Managing Epilepsy

If you see someone seized by an epileptic fit, then it is a reasonable first explanation to attribute the seizure to an evil spirit or demon, which has entered and is for a time venting its fury on the patient. Some believed that a god enters the epileptic, so the fit manifests the power of the divine. Hippocrates needed specifically to deny that epilepsy is "The Sacred Disease", asserting instead that it is a physical illness.

We know now that a fit is caused by a storm of electrical activity in the brain, triggered by some focus of abnormal electrical activity. Sometimes the focus is identifiable in an area of brain damage, but often it is not, and the underlying cause remains uncertain.

A case of epilepsy in a boy is described twice in the New Testament, in graphic terms, interpreted as spirit possession. The first is in Luke's gospel, chapter 9, 38.

And behold, a man from the multitude cried, saying,

"Master, I beseech thee to look upon my son; for he is mine only child: and behold, a spirit taketh him, and he suddenly crieth out; and it teareth him that he foameth, and it hardly departeth from him, bruising him sorely."

That is a succint description of the tragedy of epilepsy in a child, made yet more vivid by the archaic language.

In Mark's gospel, chapter 9,17, the same case is described in even more telling words. In addition it seems that the boy's epilepsy is part of a more generalized brain disease, perhaps congenital, perhaps birth injury, perhaps after infection or trauma.

And one of the multitude answered him,

"Master, I brought unto thee my son, which hath a dumb spirit; and wheresoever it taketh him, it dasheth him down: and he foameth, and grindeth his teeth, and pineth away."

... And they brought him unto him: and when he saw him, straightway the spirit tare him grievously; and he fell on the ground, and wallowed foaming.

And he asked his father, "How long time is it since this hath come unto him?"

And he said, "From a child. And oft-times it hath cast him both into the fire and into the waters, to destroy him: but if thou canst do anything, have compassion on us, and help us."

"Wheresoever it taketh him" - the cruel unpredictability of this disease.

"It dasheth him down" - the fit throws the victim down violently, often causing injury.

"He foameth, and grindeth his teeth" - the convulsive champing and salivation; the blood-stained foam on the face when the tongue has been bitten.

No mention of the embarrassment of incontinence, nor of the gnawing fear of losing control and dignity in another fit.

Jesus commands the spirit to leave, and it does, after a last and very severe fit. We are not told if the boy recovered speech and hearing. Jesus says the power to cast out such devils comes through prayer and fasting. Would it were so.

We now have we a variety of drugs useful in epilepsy; but no drug cures epilepsy, or guarantees freedom from fits. Drugs reduce the fit frequency, and must be used carefully and conservatively. Side-effects are common, and treatment demands continuing supervision and adjustment. A frequent problem is that the medication is increased if another fit occurs, so that a patient prone to fits eventually may be taking several drugs in full dose, with inevitable sedation, and other undesirable consequences. Sometimes a reduction in medication is the wisest advice.

The objective, as always, is to maximise benefit and minimise harm. In epilepsy this means finding the minimum drug dose to minimise the fit frequency. This isn't easy.

Most epileptic patients and their relatives live in fear. The prospect of another fit is alarming and painful. The only acceptable fit frequency is zero. Often this cannot be achieved, and can never be guaranteed. The physician has the difficult task of explaining that more drugs will mean more problems, and a lower quality of life.

Better to suffer the occasional fit than be constantly intoxicated.

If my child had epilepsy I would resist such advice. But I hope I would remember that only an inexperienced physician believes epilepsy can be controlled without causing side-effects.

No disease challenges the skill of a physician more than epilepsy.