so few
early reports? There are at least four possible explanations. Firstly,
the increase in the reported number of cases of schizophrenia may be an
artefact of the tremendous increase in the number of physicians and
medical researchers in the past 200 years. Secondly, modern
descriptions of schizophrenia, starting with Kraepelin's work on
dementia precox,11 have greatly facilitated the
recognition of schizophrenia by clinicians, thus possibly accounting
for the tremendous increase in cases. Thirdly, since a diagnosis of
schizophrenia requires diminished social functioning, most people with
schizophrenia in the past would have been unable to write or ensure
dissemination of information about their condition. Furthermore, given
the typical downtrodden plight of people with chronic (untreated)
schizophrenia, those with the disease may not have been an enticing
topic for description by non-patient authors. Finally, there may indeed have been some aetiological agent new since 1800 responsible for the
great increase in the number of cases. The apparent dearth of old cases
of schizophrenia is consistent with an ingenious hypothesis put forward
to explain a preponderance of patients with schizophrenia in the
northern hemisphere having been born in the first quarter of the
year12: schizophrenia occurs in individuals with
"loaded" genetic backgrounds whose mothers had low levels of
vitamin D in the second and third trimesters of pregnancy.
 | | (Credit: BRIDGEMAN ART LIBRARY) |
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St PetersburgGogol's citypainted by Vasilij Surikov in 1870
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Further checking of medical, literary, and other written sources may
yield additional old cases of schizophrenia. Increased confidence that
schizophrenia is an old disease, or not, may help in forming hypotheses
and guiding research to find better methods to treat or prevent this
common (prevalence about 1%7) and highly morbid disease.
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Acknowledgments |
I thank the staff of the UCSD Book Store for introducing
me to Gogol's wonderful story; Suzy Conway (Harvard Medical School Countway Library) for helpful discussions; and Jonathan Saville (UCSD)
for invaluable discussions and for confirming, by reading the story in
Russian, that the diagnosis is not an artefact produced by translation.
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References |
| 1.
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Gogol N.
Diary of a madman and other stories. (
Translated from Russian by R Wilks). London: Penguin Books, 1972.
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| 2.
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Diagnostic and statistical manual of mental disorders: DSM-IV.
Washington, DC: American Psychiatric Association, 1994.
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| 3.
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Hare E.
Schizophrenia as a recent disease.
Br J Psychiatry
1988;
153:
521-531[Abstract/Free Full Text].
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| 4.
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Andreasen NJ.
The artist as scientist. Psychiatric diagnosis in Shakespeare's tragedies.
JAMA
1976;
235:
1868-1872[CrossRef][Medline].
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| 5.
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Bark NM.
Did Shakespeare know schizophrenia? The case of Poor Mad Tom in King Lear.
Br J Psychiatry
1985;
146:
436-438[Free Full Text].
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| 6.
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Fedio P.
Behavioral characteristics of patients with temporal lobe epilepsy.
Psychiatr Clin North Am
1986;
9:
267-281[Medline].
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| 7.
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Schultz SK, Andreasen NC.
Schizophrenia.
Lancet
1999;
353:
1425-1430[CrossRef][Medline].
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| 8.
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Fanger D.
The creation of Nikolai Gogol.
Cambridge, MA: Belknap Press, 1979:115.
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| 9.
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Haslam J.
Observations on melancholy and madness.
London: Callow, 1809.
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| 10.
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Pinel P.
Traité médico-philosophique sur l'aliénation mentale.
2nd ed.
Paris: J A Brosson, 1809.
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| 11.
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Kohl F.
The beginning of Emil Kraepelin's classification of psychoses. A historical-methodological reflection on the occasion of the 100th anniversary of his "Heidelberg Address" 27 November 1898 on "nosologic dichotomy" of endogenous psychoses.
Psychiatr Prax
1999;
26:
105-111[Medline].
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| 12.
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Moskovitz RA.
Seasonality in schizophrenia.
Lancet
1978;
i:
664.
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© BMJ 2001
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History of schizophrenia
Nicolai Gogol
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