Sunday, 24 February 2019
A Compelling and Compassionate Book about Epilepsy

by Theodore Dalrymple

Electroconvulsive therapy, the deliberate induction of an epileptic fit in severely depressed patients, had—and perhaps still has—a very bad public reputation. To give the brain an electric shock without any real underlying theory as to why it might work seems brutal; after all, we don’t take our car to the garage when it is working imperfectly and expect the mechanics to give it a good kicking in the hope that the vibrations set up by their boots might rattle the components into good working order. And how infinitely more subtle, more delicate, than the workings of the internal combustion engine are those of the brain!

When I was a young doctor, however, I witnessed something that caused me to doubt whether the One Flew Over the Cuckoo’s Nest view of electroconvulsive therapy, then more or less the orthodoxy among bien pensant intellectuals, was quite adequate. The 1962 Ken Kesey novel and 1975 movie famously depicted it as simply a punitive measure taken against the insubordinate and rebellious.

Admitted to a medical ward in the hospital in which I worked was a patient so depressed that she was stuperose (unresponsive to others and neither eating nor talking). Shortly afterwards, she had two internally-generated epileptic fits in quick succession. They had a transformative effect upon her. She began to talk normally, to eat, and even to laugh. There was even the possibility that, with another fit or two, she might become dangerously euphoric.

Epilepsy—the disorderly electrical discharge of neurons in the brain—is a protean disease whose manifestations are so various, and sometimes so subtle, that they are easily mistaken for something else: plain bad behavior, for example. Suzanne O’Sullivan, author of Brainstorm: Detective Stories from the World of Neurology, is a London neurologist who specializes in epilepsy, and who in this captivating book recounts the stories of some of the patients (I nearly wrote cases, but that would be dehumanizing) whom she has treated.

Although epileptic attacks are usually intermittent and sometimes infrequent, they often exert a profound influence on the lives of sufferers out of all proportion to their duration. Dr. O’Sullivan brings this home to the reader very well; no one who reads this book will ever fail again to sympathize with sufferers from this mysterious condition.

Advances in the Field

Epilepsy is really a symptom rather than a disease in itself. It can be caused by a vast array of underlying causes, and its manifestations depend on what part of the brain is primarily affected. Of course, enormous strides have been made in the neurosciences, particularly in the last two or three decades, so that the causes can be pinpointed with ever-greater accuracy; but treatment so far has not improved at the same pace. There are more medications than ever available, and in some cases surgery offers a cure by excision of the epileptic focus. But medications have side-effects, sometimes worse than the condition that they treat, and can in any case fail despite being piled one on top of the other. Surgery is at best uncertain of success, and it too (unsurprisingly) can cause severe harm.

Dr. O’Sullivan is laudibly frank about this. For the moment, many of the advances offer more hope for the future than benefit in the present, though patients are nevertheless grateful for the efforts made on their behalf and are reassured by the explanation that can now be given of their fits. The act of explanation is therapeutic in itself but tragedy remains.

In one of the stories, a young epileptic man, a student, dies aged 20 in his bed in his student accommodation, for reasons that will never be fully elucidated. Unexplained death occurs in about one in 1,000 epileptics per year, which means that over the course of 20 years there is considerable risk of such death. The story is so well told that, at least a brief moment, we enter into the grief of the parents.

Epilepsy or Incivility?

The stories the author recounts provoke reflection. For example the epileptic fits of one of her patients consist of unpredictable and sudden outbursts of swearing and spitting at people without any provocation. They do not last long and the patient does not remember them, but it is not difficult to imagine the social difficulties to which they lead. One can only imagine with a slight sense of guilt how one might react to such a person on a bus, say, or at a meeting. Almost certainly, it would be with anger or disgust and the assumption that the person was reprehensible, and moreover that his conduct was just another example of the incivility of our times to which we have become wearily accustomed.

Our default position, as it were, is that of the English common law: namely that every person is responsible for his conduct unless there is proof otherwise; and since one cannot be expected to know a person’s full medical history before reacting to his conduct, one’s first reaction is to blame. Perhaps Dr. O’Sullivan’s book will make her readers a fraction less likely to jump to censorious conclusions.

Whether this would be a good thing or not is another question. Only a very tiny proportion of antisocial behavior is caused by epilepsy, but the medicalization of bad behavior can only increase its frequency by providing it with an excuse in advance. I must have “treated” (if that is quite the word for it) hundreds of men who presented their tendency to be violent to their girlfriends as if they were suffering from some kind of epileptic condition beyond their control, requiring medical treatment in the absence of which they had license to continue. It was an exculpatory explanation of their own conduct that, oddly enough, their girlfriends often accepted. Responsibility is the greatest burden mankind bears, though it is also its glory.

Scientific But Not Scientistic

I am glad to say that Dr. O’Sullivan does not go in for neurological imperialism akin to the psychiatric imperialism that some psychiatrists, particularly psychoanalysts, used to indulge in. Because one man’s swearing and spitting are caused by epilepsy does not mean that all swearing and spitting are epileptic, even if it sometimes requires sophisticated investigation and judgment to discern in which cases epilepsy is behind these acts. The author’s outlook is scientific but not scientistic; epilepsy is a technical problem, but life itself is not.

Occasionally, her style leaves something to be desired; your reviewer was brought up short by the phrase “overly cruel,” for example, which suggests that there is a proper level of cruelty to aim at. Presumably she meant “very cruel.” But this a cavil. A passage at the very end of the book is worth reproducing:

There are still gaping holes in our knowledge about the brain. Even the basic questions remain unanswered. We still don’t know why we sleep or the purpose of dreams. We don’t know how the brain creates intelligence. Or consciousness. Or how free will is created . . . For my part, I am not even certain that I want every single question answered. If we knew everything about how the brain functioned, what would we be then? Just sophisticated computers? Machines that could be programmed?

I do not think she need worry. Behind knowledge more mystery always arises, and it is in the tension between the two—knowledge and mystery—that much of the joy of human existence lies.  

First published in the Library of Law and Liberty.

Posted on 02/24/2019 7:29 AM by Theodore Dalrymple
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