553
Surgical treatment of epilepsy C. E. POLKEY
Epilepsy surgery is over 100 years old1 and most of the operations have a long and reliable track record.2 How many patients might benefit from surgery? Estimates suggest that in the USA there are about 360 000 patients with uncontrolled partial complex seizures, at least 75 000 of whom would be suitable for surgery; for the UK there might be 2000 patients who would benefit, very few of whom are assessed and treated.4 There are two methods of surgical treatment. In the first, one tries to find a focal origin for the epilepsy, usually with an underlying lesion; the aim of surgery is to remove the lesion and the accompanying focus. In the second, a surgical manoeuvre is used to alter brain activity and so modify the effect or the spread of the seizure. However, it is almost certainly impossible to make such a clear distinction because resection of a discrete focus not only removes the abnormality but also interrupts fibre tracts and, if a large amount of tissue is removed, diminishes the mass of epileptogenic neurons. In general, surgical procedures that aim to remove epileptogenic tissue together with any identifiable lesion are more common and more successful than those that attempt to modify brain activity. It is difficult to show that factors that influence epileptogenesis in laboratory animals have any effect on the development of epilepsy in man. Morrell and colleagues5 studied a group of patients treated in Montreal between 1960 and 1980. Among 123 with temporal lobe epilepsy due to histologically verified unilateral temporal tumours, there were 44 (36%) who fitted the researchers’ criteria for secondary epileptogenesis and 19(15%) of these had attacks that were shown by simultaneous electroencephalography (EEG) to arise at the secondary site. Among 57 with frontal lobe tumours operated on at the same time, there were 12 (21 %) with evidence of secondary epileptogenesis. After the surgical resection there was slow resolution of the contralateral EEG focus in about two-thirds of these cases; the focus and the seizures persisted in the remainder.
Resections Patient selection Selection for resective surgery relies on four basic lines of
inquiry. Clinical history. Patients should be asked about the clinical features of their attacks, which will give a clue to the origin; about interictal events; and about past medical history, which may reveal an event sufficient to cause brain damage and hence the seizures. Other clinical details such as family, developmental, educational, and psychiatric history should be obtained. Neuropsychological assessment, interpreted in relation to other fmdings, is useful both to reveal localised malfunction and to predict the effects of any proposed resection, especially in the temporal lobe.6 Brain imaging. In the past 10 years advances in computed tomography (CT) and in magnetic resonance imaging (MRI) have made the detection of small discrete lesions more likely. Fish7 suggests that 25-50% of patients with partial epilepsy have such lesions. MRI may detect even greater proportions of such lesions, and shows temporal lobe asymmetries more readily. Functional brain imaging such as positron emission tomography (PET) or single photon
Maudsley assessment procedure.
tomography (SPET) provides useful confirmation, especially in the temporal lobes. Neurophysiological techniques. Interictal scalp recording is of limited value and some form of telemetry is often used. Most patients need investigation for temporal lobe abnormalities and the technique of foramen ovale telemetry developed in Zurich has proved invaluable.9 If this approach does not give the answer in such patients, and in many other patients with frontal lobe epilepsy, the use of subdural electrodes, stereotactically implanted depth electrodes, or a combination of both may be required.10,11 If the epilepsy is arising in the central region then mat electrodes implanted either extradurally12 or subdurally may emission
be used. Most major centres for epilepsy surgery now use a staged assessment process; the procedure adopted at the Maudsley Hospital is shown in the figure.
Outcome Most resections are temporal; the distribution of various operations at the Montreal Neurological Institute and at the ADDRESS: Neurosurgical Unit, Maudsley Hospital, London SE5 8AZ, UK (Mr C. E. Polkey, FRCS).
