Although dermatology, as a structured part of medical science, did not appear in Spain until the 19th century,1 it has been implicitly present since the beginning of humanity, both through references to different skin diseases and through the therapies recommended for their treatment and care that can be found in various sources.

The aim of this study is to collect all dermatological references found in The Ingenious Gentleman Don Quixote of La Mancha by Miguel de Cervantes Saavedra, considered by many to be the greatest genius of Spanish-language literature (Fig. 1).

Fig. 1.

Sculptural group in Plaza de España, Madrid, dedicated to The Ingenious Gentleman Don Quixote of La Mancha. In the foreground, Don Quixote and Sancho Panza on their mounts. Behind them, Miguel de Cervantes with the symbolic book in his hand.

The author and medicine

Cervantes2 was born in Alcalá de Henares on September 29, 1547. His father, Rodrigo de Cervantes, was a cirujano romancista, that is, he did not know Latin and his training was mainly practical. After his early youth, Cervantes enlisted as a soldier in the company of Captain Diego de Urbina. On October 7, 1571, he took part in the Battle of Lepanto against the Turks and suffered an arquebus shot to his left hand, leaving it useless and immobile. He was treated by Gregorio López, then physician to King Charles I. From 1575 to 1580 he remained captive in Algiers, where he came into contact with another culture and another form of medicine, enduring hardship and 4 escape attempts. He died in Madrid on April 22, 1616, from the diabetes mellitus from which he suffered. He was buried humbly in the monastery of San Ildefonso and San Juan de Mata, the former Convent of the Trinitarias Descalzas de San Ildefonso, in Madrid. However, the exact place where his remains rest is unknown because of the renovation the convent underwent in 1639, which caused the disappearance of any marker that might have indicated his tomb.

The education he received from his surgeon father, his diseases and wounds, his contact with illustrious physicians, his travels, and his eagerness to learn undoubtedly influenced the important knowledge of the medicine of his time that the author demonstrates in his writings.

The novel: The ingenious gentleman Don Quixote of La Mancha3

Considered by most scholars to be the first modern novel, it has exerted an enormous influence on all European narrative. The first part was published by Juan de la Cuesta's press in Madrid in 1605, and the second in 1615, when Cervantes was already 68 years old.

The first part narrates the adventures of the gentleman Alonso Quijano, who, fond of reading books of chivalry, comes to believe himself to be one of the knight-errants who are the protagonists of such stories. He sets out in search of similar adventures, to save maidens and right wrongs, accompanied by Sancho Panza, a peasant whom he takes as his squire, and by Rocinante, his old and ungainly horse. Dulcinea del Toboso is his beautiful beloved lady, although in reality she is a peasant woman to whom he attributes beauty and honors. The second part narrates the gentleman's new adventures after a period of apparent sanity, accompanied, as in the first part, by his faithful squire, the peasant Sancho Panza, and by his aged horse Rocinante. He searches for his lady Dulcinea del Toboso and, after many vicissitudes, returns home, where he dies lucid and accompanied by his family and friends.

The work constitutes an extraordinary lesson in lifestyle, morality, and the history of the period. A careful reading also allows us to learn what skin medicine, which we now call dermatology, was like.

Diseases

We refer below to the mentions of diseases in which the skin is present in some way in The Ingenious Gentleman Don Quixote of La Mancha. They are presented in order of appearance, indicating in each case the part and chapter to which they correspond.

First part

Scabies: Part I, Chapter 12Of what a goatherd told those who were with Don Quixote

Pedro, one of the goatherds whom Don Quixote has met, begins to tell the story of Grisóstomo and Marcela:

Perhaps, and even without perhaps, you will never have heard such a thing in all the days of your life, though you live longer than scabies.

“Say Sarah,” replied Don Quixote, unable to bear the goatherd's misuse of words. “Scabies lives long enough,” answered Pedro; “and if, sir, you are going to keep correcting my words at every step, we shall not finish in a year.”

“Forgive me, friend,” said Don Quixote, “for I said it because there is such a difference between scabies and Sarah; but you answered very well, because scabies lives longer than Sarah.”

Here the long and difficult cure of scabies at that time is compared with the age of Sarah, Abraham's wife, who lived 127 years. For centuries, scabies was a disease present in society without an effective remedy. It is implied that scabies lasted as long as the life of the person who suffered from it (Fig. 2). When immunity or hygiene was deficient, scabies acquired an intensely hyperkeratotic, extensive, and highly contagious form. This is what we now call crusted, or Norwegian, scabies (Fig. 3).Pediculosis capitis, pediculosis pubis – lice infestation –: Part I, Chapter 13Where the tale of the shepherdess Marcela is brought to an end, with other events

Fig. 2.

