Brain (2005), 128, 2470–2473
BOOK REVIEW
Neurology and literature
Depictions of neurological illnesses in literature prompt
questions as to how such representations can inform lay
readers about the realities of neurological disease and what
relevance such books have for the neurologist.
Medicine and literature make regular bedfellows. Characterizations of disease abound in fiction and serve either
to embellish descriptive prose, to illustrate elements of the
human condition or, perhaps more interestingly, to provide
social or political allegory. A disease, after all, is a deviation
from normality and may thus be a synonym for a whole
manner of human struggles. A fictional plague in a midEuropean town is the basis for political commentary in Albert
Camus’ The Plague. An unusual form of epidemic ‘white
blindness’ allows José Saramago to study late twentieth
century society in his novel Blindness in which chaos descends
on a fictional community revealing the true nature of society’s
sightlessness. The disturbance of vision, one of the most
fundamental of neurological functions, is perhaps the commonest of allegories used in literature.
Neurology lends itself well to such tales for the brain is the
seat of knowledge, the ‘soul’ and creativity. Many an author
has written on how creativity and freedom of expression can
be dulled by various forms of brain manipulation. In Yevgeny
Zamyatin’s futuristic novel, We, free will is suppressed by
surgical removal of imagination; and in Anthony Burgess’
A Clockwork Orange, the Ludovico technique is used to
‘brainwash’ miscreant youths. Social faults are again
highlighted in Mikhail Bulgakov’s Heart of a Dog in which
neuroendocrine tissue from a human is transferred into a dog
that subsequently takes on a corrupt persona.
Such illnesses and neurological treatments are fictitious,
but what of the depiction of real illnesses in literature? Oliver
Sacks popularized neurological science with descriptions of
various disorders in The Man who Mistook His Wife for a Hat.
This book allowed readers with no specialist knowledge to
explore the intricacies of neurological function and dysfunction. But neurological diseases also offer rich pickings for the
writer of fiction. As a clinician learns function from the study
of brain lesions, a writer may explore the nature of character
by describing neurological deficits. For instance, we learn a lot
more about the erstwhile minor character of M. Noirtier after
he suffers a devastating stroke and effectively becomes
‘locked-in’ in Alexandre Dumas’ novel The Count of Monte
Cristo. Interestingly, this character was described by Dumas
well before any clinical description of ‘locked-in’ syndrome
had been presented. It is intriguing, therefore, to postulate
#
EPILEPTIC
By David B 2005.
London: Jonathan Cape.
Price £16.99
ISBN 0-22407502-0
SATURDAY
By Ian McEwan 2005.
London: Jonathan Cape.
Price £17.99
ISBN 0-22407299-4
whether he had seen a person with this neurological phenotype or whether M. Noirtier was solely the product of Dumas’
imagination. Another description of ‘locked-in’ syndrome
comes from Jean-Dominique Bauby’s account of his own
illness, The Diving Bell and the Butterfly, dictated painstakingly through the blinking of his eyelid. Writers’ descriptions
of their own illness often provide the most insight into not
only the human spirit, as in Bauby’s case, but also clinical
observations on neurological disease. For instance, Fyodor
Dostoevsky’s description of Prince Myshkin’s temporal
lobe seizures in The Idiot, based on the writer’s own epileptic
experiences, provides fascinating clinical vignettes.
The Author (2005). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: [email protected]
Book Review
As well as providing thought-provoking scientific
commentaries, fiction might educate the reader on two
levels. It may provide information for a patient affected
by a particular disease or for the family of those caring for
one affected. But does the professional reader gain from reading such novels? Do such novels deepen understanding of
disease or improve professional practice? Is the neurologist-reader provided with insights over and above those
that any general reader will gain? Epileptic by David B, The
Curious Incident of the Dog in the Night-Time by Mark
Haddon, and Saturday by Ian McEwan illustrate many aspects
of these questions.
Epileptic by David B is an important book. It is a ‘witnessed
account’, composed by the brother of a young man, JeanChristophe, who develops intractable epilepsy during childhood. This is a ‘graphic novel’—comprising several thousand
illustrated frames in comic-book style, a medium well suited
to the ideas portrayed on its pages. The story of JeanChristophe’s journey though life is indeed an anguished
commentary, and here epilepsy is centre-stage. The book
works on many levels and is truly remarkable for its conceptual complexity told in a series of apparently simple, but often
dark and harrowing, illustrations. The book is a commentary
on the inadequacies of medicine, the stupidity and love of a
family, the sordid reactions of society and the deep suffering
induced by hopelessness. The experience of epileptic seizures
themselves is interesting and extremely well illustrated, often
in allegorical or historical guise. For the neurologist-reader
there is much here—universal truths about experiencing
illness and the lack of congruity between the disease as
perceived by the sufferer and by those around him. As his
brother exasperatedly exclaims ‘we are all sick with his illness’.
