Descriptions of Clinical Semiology of Seizures in Literature
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Review article Epileptic Disord 2006; 8 (1): 3-10 Descriptions of clinical semiology of seizures in literature Peter Wolf Danish Epilepsy Centre Dianalund & National Hospital, Neurocentre, Epilepsy Clinic, Copenhagen, Denmark Received August 3, 2005; Accepted September 5, 2005 ABSTRACT – Literary texts are an important part of the cultural history of many fields of medicine. Accounts of epilepsy are frequent, and descriptions of seizure semiology are often included with varying detail. This review looks at these, and considers the authors’ background knowledge of epilepsy. The first group of writers suffered seizures themselves. Some of them provide remarkable and novel insights into the subjective symptoms and experiences in and around seizures. A second group draws from their own observations of seizures in others who may have been close relatives or fortuitous strangers. Here, the outside view prevails, and seizures may be described with clinical objectiveness. Commonly, the reactions of onlookers become part of the narrative beyond the seizure description. The third group writes from second-hand knowledge, which may be other observer reports, interviews with people with epilepsy or with experts, informa- tion being available in dictionaries, medical textbooks and the like. The professional standard of most writers means that the resulting descriptions are quite accurate, but there are also examples of poor use of such information. Many authors’ sources are not known, but can be assumed to belong to one of the above categories, and we can sometimes guess. It appears that even authors with no first-hand knowledge are often aware of seizure types other than the most widely known, generalised tonic-clonic, and there is a widespread interest in warnings and how the afflicted respond to them. The quality of an author’s fictional account of epilepsy should not be judged from a translation, because specific aspects and the language involved in the description may have been misunderstood by the translator. Key words: epilepsy in fiction, seizure types, semiology, cultural history, images of epilepsy Literary accounts of epilepsy are fre- res. Sometimes only certain aspects quent, and the writers’ objectives for are depicted, or the epilepsy is merely using epilepsy in fiction are varied mentioned. However, the corpus of Correspondence: P. Wolf (Ozer 1991, Vanzan Paladin 1995, literary seizure descriptions is large Epilepsihospitalet, Wolf 1995). Their ambition is not enough to raise the question as to Kolonivej 1, DK, usually to write a correct medical case what they are based upon. In quite a 4293 Dianalund, Denmark, history, the epilepsy serves a literary few instances, this is generally known. Tel.: (+00 45) 58 27 10 73, Fax: (+00 45) 58 27 10 50. purpose. This does not always neces- In others, I have had to contact the <[email protected]> sitate a detailed description of seizu- authors, and many of them have been Epileptic Disord Vol. 8, No. 1, March 2006 3 P. Wolf kind enough to give this information. In a few instances, a At about the same time, Danish writer Ernesto Dalgas good guess is possible, but there are still a number of (1871-1899) published his novel Lidelsens vej (The way of descriptions the sources of which are unknown. suffering, 1898), which has a strongly autobiographic It is the authors’ background knowledge that is therefore background, and where the protagonist experiences sei- used to structure this review, starting with descriptions zures consisting of an illusion of derealisation where the based on first-hand knowledge that writers acquire be- people surrounding him look like lifeless masks. These cause they have epilepsy themselves. occur in highly significant, emotional moments like in church during his confirmation ceremony, and during a moment of erotic seduction (Wolf 1973). In Norwegian writer Tryggve Andersen’s (1867-1920) Descriptions based on personal experience novel Mot kvæld (Towards evening, 1900), the protagonist has hallucinatory experiences which would not immedi- One of the fundamental facts about the semiology of ately be interpreted as epileptic symptoms. However, as seizures is that there may be subjective or objective signs Aarli (1993) found out when he went through the author’s and symptoms, or both. The subjective experiences are hospital files, the descriptions include in fact, symptoms of known only to the patient, whereas the objective signs epileptic seizures which were diagnosed after Andersen remain hidden to him to the extent that he loses conscious- had written the novel. ness during the seizures or part of them. Writers with The only other known example of literary expressions of epilepsy can be expected to give particularly elaborate epileptic experiences when the writer was still unaware of and accurate accounts of subjective seizure experiences. the diagnosis is by British author Margiad Evans (1908- The