554
RESECTIONS UNDERTAKEN AT TWO CENTRES
I
I
Maudsley Hospital is shown in the table. The precise operative technique in the temporal lobe depends on the findings during investigation and on the nature of the lesion.13 Resective surgery is usually highly successful. In a survey published in 198714 of 3245 operations conducted at 40 centres, a significant proportion (53%) of patients had their epilepsy relieved completely and most (80%) had some relief. The complication rate was low, with mortality rates of less than 0.5% for temporal lobe resections and substantial morbidity in about z 55% of patients who underwent temporal lobe resections became seizure free and 80% were improved; for extratemporal resections the figures were 43 % and 71 %, respectively, and for hemispherectomy 77 % and 96%. Hemispherectomy acquired a bad reputation because it was associated with late delayed bleeding; this complication has been virtually eliminated by modifications to the original technique.16,17
Relapse The longer that patients are followed-up the less likely they are to remain fit free. Our own unpublished figures show that, in patients undergoing temporal lobectomy, if their seizure frequency was less than a quarter of the preoperative frequency at one year, they almost never revert to their preoperative state. Van Buren and colleagues’8 found that 10% of patients who were fit free 5 years after temporal lobectomy had occasional seizures after that. In the Maudsley series, 13 of 90 patients had recurrent seizures after being fit free for 2-8 years postoperatively. Other benefits In many patients surgical relief of the seizures is accompanied by improvements in behaviour and social adjustment, especially after temporal lobectomy and hemispherectomy.19,20 There is also evidence, as in the Oxford longitudinal study,21 that when appropriate surgery is carried out successfully in childhood it carries such
benefits.
Histopathological correlates The relation between the histopathological features in the resected specimen and the results of operation is intriguing. There is no doubt that if there is a lesion in the specimen then the results of surgery are likely to be excellent; in the temporal lobe, for example, the outcome seems to be almost independent of the operative procedure used. 13
Modification of brain activity
change brain function are less
and less successful than resective surgery. Stereotactic lesions in the brain produce an improvement rate of about 30%."" In two reviews of this topic, separated by more than 10
Operations
to
common
no evidence of substantial progress.24,25 Two procedures merit brief consideration. There is a resurgence of interest in callosotomy. With modern neurosurgical techniques this operation has become much safer; seizure control is improved in up to 50% of patients but patients seldom rendered seizure free.26,27 The major are neuropsychological complications of this procedure can be
years, there is
avoided but there may be more subtle intellectual and personality changes.28 The other procedure is multiple subpial transection, which was pioneered by Morrell and his associates 29 This technique is used in eloquent areas such as the motor cortex; horizontal fibres are divided to reduce seizures while the vertical fibres are spared, so preserving function. REFERENCES Horsley V. Brain-surgery. Br Med J 1886; ii: 670-75. 2. Jensen I. Temporal lobe surgery around the world. Results, complications, mortality. Acta Neurol Scand 1975; 52: 354-73. 3. Dreifuss FE. Goals of surgery for epilepsy. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 31-49. 4. Editorial. Surgery for temporal lobe epilepsy. Lancet 1988; ii: 1115-16. 5. Morrell F, Wada J, Engel J. Potential relevance of kindling and secondary epileptogenesis to the consideration of surgical treatment of epilepsy. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1.