The story shows Jean-Christophe becoming more isolated and
ostracized as his seizures continue, and as those around him
persistently fail to understand his feelings and suffering. The
neurologist-reader will gain much from the description of his
descent into despair.
Throughout the book we are reminded of the Kafkaesque
nightmare that the disease has wrought on the family.
Jean-Christophe and his family are akin to Josef K, trying
Brain (2005), 128, 2470–2473
2471
THE CURIOUS
INCIDENT OF THE
DOG IN THE
NIGHT-TIME
By Mark Haddon 2004.
London: Vintage.
Price £6.99
Paperback
ISBN 0-09945025-9
to find out why they have been dealt this card in life. It is
probably not a coincidence that one of David B’s dream
sequences portrayed in the book is called The Judgement,
which echoes one of Kafka’s most noted stories. Mysticism
also plays a large part in Epileptic and is perhaps meant to
remind us of the medieval ideas on the origins of epilepsy
which, to some extent, still exist and cause much of the social
difficulties associated with the disease. Jean-Christophe’s
seizures are depicted as a serpent emerging from him and
consuming both him and those around. Many of the characters appear as mythological animals and the bird-like ghost
of his dead grandfather follows David B through his journey.
In the face of a cruel and irrational disease, the strange and
diverse allegories add to the feelings of helplessness.
Jean-Christophe’s experience of medicine and of doctors is
an instructive element of the novel. His parents take the young
boy to be ‘treated’ by a whole manner of practitioners from
conventional clinicians to alternative ‘macrobioticists’;
however, his condition worsens and he and his family become
more disillusioned and more outcast. Jean-Christophe visits
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Brain (2005), 128, 2470–2473
Professor T at the St-Anne hospital in Paris. These visits are
theatrical farces. The book catches well the hubris of the
professor and the inadequacies of his treatment. We should
be ashamed of the unthinking application of technology and
science, and of alternative medicine—equally ineffective and
equally fraudulent. When his parents refuse the opportunity
for surgery—the doctors ‘are not at all happy to see their
nice experiment vanish, just like that. Jean-Christophe’s
operation becomes Professor T’s operation. . .’ ‘What ? You’re
refusing Professor T’s operation? Get the hell out! There’s
nothing for you here. . .’ At another level, the fantasy life of
Jean-Christophe, the effect that his epilepsy has on those
around him and on his own sense of identity are very well
conveyed.
This is an extraordinary and powerful book. Drawing on
mystic and archaic ideas of the origin of epilepsy, it provides a
highly interesting and enthralling memoir.
By contrast, The Curious Incident of the Dog in the NightTime is a purely fictional account written from the perspective
of someone with Asperger’s syndrome. The novel is a first
person account of a disease. This has become a common genre
and there are many recent examples, more or less literate
accounts and usually anguished—for whatever else, neurological disease results universally in suffering and life-contraction. To the neurologist-reader, such books provide the
Book Review
opportunity for deeper understanding gained from the language and signification of the first person sufferer. The
Curious Incident of the Dog in the Night-Time tells of
Christopher Boone, a 15 year old boy living with his father
in suburban England, who discovers the body of a dead dog in
his next-door neighbour’s garden. As a challenge to his highly
logical mind he sets out on a mission to discover the identity
of the killer of the dog.
In terms of education and raising awareness of Asperger’s
and autism, this book has something to offer. To those with
little prior knowledge of the condition, it explains many of the
issues in a clear and instructive way. Of particular note are the
descriptions concerning ‘Theory of Mind’ and the lack of
social interaction characterized by an inability to comprehend
facial gestures or understand metaphors. These are described
non-judgementally, while showing the significant effect these
issues can have on family and friends. Stereotyped, repetitive
behaviours and the obsession with routine are covered, and
the common interest in numbers and mathematics provide
an interesting backdrop to the book.
This book is not anguished and is highly original, for whilst
it is largely a meditation on autism, this is spun into a
‘whodunit’ format. In fact, the book borrows its title from
a Sherlock Holmes’ story and reflects the protagonist’s interest
in logic and detective stories. The language is certainly
unusual as are the purported thought-processes of the autistic
hero—and this curiosity is surely the source of the popularity
of this book (it won the McKitterick prize). In this sense the
book succeeds, but on what is an essentially voyeuristic level
for there is little of interest in terms of story, plot or moral
dimension. For the neurologist-reader though, it surely
disappoints. In one respect it can inform those with little
knowledge of the disease with salient features of the condition.
In another, however, it leaves open to question whether a book
like this can be a true expression of the voice of Asperger’s. By
its very nature this is a condition which renders expression of
emotions and participation in social conventions difficult,
and thus impossible to depict faithfully as an autobiographical
representation in conventional literature. There is little that
informs about the real meaning of autism, nor does the
Book Review
neurologist-reader gain any general insight. The language and
thought-processes seem frankly too simplistic and
monochromatic to ring true; autism is a complex disorder,
and persons with Asperger’s syndrome are complex persons,
and this straightforward narrative does not reflect this complexity. Autism deserves a better first person account.
