Volume 1, Issue 3: Epilepsy, or About Turning Health into Units

Epilepsy, or About Turning Health into Units

Vasia Lekka: The Neurological Emergence of Epilepsy: The National Hospital for the Paralysed and Epileptic (1870-1895). New York: Springer, 2015. pp. xiii-209. Hardcover ISBN 978-3-319-06292-1. €128, 39. 

As philosophy of science is moving from its earlier general perspective to the new directions of philosophies of sciences, general sociological and historical approaches to science are dividing as well into various sub-researches like sociology and history of medicine. One of the last approaches to this field is Vasia Lekka’sThe Neurological Emergence of Epilepsy – The National Hospital for the Paralysed and Epileptic (1870–1895)dealing with the history and social embeddedness of epilepsy in the late Victorian era of England. Lekka’s book is an attracting work containing many important documents, materials, data and it deals with them from a well-focused perspective, raising far-reaching questions. It aims to be “a sociology of epilepsy and epileptics in late Victorian England” (p. 72). Nevertheless, as I will argue, the work had more potential than it has realized.

         The book is divided into six chapters, the first serving as a summary by setting the scene for the later inquiries. Lekka describes the recent depersonalized treatments and medical approaches to epilepsy: though the medical condition is quite controllable, “the constant feelings of isolation, marginalization and, eventually, stigmatization that most epileptics do actually experience, are most closely related to the challenging difficulties resulting from most people’s fear towards them, rather than to the seizures per se” (p. 5). In order to understand how epilepsy became joined once again with such negative and condescending manners, the author argues that we shall turn our attention to the nineteenth-century discourse surrounding science and medicine. Thus she analyzes those historical and sociological conditions in which the discourse on epilepsy was created more than one hundred years ago.

         Though some theoretical background is supported along the lines of Michel Foucault, a more detailed account would have been necessary if the work is to be used also as a textbook or a more general source-book for the laymen who are not familiar with the methods and history of the related disciplines. While one could generally argue that the results of a work are able to justify its method and presumptions, the present work as it stands may require some more additions for that. (Chapter 5 actually presents some of the required interpretation and theoretical tools, but as we will see, it is a general feature of the book that it provides the necessary guidance always a bit late.)

         Chapter 2 discusses the social, economic, and political context for the upcoming sociological and philosophical investigations. The social history of Victorian England and in general of the nineteenth century enables us to understand how specific institutions and treatments emerged in the discussed period in a particular society. We got to know those factors and events which made human life and especially health recognized as important and valuable for governments; how medicine, doctors and their work became the primary subjects of the political power to control the members of the society for the ‘greater good’. Lekka argues that political and social changes are responsible for those transformations that “had a major impact upon the role and status of those who practised medicine, as well as upon their relations, disputes and contentions” (p. 25.). In the spirit of Foucault, Lekka tries to show (and presents a plausible and insightful story) that due to population-grow in the nineteenth century, governmental groups recognized the economic and power-related significance of healthy people. 

         A rather short, but interesting history of epilepsy from Hippocrates to the nineteenth century is also presented (pp. 26-34). Like other disorders and abnormalities, epilepsy had the most varying treatments and approaches. During the early modern era, many believed that “the sight of just one epileptic seizure would suffice […] to transmit the disease from one person to another” (p. 32.). Therefore, epileptic patients were confined together with madmen and criminals, but in time, during the nineteenth century, epileptics became institutionalized in psychiatric asylums.

         And that is the point where Lekka’s main story begins. In May 1860, the first neurological hospital, the National Hospital for the Paralysed and Epileptic opened its gates, thus “neurology was just making its first steps as a distinct medical specialty” (p. 41. n. 2) after being categorized along with murderers and madmen. The institute was run by John Hughlings Jackson (1835-1911) who transformed diametrically how epilepsy and epileptics became conceived medically in the forthcoming decades (p. 41). Chapter 3 is Lekka’s major undertaking with its sixty pages where the author distinguishes between four periods of the institute and describes with an overwhelming amount of data how doctors proceeded with patients. We got to know how they recorded their life, previous illness, family status, age, and job. Exactly because of this, these sections are quite heavy to read with many similar passages:

In reference to epileptic patients’ age, which was not stated in just two cases, two patients were up to ten years old, twenty patients were between eleven and twenty years old, nine between twenty-one and thirty, one between thirty-one and forty, one between forty-one and fifty, and one patient was over fifty years old; that is, almost 65 % was under twenty years old and just 9 % was over thirty. (p. 44.)