1987: 701-07. 6. Rausch R. Psychological evaluation. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 181-95. 7. Fish D. CT and PET in drug-resistant epilepsy. In: Trimble MR, ed. Chronic epilepsy, its prognosis and management. Chichester: Wiley, 1989: 59-72. 8. Schorner W, Meencke HJ, Felix R. Comparison of CT and magnetic resonance imaging. Am J Radiol 1987; 149: 1231-39. 9. Wieser HG, Elger CE, Stodieck SRG. The ’foramen ovale electrode’: a new recording method for the preoperative evaluation of patients suffering from mediobasal temporal lobe epilepsy. Electroencephalog Clin Neurophysiol 1985; 61: 314-22. 10. Hahn JF, Luders H. Placement of subdural grid electrodes at the Cleveland Clinic. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 621-27. 11. Jensen I, Larsen JK. Mental aspects of temporal lobe epilepsy: follow-up of 74 patients after resection of a temporal lobe. J Neurol Neurosurg Psychiatry 1979; 42: 256-65. 12. Goldring S, Gregorie EM. Surgical management of epilepsy using epidermal mats to localise the seizure focus: review of 100 cases. J Neurosurg 1984; 60: 457-66. 13. Polkey CE. Surgical alternatives for the treatment of temporal lobe epilepsy. Br J Neurosurg 1988; ii: 143-52. 14. Engel J. Outcome with respect to epileptic seizures. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 553-71. 15. Van Buren JM. Complications of surgical procedures in the diagnosis and treatment of epilepsy. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 465-75. 16. Adams CBT. Hemispherectomy-a modification. J Neurol Neurosurg Psychiatry 1983; 46: 617-19. 17. Rasmussen T. Cortical resection for multilobe epileptogenic lesions. In: Wieser HG, Elger CE, eds. Presurgical evaluation of epileptics. Berling: Springer, 1987: 344-51. 18. Van Buren JM, Ajmone-Marsan C, Mutsaga N, Sadowsky D. Surgery of temporal lobe epilepsy. In: Purpura DP, Penry JK, Walter RD, eds. Neurosurgical management of the epilepsies. New York: Raven, 1975: 155-96. 19.Beardsworth ED, Adams CBT. Modified hemispherectomy for epilepsy: early results in 10 cases. Br J Neurosurg 1988; 2: 73-84. 20. Taylor DC. Psychiatric and social issues in measuring the input and outcome of epilepsy surgery. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 485-503. 21. Ounstead C, Lindsay J, Richards P. Developmental aspects of focal epilepsies of childhood treated by neurosurgery. In: Temporal lobe epilepsy: a biographical study 1948-1986. Oxford: Blackwell, 1987: 70-86. 22. Talairach J, Bancaud J, Szilka G, Bonis A, Geier S, Vedrenne C. Approche nouvelle de la neurochirugie de l’epilepsie. Methodologie stereotaxique et resultats therapeutiques. Neurochirugie 1974; (suppl 2). 23. Vaernat K. Stereotactic amygdalotomy in temporal lobe epilepsy. Confinia Neurologica 1972; 34: 176-80. 24. Ojemann GA, Ward AA. Stereotactic and other procedures for epilepsy. In: Purpura DP, Penry JK, Walter RD, eds. Neurosurgical management of the epilepsies. New York: Raven, 1975: 241-63.
555
25. Spencer DD. Postscript: Should there by a surgical treatment of choice, and if so, how should it be determined? In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 477-84. 26. Spencer SS, Gates JR, Reeves AR, Spencer DD, Maxwell RE, Roberts D. Corpus callosum section. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 425-44. 27. Williamson PD. Corpuus callosum section for intractable epilepsy: Criteria for patient selection. In: Reeves AG, ed. Epilepsy and the corpus callosum. New York: Plenum, 1985: 243-57. 28. Rayport M, Ferguson S, Corrie WS. Outcomes and indications of corpus callosum section for intractable seizure control. Appl Neurophysiol
1983; 46: 47-51. 29. Morrell F, Whisler WW, Bleck TP. Multiple subpial transection: a new approach to the surgical treatment of focal epilepsy. J Neurosurg 1989;
70: 231-39.
VIEWPOINT Occasional book: Mesozoic stomp RAYMOND TALLIS The encomium on the dust cover, from a prominent critic, claims that The Dinosaur’s BalP does for medicine "what Kafka did for the law and civil service". Critics’ overreadiness to invoke Kafka is tedious (like the habit of comparing all female novelists with Jane Austen); besides, it undermines the subversive purpose of fiction by rendering it familiar in advance. But don’t be put off-Cristopher Nash’s first novel contains marvellous and terrible things. The plot is very simple: the course of the illness suffered by Wall, the protagonist, is followed from the first slight, non-specific symptoms and doubtful test results to the final apnoea. The journey is largely neurological, with some
recognisable landmarks-peripheral neuropathy, epileptic fits, locked-in syndrome. However, despite the plausibility with which both objective features and subjective experiences are described, the illness is primarily metaphorical and metaphysical. Wall’s ascending paralysis is not an MRCP grey case; it is Approaching Death. At first, the tone is satirical. The patient counters the doctor’s crass chirpiness with chirpiness of his own. But on admission to hospital, Wall’s defences start to crumble, although his wits and his wit remained unimpaired. He observes not only his own disintegration but also that of his fellow patients; he is the recipient of their stories and the observer of their woes. The turning point is a lengthy seizure, after which Wall finds he is tetraplegic and unable to communicate. As death approaches, agency yields to patienthood; Wall can no longer act upon the world that acts upon him. External reality attenuates to overheard voices spliced in with his own thoughts until all voices give way to silence and the reader is left with his own thoughts and overheard voices. A novelist following a character depicted from within to the very end of consciousness faces formidable technical difficulties; consciousness does not normally tell itself who or what it is and what is going on around it; even less does it articulate its own inarticulacy, informing itself that it cannot say "breakfast". Nash does not address this problem: Wall, even on the verge of death, never ceases to be articulate. ADDRESS. Department of Geriatric Medicine, Clinical Sciences Building, Hope Hospital, Manchester M6 8HD, UK (Prof R. C.