Scabies. Burrow drawn by the mite Sarcoptes scabiei as it moves through the epidermis. When lesions appeared on the hands, pruritus forced scratching, which in writings of the period was euphemistically called “playing the guitar.”.

Fig. 3.

Crusted scabies. The innumerable causative mites spread and proliferate when immunity or hygiene is deficient. These circumstances must have occurred often in Cervantes’ time.

Don Quixote, during his conversation with Vivaldo, one of the travelers who has asked him why he is dressed in that way, says that he is a knight-errant. The traveler compares him with monks, and Don Quixote says:

I do not mean, nor does it cross my mind, that the state of the knight-errant is as good as that of the cloistered religious man; I only wish to infer, from what I suffer, that it is undoubtedly more laborious and battered, and more hungry and thirsty, miserable, ragged, and lousy, for there is no doubt that the knights-errant of the past endured much misfortune in the course of their lives.

Pediculosis appears here as a parasitosis accompanying an arduous, poor, and unhygienic life, more present in the nomadic existence of knight-errants than in that of monks (Fig. 4).Trauma to the skin and mucous membranes: Part I, Chapter 18Where the conversation Sancho Panza had with his master Don Quixote is recounted, together with other adventures worthy of being told

Fig. 4.

Pediculosis pubis. Phthiriasis, or pediculosis of the pubis, is caused by Pthirus pubis, also known as the crab louse or pubic louse. The image shows a crab louse and numerous cerulean macules, small grayish-brown spots caused by the anticoagulant activity of the lice while feeding, which produce small hemorrhages under the skin.

Don Quixote charges at some sheep, believing them in his delirium to be enemies, and the shepherds tending them throw stones at him.

Then a smooth pebble from the stream arrived … carrying off along the way 3 or 4 teeth and molars from his mouth.

This is an example of the pinpricks, lashes, falls, blows with oil lamps, kicks, cudgel blows, sword thrusts, blows, lance wounds, blanket tossings, slaps, bites, stick blows, kicks, stonings, pinches, thumps, punches, fist blows, beatings, or trips; bruises, bumps, crackings, fainting, battering, and breakings, with concomitant damage to the skin, although not specified as such, that also appear in other chapters. In this case, although the stone knocks out teeth and molars, it is evident that it simultaneously damaged the skin and mucous membranes of the face and mouth.Fevers and pestilences – infections with cutaneous involvement –: Part I, Chapter 19Of the discreet conversation Sancho had with his master, and of the adventure that befell him with a dead body, together with other famous events

Don Quixote encounters some monks carrying a corpse from Baeza to Segovia.

… Whose fearful vision entirely overcame the spirit of Sancho Panza, who began to chatter his teeth like someone with a quartan fever.

The cause of death is explained as an infection with cutaneous involvement, although there are no explicit data that would allow a specific diagnosis to be affirmed.Tinea: Part I, Chapter 40Where the captive's story continues

The captive who had been imprisoned in Algiers continues his story:

In short, the fleet returned to Constantinople triumphant and victorious, and a few months later my master Uchalí died, whom they called Uchalí Fartax, which in the Turkish language means the tinea-affected renegade, because that is what he was.

Among the Turks, it was common to add names referring to some physical defect, apart from the 4 surnames of the lineage of the Ottoman house. In this case it was tinea, although its clinical features are not described, only its existence, which he must have suffered for a long time, long enough for the nickname to be assigned to the Turk (Fig. 5).

Fig. 5.

Tinea corporis. Tinea is an infection caused by dermatophyte fungi, named according to the body area affected. The image shows tinea of the body, with the typical rounded circular lesion and an actively growing border. Today, effective antifungal treatments usually allow cure.

Don Quixote replies in this way, pleased, confirming the imagined beauty of his lady:

… For nature placed nothing in Dulcinea that was not perfect and well finished; and thus, if she had 100 moles like the one you mention, in her they would not be moles, but shining moons and stars.

However, the mole described is not beautiful. It represents an intradermal melanocytic nevus with hairs (Fig. 6), which, because of the Platonic love he suffers from, he considers beautiful despite everything.Warts/rhinophyma: Part II, Chapter 14Where the adventure of the Knight of the Wood continues

Fig. 6.

Intradermal melanocytic nevus. This is a raised, skin-colored lesion in this case, although it may have a chestnut or dark-brown tone. Long hairs are observed, graying because of the patient's age. It is benign, although it often causes aesthetic concern, sublimated into beauty in the case of Don Quixote.