With all these data and information, some charts here would improve the reader’s focus and understanding of the numbers. One easily forgets the beginning of the sentence on the rood till the end. Already in the 1930s, the famous logical empiricists and educationist Otto Neurath claimed that many people are simply “intimated by numbers” and this is “not without a reason. Most people’s memory is not capable of handling this kind of thing” (Neurath 1931/2017, 111). Thus, as his own educational verdict goes, “to remember simplified pictures is better than to forget accurate figures” (Neurath 1933/1973, 220). This is not to say that such a socio-historically aimed investigation as Lekka’s shall discern numbers all the way; actually, the book is backed up with a nice package of material: between 1870 and 1895, 1453 inpatients of Jackson are discussed, 783 men and 670 women. But, and even worse, in this chapter, we got only the numbers and their detailed discussions are postponed to the next chapter (something like fifty-sixty pages later). Though one has to state the data first to analyze it later, some more visible and comprehensible way of presenting the material would have been fortunate.

         But, as it turns out, in Chapter 4, we got references to certain tables that are located in Appendix I, at the very end of the book (pp. 191-198). Why we shall be happy now, it is quite uncomfortable to turn always to the last pages when the numbers are analyzed in the chapter, and again, why here and why not in the previous chapter when all these were introduced at the first place. A somewhat more conventional structuring would have been instrumental in facilitating our understanding with regard to this more than interesting issue.

         To come back to Chapter 3, Lekka raises many questions about how to interpret the given numbers from a social, economic and cultural point of view. And those questions are both relevant and interesting at the same time. For example, the medical records show a steadily high number of young patients: almost 70% of the treated were under twenty, many of them less than ten years old. The question, mentioned by the author (p. 49) is whether this should be seen “as accidental, or as indicative of both the dominant social attitudes towards elderly people and the extent of epilepsy’s medicalization.”

         Besides raising good questions that are not answered for a while, another characteristic feature of Lekka’s book was surfaced in this chapter. Often happens that she points out some curious features of the numbers, or describes an astonishing distribution across them, raising themselves several possible interpretations but these are usually just shorted out. Take for example the case of the patient’s geographical origin. As the data shows, most patients came from the countryside and only a minority from the various suburbs of London. According to Lekka, this simply “illustrate[s] the hospital’s fame [...] as well as its doctors’ reputation” (p. 51). This is almost replicated in the next section as “in all probability, [the numbers were] indicative of the lack of specialized institutions outside London, as well as of the National Hospital’s widespread fame” (p. 57). This is very plausible, of course; furthermore, it might be true as well. But nothing peculiar and substantial reason is indicated here to back up, not to say, to argue for this point. Why not hypostasize then about the social estimation of illness in the city that might also influence the behavior of people in their social and cultural nexus, that is, how social reputation might prevent public action by admitting the illness of the given people. Plausible? Well, at least not worse than any other possibilities that were dropped.

         Or take another example. Lekka’s explanation of the oversizing number of young patients is connected to their social status. Namely, since young generations “retain the wheel within society”, we should be not surprised regarding “this huge interest in the preservation of its health and the improvement of its quality of life” (p. 78). Roger that. But what about medical precaution, about the parental care for their children, or the fact that children (rather than hard-working adults) had the required social and economic backup from their families to spend time in a hospital, usually for months. This sounds as good as anything else.

         A further typical issue in the book is that Lekka mentions certain information from the nineteenth century Victorian England without any further explanation or comparison. At one point she notes that in a rehabilitation center that collaborated with the National Hospital, “the weekly cost was five shillings” (p. 58). Is that much or not? How is it relevant and how to understand that piece of information? Perhaps for lovers of the Victorian age or the economic history of England, this datum tells something immediately and makes them laugh or raise their eyebrows, but for mortals, this is just ‘interesting’.

         But already the pure data from the records of patients (presented in Chapters 3 and 4) are telling. They show in what issues were medical doctors interested (at first nothing personal), and how the patients were treated in relation to their history, illness, and to their examiners and nurses. Finally, questions and recordings about their inner organs show also where exactly they tried to find the sources and possible treatments of epilepsy (p. 65). That is, with time, medical examinations developed into more scientific, standardized and systematic practices. Perhaps it would have been again more illuminating to see all this in the context of other medical (and scholarly conceived) fields, to see whether we are dealing here with a local issue or a general trend. (See below, though.)