Tallis, FRCP).
Nash also falls into the trap of making many of his characters as witty as himself. Wall’s physician, for example, tends to speak in the allegorical mode; in real life, he would have been
bleeped away mid-metaphor. However, it is very difficult to regret that so many of the characters aspire to the condition of Cristopher Nash when the consequence is that there is not a duff sentence in the entire novel. Nash has perfect pitch for linguistic register and idiolect. His unsleeping prose is continuously pleasurable and his wit inexhaustible-a far cry from the allotropes of coma that pass for contemporary prose. The book crackles with needle-sharp observations and exchanges. And beyond the wit and flashes of lyricism there is a deep human sympathy. For a few days after reading the book, I found it easier to see my wards from the tilt-shot of the patients in them. I don’t know whether this made me a better doctor but, like being ill oneself, it was a salutary
experience. There is some silliness. Both the protagonist and his main attendant have the same name, and much is made of this engineered coincidence: in the solipsistic world picture of the book, one’s antipodes is within one, doctor and patient are one, death is a kind of pregnancy, and one’s extinction is the ultimate in self-expression. Hmm... And then there is the mysterious Hinkle-harbinger of death, and obese with symbolic significance and literary ancestry-who is remembered at odd times during the plot. The lapses into cliche are not instantly endearing. Wall’s dim, heartless, venal, unredeemedly practical wife Treeza, protecting herself through her dim practicality from any larger or starker truths, is brilliantly realised but also deeply familiar. The impenetrable, patronising cheerfulness of some of the non-communicating doctors and nurses is another cliche. Nevertheless, within the meshes of these cruel stereotypes, Nash achieves some delicious effects. There are one or two minor slips. The physiotherapist is referred to as Sister Dingle throughout, which prompts speculation about a Holy Order of physios-the Little Groinstrainers of the
Poor, perhaps. If the book has
important fault, it is that it is not intuition that underlies it: it confuses its indignations. The surface targets-non-communicative and tactless professionals who seem to have the secrets of your body and its death in their keeping; selfish spouses who think only of the implications of your illness for themselves--distract from the general metaphysical rage at not knowing why we are here or, more particularly, why we, one day, should cease to be here. If hospitals are sometimes terrible places, it is not only because of the congenital tactlessness that those who work in them share with the rest of the human race, or of the additional institutional tactlessness arising out of the asymmetrical, one-many relation between patients and staff but also because they are a battlefield between ordinary meanings of an ordinary Tuesday and the unmeaning that threatens them. Things medical-terms, procedures, operations-mediate between meaning and unmeaning and are for this reason themselves frightening. For we know that, in the end, unmeaning wins out: mortality is the common condition of humanity; ordinary coexistence and ordinary purpose are temporary straw fires lit on the void; and the portion of light granted to us is a razor-thin slit between infinitely thick walls of darkness. an
consistently true to the
1. The Dinosaur’s Ball. Cristopher Nash. Manchester: Carcanet. £12.95. ISBN 0-856358541.
Pp
235.