best-known example of this is Fyodor M. Dostoyevsky 1958). In her book A Ray of Darkness (1952), she de- (1821-1881). The description, given by the character Kir- scribes in minute detail the events preceding and sur- illov in Besy (Devils, 1872), of a feeling of utmost happi- rounding her first generalised tonic-clonic seizure which ness, the presence of eternal harmony in an aura which, she had experienced in 1950 at the age of 42. It was due to however, can only be tolerated for a few seconds, is a brain tumour from which she would eventually die at the famous, and indeed, ecstatic auras have sometimes been age of 50. The seizure made her aware that for many years called “Dostoyevsky’s aura”. In Idiot, he also gave two she had had isolated auras with an indescribable experi- detailed descriptions of Prince Myshkin’s experiences and ence of double reality which, in the book, she tries to behaviour during the crescendo of epileptic prodromes. explain with many reformulations in a way that is typical One seems to be aborted when, in his growing excite- of sufferers’ descriptions of temporal lobe seizures (Wolf et ment, he manages to knock over and smash a precious al. 2000). She found that these experiences made her Chinese vase, but then it returns and ends in a convulsive particularly able to create oxymora, literary devices which seizure. During the other, he becomes increasingly preoc- combine two opposing concepts into one. She saw them cupied with the image of a knife; at the end he meets his as a hallmark of her art, of which she was very proud. An friend/rival Rogoshin who steps forward to kill him with example of an oxymoron is the title A Ray of Darkness, and this very knife, and he collapses in a severe seizure. the description includes several others, such as “loud Unlike Dostoyevsky, another 19th century author, Brazil- silence” or “sunny shadow”. Looking into her earlier writ- ian Joaquím Maria Machado de Assis (1839-1908) did all ings, oxymora could not be found in her first books, but he could, though with little success, to hide his epilepsy, they are there in Autobiography (1943), which she had possibly a right temporal lobe epilepsy (Guerreiro 1992) started to write in 1939, and in stories written from 1944 from the public. He went as far as replacing the word onwards and included in the collection The Old and the “epileptic” (used as a simile) in his novel Memorias pós- Young (1948). These probably reflect frequent auras expe- tumas de Brás Cubas (The Posthumous Memoirs of Brás rienced during that period (Wolf 2004). Cubas, 1882) by “convulsive” in a later edition. However, In A Ray of Darkness, Evans also expresses a unique view in the same novel he gave a description of a seizure with of a well-known, superstitious association of epilepsy: an elaborate visual illusion. In Quincas Borba (1891), a “The old idea of demoniac possession, I am sure, arose not novel that was probably influenced by Dostoyevsky’s from the onlookers of sufferers in fits but from the sufferers Idiot, one scene seems to represent an elaborate epileptic themselves. Because in the violent attacks one feels as experience, an experiential aura triggered by decision- though the body has been entered by a terrific alien making (Forster et al. 1975), consisting of the arousal of the power; and that that power is trying, after entrance, to memory of a seizure with loss of consciousness, which push its way out again.” was provoked by the observation of an execution. At A similar observation is made by German author Monika Machado’s time, complex partial seizures and their semi- Maron (*1941), who in Animal triste (1996) uses her ology were virtually unknown, and he was able to make personal experience of an isolated, generalised tonic- literary use of his experiences without giving the diagnosis clonic seizure (personal communication) to describe an away. event experienced by her protagonist. The seizure starts 4 Epileptic Disord Vol. 8, No. 1, March 2006 Seizures in literature with a “sudden mysterious numbness” in her tongue “that To conclude, the descriptions of seizures by authors who soon spread to the rest of my senses. What happened have epilepsy, not surprisingly deal mostly with auras and during the next twenty minutes, I only know from the other subjective experiences, and these can be rich and report of a young woman...” After an account of the novel in detail. All these authors have integrated them into convulsions which others had observed, the author gives a their literary work, although not always overtly. It is often rare report of more subtle symptoms during recovery: “For fascinating to follow this part of the creative process. several weeks I had at times the impression that something An interesting consideration is, whether similarly convinc- in my head didn’t function as it did before the spell – ing, subjective accounts of seizure symptoms in the writ- reversed sides, as if someone had switched the poles ings of other authors allow the conclusion that they also around.