         In Chapter 5, containing the epistemological analysis, Lekka draws such a narrative that points towards some general patterns. The author shows how politics and theory were intertwined in the nineteenth century, that is, how the theoretical writings of Jackson and others backed up their political views and vice versa. She explained this neat and multilayered relation as follows:

Within this frame, the hierarchical model of the human brain, as it was elaborated in Jackson’s neurophysiology, did actually reflect the power that the upper classes of Victorian society wanted avidly to exert over the “unruly”, “insubordinate” and “dangerous” lower social classes, by whom they were feeling threatened; in other words, it reflected the much needed hierarchical conception and view of the English society. (p. 151.)

This chapter of the book is the much Foucault-inspired part, showing in a detailed manner (with references to the previously given numbers) how non-normal behavior and illness became the subject of scientific investigation in order to reintegrate the patients to the field of work. As Lekka says succinctly, the hospital reforms of the nineteenth century are the “direct outcome of the necessities of the capitalist industrialized society and its urgent imperative for healthy, robust and productive bodies” (p. 72). The way patients were treated and admitted in the National Hospital shows how people became just “cases” in the institute, having conditions, symptoms, instantiating patterns and general features. By finding such restricted and narrow problems that could be subsumed under some specific headings, time of hospitalization could be reduced in order to let people participate in the market again.

         The book should have started with Section 5.9 where Lekka introduces, explains and gives a detailed presentation of her method, and especially of its philosophical and historical background. We got to see the connection between statistics and the state, the correlation between numbers and power, and how calculation, work and health were joined in the capitalist era. “Medicine had become a strictly political issue and an inseparable part of a continuously growing state interventionism” (p. 154). It is a really clear and insightful discussion enlightening and making explicit the book’s major points, but it is quite sad that the reader had to wait for one hundred and fifty pages for this.

         Lekka discusses also how the treatment of epilepsy moved from former mystical ideas about madness to the scientific approach of illness. The road was a long one, influenced by political and social powers. This is made crystal clear. Nonetheless, we again got such statements as this: “it was actually the Victorian period that witnessed the final abandonment of the, until then, dominant theological explanatory framework and the concomitant adoption of a purely scientific discourse” (p. 141). But what makes an approach scientific – besides some vague ideas concerning the usage of numbers, quantitative data and neutral descriptions – mostly lies in the dark.

         In the final major part of the book, Chapter 6, Lekka just summarizes the main general points of her investigations but projects the results and reasons into the twenty-first century. She uncovers hidden patterns and warns us about the dangers of scientism; namely how the allegedly neutral approach toward patients and their seemingly abnormal conditions could be utilized in political debates. That is, when epilepsy and similar diseases became subsumed under purely physiological descriptions and medical diagnoses backed up with numbers, discrimination became motivated and reasoned by quasi-scientific bases and not just on purely emotional and irrational grounds.

         Her final conclusions are alarming and pessimistic. “To conclude, we are living in an era, where every aspect of twenty-first-century individuals is viewed through medicine’s lens, that is, at a purely molecular/biological level” (p. 183). To see how we arrived at this state of public, scientific, and most importantly, political discourse, Lekka’s book provides important guidance. To summarize, The Neurological Emergence of Epilepsyis a grandiose project with a narrow but well-defined and motivated focus on how epilepsy as a medical subject developed in the nineteenth century under the aegis of scientific requirements. Lekka’s story is structured around numbers and medical reports, thus her book aims to combine two general approaches of sociology: namely the quantitative and the qualitative. In other words, after the text is overrun by such an amount of numbers that are barely manageable fluently, Lekka tries to interpret her data in a broad context, pointing out the meanings and reasons behind the numbers. Nonetheless, as I sketched it above, some of these interpretations stop at a preliminary level and floats in a space of reasons – and some more details would have been helpful to anchor them – but at least various possibilities of understanding are opened up.

Adam Tamas Tuboly

Postdoctoral Researcher, Institute of Philosophy, Hungarian Academy of Sciences

Supported by the MTA BTK Lendület Morals and Science Research Group.

References

·          Neurath, Otto (1931/2017). “Pictorial Statistics Following the Vienna Method.” ARTMargins6 (1): 108-118.

·          Neurath, Otto (1933/1973). “Museums of the Future.” In Marie Neurath and Robert S. Cohen (eds.), Empiricism and Sociology. Dordrecht: D. Reidel, 218-223.