Surgical treatment of epilepsy C. E. POLKEY
Epilepsy surgery is over 100 years old1 and most of the operations have a long and reliable track record.2 How many patients might benefit from surgery? Estimates suggest that in the USA there are about 360 000 patients with uncontrolled partial complex seizures, at least 75 000 of whom would be suitable for surgery; for the UK there might be 2000 patients who would benefit, very few of whom are assessed and treated.4 There are two methods of surgical treatment. In the first, one tries to find a focal origin for the epilepsy, usually with an underlying lesion; the aim of surgery is to remove the lesion and the accompanying focus. In the second, a surgical manoeuvre is used to alter brain activity and so modify the effect or the spread of the seizure. However, it is almost certainly impossible to make such a clear distinction because resection of a discrete focus not only removes the abnormality but also interrupts fibre tracts and, if a large amount of tissue is removed, diminishes the mass of epileptogenic neurons. In general, surgical procedures that aim to remove epileptogenic tissue together with any identifiable lesion are more common and more successful than those that attempt to modify brain activity. It is difficult to show that factors that influence epileptogenesis in laboratory animals have any effect on the development of epilepsy in man. Morrell and colleagues5 studied a group of patients treated in Montreal between 1960 and 1980. Among 123 with temporal lobe epilepsy due to histologically verified unilateral temporal tumours, there were 44 (36%) who fitted the researchers’ criteria for secondary epileptogenesis and 19(15%) of these had attacks that were shown by simultaneous electroencephalography (EEG) to arise at the secondary site. Among 57 with frontal lobe tumours operated on at the same time, there were 12 (21 %) with evidence of secondary epileptogenesis. After the surgical resection there was slow resolution of the contralateral EEG focus in about two-thirds of these cases; the focus and the seizures persisted in the remainder.
Resections Patient selection Selection for resective surgery relies on four basic lines of
inquiry. Clinical history. Patients should be asked about the clinical features of their attacks, which will give a clue to the origin; about interictal events; and about past medical history, which may reveal an event sufficient to cause brain damage and hence the seizures. Other clinical details such as family, developmental, educational, and psychiatric history should be obtained. Neuropsychological assessment, interpreted in relation to other fmdings, is useful both to reveal localised malfunction and to predict the effects of any proposed resection, especially in the temporal lobe.6 Brain imaging. In the past 10 years advances in computed tomography (CT) and in magnetic resonance imaging (MRI) have made the detection of small discrete lesions more likely. Fish7 suggests that 25-50% of patients with partial epilepsy have such lesions. MRI may detect even greater proportions of such lesions, and shows temporal lobe asymmetries more readily. Functional brain imaging such as positron emission tomography (PET) or single photon
Maudsley assessment procedure.
tomography (SPET) provides useful confirmation, especially in the temporal lobes. Neurophysiological techniques. Interictal scalp recording is of limited value and some form of telemetry is often used. Most patients need investigation for temporal lobe abnormalities and the technique of foramen ovale telemetry developed in Zurich has proved invaluable.9 If this approach does not give the answer in such patients, and in many other patients with frontal lobe epilepsy, the use of subdural electrodes, stereotactically implanted depth electrodes, or a combination of both may be required.10,11 If the epilepsy is arising in the central region then mat electrodes implanted either extradurally12 or subdurally may emission
be used. Most major centres for epilepsy surgery now use a staged assessment process; the procedure adopted at the Maudsley Hospital is shown in the figure.
Outcome Most resections are temporal; the distribution of various operations at the Montreal Neurological Institute and at the ADDRESS: Neurosurgical Unit, Maudsley Hospital, London SE5 8AZ, UK (Mr C. E. Polkey, FRCS).