The narrator recounts:

But scarcely had the light of day allowed things to be seen and distinguished when the first thing that appeared before Sancho Panza's eyes was the nose of the squire of the Wood, which was so large that it almost cast a shadow over his whole body. Indeed, it is said that it was excessively large, crooked in the middle, and entirely covered with warts, purplish in color, like an eggplant.

It is hard to know whether this referred to viral warts or to the bulky papules of rhinophyma due to phymatous rosacea, which seems more likely because of the color and description.Syphilis – the French disease –: Part II, Chapter 22Where the great adventure of the Cave of Montesinos, in the heart of La Mancha, which the valiant Don Quixote of La Mancha brought to a happy conclusion, is recounted

A cousin invited to Quiteria's wedding speaks of a great book he owns.

Virgil forgot to tell us who was the first person in the world to have a cold, and the first who took the unctions to cure himself of the French disease.

The disease is not described, but syphilis, or the French disease, is mentioned, at that time considered to be of French origin.Pediculosis capitis – lice infestation –: Part II, Chapter 29Of the famous adventure of the enchanted boat

Don Quixote says, regarding the voyages of the boat he believes to be enchanted:

One of the signs they have to know that they have crossed the equinoctial line I told you about is that all those who are on the ship have their lice die, without a single one remaining.

He establishes a curious relationship between location and the life of lice, as if climate or hemisphere influenced their existence.Leprosy: Part II, Chapter 29Of the famous adventure of the enchanted boat

The narrator says:

And after Don Quixote's dissertation on the calculations of the cosmographer Ptolemy, Sancho understands […] that Your Grace brings me as witness to what he says a person who is a cuckold and a gafo.

Gafo or gafe refers to the claw hand secondary to leprosy with neural involvement. The term arose because the damaged hand resembles the claw- or hook-shaped implement called gafo, which was used to load crossbows.Pediculosis capitis – lice infestation –/seborrheic dermatitis: Part II, Chapter 44 How Sancho Panza was taken to his governorship, and of the strange adventure that befell Don Quixote in the castle

Altisidora says in her ballad to Don Quixote, with whom she pretends to be in love:

Oh! Who might see herself in your arms, or else beside your bed, scratching your head and killing your dandruff!

It is evident that she wants to kill the lice and reduce the pruritus they cause by scratching. However, it may also be interpreted that dandruff additionally represents seborrheic dermatitis. We have no clinical data, only the mention of pruritus and dandruff, which she would like to “kill” (Fig. 7).Smallpox: Part II, Chapter 47Where the account continues of how Sancho Panza behaved in his governorship

Fig. 7.

Seborrheic dermatitis. When it affects the scalp, this chronic inflammatory disease shows erythema and scaly areas or dandruff, which may become thick, as in the image. It causes itching; the reference in Don Quixote – “scratching your head and killing your dandruff” – appears to confirm this diagnosis.

A peasant explains that his son fell in love with the beautiful Clara Perlerina.

Although, to tell the truth, the maiden is like an oriental pearl, and, seen from the right side, she looks like a flower of the field; from the left, not so much, because she lacks that eye, which was knocked out by smallpox; and although the pits on her face are many and large, those who love her well say that they are not pits, but tombs where the souls of her lovers are buried.

A frequently fatal disease, when smallpox healed, it left intense crateriform scars that adopted the morphological term “varioliform” from their origin.

Also in Chapter 17, Of the troubles they suffered at the inn, which, to his misfortune, he thought was a castle, the balm is mentioned again, as in the first part, together with its natural ingredients and the vomiting that occurs after ingesting it.Cosmetics: Part I, Chapter 20Of the never-before-seen or heard-of adventure that was completed with less danger than any by a famous knight in the world, as the valiant Don Quixote of La Mancha completed it

Sancho said:

… Torralva followed him, and followed him on foot and barefoot from afar, with a staff in her hand and saddlebags around her neck, in which she carried, according to report, a piece of mirror and another of a comb, and I know not what little jar of face preparations …

This alludes to cosmetic and hygiene care for healthy skin, also an objective within the field of dermatology. The little jar of mudas refers to a container used to store or transport things during moves or journeys, as in this case. Since it was for the face, it is assumed to have contained some beauty cream or lotion.

This was the general belief of people at the time, who often distrusted the medicine commonly used.

Although this reference does not directly concern dermatology, we include it because dermatology at that time was practiced by any physician. Here, the curricular value of the place where one studied and learned is demonstrated, as is how, when the physician was good and prestigious, he was admired and honored.