To a large extent Saturday by Ian McEwan is also concerned
with challenging existing perceptions. The book is also more
sophisticated than either of the other two novels, operating on
a number of different levels and with several disparate themes.
One is the fragility of existence, and how simple and seemingly
random or unconnected event, may have such dramatic
effects. The neurological interest is strong and the book will
appeal to ‘those in the trade’ purely because of references to
neurological disease, neurosurgical training and the description of operations, such as the memorable account of a transsphenoidal hypophysectomy. The setting of the novel is also
of interest; although not directly named, the protagonist’s
hospital is the National Hospital for Neurology and Neurosurgery at Queen Square. McEwan spent time shadowing
Neil Kitchen, consultant neurosurgeon at the hospital, and
his descriptions are well observed.
The book starts in a menacing tone by describing neurosurgeon Henry Perowne’s observation of a blazing aeroplane
in the night sky. Believing the ‘plane to have been hijacked
and set alight by terrorists, he imagines a multitude of
implications for what turns out to be an ‘innocent’ fire. As
a social commentary on post-9/11 twenty-first century paranoia and political manipulation this is an effective opening
storyline. The central character, the villain, has Huntington’s
disease. The book is constructed around the disease, and it
is the disease that drives the story. Strangely, however, it is
the medical aspects which are least well-done and for the
neurologist-reader, the book is likely to be very disappointing.
The descriptions of the disease are in textbook mode, dry and
unrevealing. Neurological detail is used, it seems to us, largely
for effect and adds little. One has the impression that McEwan
wallows in neurological terms for their sound and obscurity.
There is little to gain here about the reality or meaning
of disease—a contrast to David B’s account of epilepsy—
and often the narrative descends to naivety. As our hero
neurosurgeon is about to be mugged by the psychopath
with Huntington’s disease ‘there remains in a portion of
his thoughts a droning, pedestrian diagnostician who notes
poor self-control, emotional lability, explosive temper, suggestive of reduced levels of GABA among the appropriate
binding sites on striatal neurones. This in turn is bound to
imply the diminished presence of two enzymes in the striatum
and lateral pallidum. Who could ever reckon up the damage
done to love and friendship and all hopes of happiness by a
surfeit or depletion of this or that neurotransmitter?’ Who
indeed? The storyline is also rather trying. Baxter, the villain
with Huntington’s disease, crashes into Perowne’s car, threatens to mug him, Perowne escapes, plays squash and then goes
home, only to have Baxter break into his home, beat up his
father-in-law, and threaten his daughter with rape. She then
Brain (2005), 128, 2470–2473
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strips naked and reveals that she is pregnant. Baxter goes
upstairs with Perowne to look at medical papers promising
a cure by stem cell transplant, falls down the stairs and requires
emergency surgery by—guess who—Perowne. A day in the
life of a neurosurgeon?’
But what is the underlying theme of the book? Henry is a
man who dissects things down to a base level, to molecules
and genes. He needs an exact explanation for everything and is
not very good at things that aren’t black or white. In that
respect the surgical personality is well observed. On a broader
theme it highlights the fragility of our lives, being determined
by such seemingly random chemical and genetic events. On
the background of world unrest, the message is all the more
powerful. This is a book of big ideas, but the end is
disappointingly clinical and unemotional. The book has
other themes which are much more successful. The portrait
of Perowne is drawn in detail and with sympathy, and the
political and social events of that Saturday are depicted in
interesting detail. In fact it is awash with descriptive detail,
often vivid and well-wrought. Politics, ambition and compassion are well-described and the sense of place and time are
impeccable.
The best books aim to expand our knowledge and challenge
our viewpoints. Depictions of characters with neurological
illness in novels can go a long way to demystify what is
still a poorly understood subject for the general public. To
portray the issues of illness in an accessible and balanced
way is a socially uplifting experience. Novels are not only
important for education of the lay public, they also have a
vital role in emphasizing to the clinician the true impact
and experience of disease. Perhaps more of these novels
should be on the curriculum for medical school and beyond.
However, books with neurological disease at the centre of
their narrative, to be worthwhile to the neurologist-reader,
must depict the biography of disease in a way that transcends
medical textbooks. If they do not, the disease becomes a
tendentious device. In Saturday, Perowne muses: ‘The
sea of neural misery is wide and deep’, and the medicalization
of a story should add more information about emotional
responses or even the human condition. This novel
disappoints in these regards, and indeed the medical
details annoy and detract rather than illuminate—a strong
contrast to the image of disease by David B. It could be
argued that Huntington’s disease is not the point of the
novel, and that the reviewer should get a life. There is
some truth in this, and in the end, perhaps a novel is
just a novel. As Perowne’s exasperated daughter exclaimed
when her father fails to understand the attraction
of magical realists: ‘You ninny, you gradgrind. It’s literature,
not physics!’
Alastair Wilkins and Simon Shorvon
National Hospital for Neurology and Neurosurgery
London
doi:10.1093/brain/awh633