554
RESECTIONS UNDERTAKEN AT TWO CENTRES
I
I
Maudsley Hospital is shown in the table. The precise operative technique in the temporal lobe depends on the findings during investigation and on the nature of the lesion.13 Resective surgery is usually highly successful. In a survey published in 198714 of 3245 operations conducted at 40 centres, a significant proportion (53%) of patients had their epilepsy relieved completely and most (80%) had some relief. The complication rate was low, with mortality rates of less than 0.5% for temporal lobe resections and substantial morbidity in about z 55% of patients who underwent temporal lobe resections became seizure free and 80% were improved; for extratemporal resections the figures were 43 % and 71 %, respectively, and for hemispherectomy 77 % and 96%. Hemispherectomy acquired a bad reputation because it was associated with late delayed bleeding; this complication has been virtually eliminated by modifications to the original technique.16,17
Relapse The longer that patients are followed-up the less likely they are to remain fit free. Our own unpublished figures show that, in patients undergoing temporal lobectomy, if their seizure frequency was less than a quarter of the preoperative frequency at one year, they almost never revert to their preoperative state. Van Buren and colleagues’8 found that 10% of patients who were fit free 5 years after temporal lobectomy had occasional seizures after that. In the Maudsley series, 13 of 90 patients had recurrent seizures after being fit free for 2-8 years postoperatively. Other benefits In many patients surgical relief of the seizures is accompanied by improvements in behaviour and social adjustment, especially after temporal lobectomy and hemispherectomy.19,20 There is also evidence, as in the Oxford longitudinal study,21 that when appropriate surgery is carried out successfully in childhood it carries such
benefits.
Histopathological correlates The relation between the histopathological features in the resected specimen and the results of operation is intriguing. There is no doubt that if there is a lesion in the specimen then the results of surgery are likely to be excellent; in the temporal lobe, for example, the outcome seems to be almost independent of the operative procedure used. 13
Modification of brain activity
change brain function are less
and less successful than resective surgery. Stereotactic lesions in the brain produce an improvement rate of about 30%."" In two reviews of this topic, separated by more than 10
Operations
to
common
no evidence of substantial progress.24,25 Two procedures merit brief consideration. There is a resurgence of interest in callosotomy. With modern neurosurgical techniques this operation has become much safer; seizure control is improved in up to 50% of patients but patients seldom rendered seizure free.26,27 The major are neuropsychological complications of this procedure can be
years, there is
avoided but there may be more subtle intellectual and personality changes.28 The other procedure is multiple subpial transection, which was pioneered by Morrell and his associates 29 This technique is used in eloquent areas such as the motor cortex; horizontal fibres are divided to reduce seizures while the vertical fibres are spared, so preserving function. REFERENCES Horsley V. Brain-surgery. Br Med J 1886; ii: 670-75. 2. Jensen I. Temporal lobe surgery around the world. Results, complications, mortality. Acta Neurol Scand 1975; 52: 354-73. 3. Dreifuss FE. Goals of surgery for epilepsy. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 31-49. 4. Editorial. Surgery for temporal lobe epilepsy. Lancet 1988; ii: 1115-16. 5. Morrell F, Wada J, Engel J. Potential relevance of kindling and secondary epileptogenesis to the consideration of surgical treatment of epilepsy. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1.
