Looking Back

One of the oldest cases of schizophrenia in Gogol's Diary of a Madman

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7327.1475 (Published 22 December 2001) Cite this as: BMJ 2001;323:1475
  1. Eric Lewin Altschuler (ealtschuler@ucsd.edu), assistant director
  1. Brain and Perception Laboratory, University of California, San Diego, 9500 Gilman Drive, 0109, La Jolla, CA 92093-0109, USA

    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

    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 sketch—albeit a most brilliant one—of the disease

    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 factor—a 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.

    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, …

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