1987: 701-07. 6. Rausch R. Psychological evaluation. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 181-95. 7. Fish D. CT and PET in drug-resistant epilepsy. In: Trimble MR, ed. Chronic epilepsy, its prognosis and management. Chichester: Wiley, 1989: 59-72. 8. Schorner W, Meencke HJ, Felix R. Comparison of CT and magnetic resonance imaging. Am J Radiol 1987; 149: 1231-39. 9. Wieser HG, Elger CE, Stodieck SRG. The ’foramen ovale electrode’: a new recording method for the preoperative evaluation of patients suffering from mediobasal temporal lobe epilepsy. Electroencephalog Clin Neurophysiol 1985; 61: 314-22. 10. Hahn JF, Luders H. Placement of subdural grid electrodes at the Cleveland Clinic. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 621-27. 11. Jensen I, Larsen JK. Mental aspects of temporal lobe epilepsy: follow-up of 74 patients after resection of a temporal lobe. J Neurol Neurosurg Psychiatry 1979; 42: 256-65. 12. Goldring S, Gregorie EM. Surgical management of epilepsy using epidermal mats to localise the seizure focus: review of 100 cases. J Neurosurg 1984; 60: 457-66. 13. Polkey CE. Surgical alternatives for the treatment of temporal lobe epilepsy. Br J Neurosurg 1988; ii: 143-52. 14. Engel J. Outcome with respect to epileptic seizures. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 553-71. 15. Van Buren JM. Complications of surgical procedures in the diagnosis and treatment of epilepsy. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 465-75. 16. Adams CBT. Hemispherectomy-a modification. J Neurol Neurosurg Psychiatry 1983; 46: 617-19. 17. Rasmussen T. Cortical resection for multilobe epileptogenic lesions. In: Wieser HG, Elger CE, eds. Presurgical evaluation of epileptics. Berling: Springer, 1987: 344-51. 18. Van Buren JM, Ajmone-Marsan C, Mutsaga N, Sadowsky D. Surgery of temporal lobe epilepsy. In: Purpura DP, Penry JK, Walter RD, eds. Neurosurgical management of the epilepsies. New York: Raven, 1975: 155-96. 19.Beardsworth ED, Adams CBT. Modified hemispherectomy for epilepsy: early results in 10 cases. Br J Neurosurg 1988; 2: 73-84. 20. Taylor DC. Psychiatric and social issues in measuring the input and outcome of epilepsy surgery. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 485-503. 21. Ounstead C, Lindsay J, Richards P. Developmental aspects of focal epilepsies of childhood treated by neurosurgery. In: Temporal lobe epilepsy: a biographical study 1948-1986. Oxford: Blackwell, 1987: 70-86. 22. Talairach J, Bancaud J, Szilka G, Bonis A, Geier S, Vedrenne C. Approche nouvelle de la neurochirugie de l’epilepsie. Methodologie stereotaxique et resultats therapeutiques. Neurochirugie 1974; (suppl 2). 23. Vaernat K. Stereotactic amygdalotomy in temporal lobe epilepsy. Confinia Neurologica 1972; 34: 176-80. 24. Ojemann GA, Ward AA. Stereotactic and other procedures for epilepsy. In: Purpura DP, Penry JK, Walter RD, eds. Neurosurgical management of the epilepsies. New York: Raven, 1975: 241-63.
555
25. Spencer DD. Postscript: Should there by a surgical treatment of choice, and if so, how should it be determined? In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 477-84. 26. Spencer SS, Gates JR, Reeves AR, Spencer DD, Maxwell RE, Roberts D. Corpus callosum section. In: Engel J, ed. Surgical treatment of the epilepsies. New York: Raven, 1987: 425-44. 27. Williamson PD. Corpuus callosum section for intractable epilepsy: Criteria for patient selection. In: Reeves AG, ed. Epilepsy and the corpus callosum. New York: Plenum, 1985: 243-57. 28. Rayport M, Ferguson S, Corrie WS. Outcomes and indications of corpus callosum section for intractable seizure control. Appl Neurophysiol
1983; 46: 47-51. 29. Morrell F, Whisler WW, Bleck TP. Multiple subpial transection: a new approach to the surgical treatment of focal epilepsy. J Neurosurg 1989;
70: 231-39.
VIEWPOINT Occasional book: Mesozoic stomp RAYMOND TALLIS The encomium on the dust cover, from a prominent critic, claims that The Dinosaur’s BalP does for medicine "what Kafka did for the law and civil service". Critics’ overreadiness to invoke Kafka is tedious (like the habit of comparing all female novelists with Jane Austen); besides, it undermines the subversive purpose of fiction by rendering it familiar in advance. But don’t be put off-Cristopher Nash’s first novel contains marvellous and terrible things. The plot is very simple: the course of the illness suffered by Wall, the protagonist, is followed from the first slight, non-specific symptoms and doubtful test results to the final apnoea. The journey is largely neurological, with some
recognisable landmarks-peripheral neuropathy, epileptic fits, locked-in syndrome. However, despite the plausibility with which both objective features and subjective experiences are described, the illness is primarily metaphorical and metaphysical. Wall’s ascending paralysis is not an MRCP grey case; it is Approaching Death. At first, the tone is satirical. The patient counters the doctor’s crass chirpiness with chirpiness of his own. But on admission to hospital, Wall’s defences start to crumble, although his wits and his wit remained unimpaired. He observes not only his own disintegration but also that of his fellow patients; he is the recipient of their stories and the observer of their woes. The turning point is a lengthy seizure, after which Wall finds he is tetraplegic and unable to communicate. As death approaches, agency yields to patienthood; Wall can no longer act upon the world that acts upon him. External reality attenuates to overheard voices spliced in with his own thoughts until all voices give way to silence and the reader is left with his own thoughts and overheard voices. A novelist following a character depicted from within to the very end of consciousness faces formidable technical difficulties; consciousness does not normally tell itself who or what it is and what is going on around it; even less does it articulate its own inarticulacy, informing itself that it cannot say "breakfast". Nash does not address this problem: Wall, even on the verge of death, never ceases to be articulate. ADDRESS. Department of Geriatric Medicine, Clinical Sciences Building, Hope Hospital, Manchester M6 8HD, UK (Prof R. C.
Tallis, FRCP).
Nash also falls into the trap of making many of his characters as witty as himself. Wall’s physician, for example, tends to speak in the allegorical mode; in real life, he would have been
bleeped away mid-metaphor. However, it is very difficult to regret that so many of the characters aspire to the condition of Cristopher Nash when the consequence is that there is not a duff sentence in the entire novel. Nash has perfect pitch for linguistic register and idiolect. His unsleeping prose is continuously pleasurable and his wit inexhaustible-a far cry from the allotropes of coma that pass for contemporary prose. The book crackles with needle-sharp observations and exchanges. And beyond the wit and flashes of lyricism there is a deep human sympathy. For a few days after reading the book, I found it easier to see my wards from the tilt-shot of the patients in them. I don’t know whether this made me a better doctor but, like being ill oneself, it was a salutary
experience. There is some silliness. Both the protagonist and his main attendant have the same name, and much is made of this engineered coincidence: in the solipsistic world picture of the book, one’s antipodes is within one, doctor and patient are one, death is a kind of pregnancy, and one’s extinction is the ultimate in self-expression. Hmm... And then there is the mysterious Hinkle-harbinger of death, and obese with symbolic significance and literary ancestry-who is remembered at odd times during the plot. The lapses into cliche are not instantly endearing. Wall’s dim, heartless, venal, unredeemedly practical wife Treeza, protecting herself through her dim practicality from any larger or starker truths, is brilliantly realised but also deeply familiar. The impenetrable, patronising cheerfulness of some of the non-communicating doctors and nurses is another cliche. Nevertheless, within the meshes of these cruel stereotypes, Nash achieves some delicious effects. There are one or two minor slips. The physiotherapist is referred to as Sister Dingle throughout, which prompts speculation about a Holy Order of physios-the Little Groinstrainers of the
Poor, perhaps. If the book has
important fault, it is that it is not intuition that underlies it: it confuses its indignations. The surface targets-non-communicative and tactless professionals who seem to have the secrets of your body and its death in their keeping; selfish spouses who think only of the implications of your illness for themselves--distract from the general metaphysical rage at not knowing why we are here or, more particularly, why we, one day, should cease to be here. If hospitals are sometimes terrible places, it is not only because of the congenital tactlessness that those who work in them share with the rest of the human race, or of the additional institutional tactlessness arising out of the asymmetrical, one-many relation between patients and staff but also because they are a battlefield between ordinary meanings of an ordinary Tuesday and the unmeaning that threatens them. Things medical-terms, procedures, operations-mediate between meaning and unmeaning and are for this reason themselves frightening. For we know that, in the end, unmeaning wins out: mortality is the common condition of humanity; ordinary coexistence and ordinary purpose are temporary straw fires lit on the void; and the portion of light granted to us is a razor-thin slit between infinitely thick walls of darkness. an
consistently true to the
1. The Dinosaur’s Ball. Cristopher Nash. Manchester: Carcanet. £12.95. ISBN 0-856358541.
Pp
235.
