Dostoevsky's Epilepsy : A Case Report and Comparison

Howard Morgan, M.D .

Methodist Hospital, Lubbock, Texas

Morgan H. Dostoevsky's epilepsy : a case report and comparison .Surg Neurol 1990 ;33 :413-6 .

The Russian writer Dostoevsky (1821-1881) sufferedfrom a rare form of temporal lobe epilepsy termed "ec-static epilepsy ." Dostoevsky used his epileptic experiencesto create Prince Myshkin, the protagonist of The Idiot .The recent case of a patient who experienced ecstaticepilepsy as a result of a temporal lobe brain tumor ispresented and compared with that of Prince Myshkin .Reading Dostoevsky can give the contemporary physicianan insight into the inner life of an epileptic patient-anexample of how art can directly benefit medical practice .

KEY woRDS : Epilepsy ; Dostoevsky ; Temporal lobe epilepsy ;Ecstatic epilepsy

IntroductionThis paper compares two cases of a rare form of epilepsyseparated by more than a century . The first case is thatof Prince Myshkin, the protagonist in Dostoevsky'snovel, The Idiot. The second case is a recent patientwith a brain tumor treated by the author . Dostoevsky isrecognized as one of the world's greatest writers . Twoof his better known novels, Crime and Punishment (1866)and The Brothers Karamazov (1880), are recognized asforerunners in the study of abnormal psychology .

Ecstatic epilepsy is defined as a temporal lobe seizurephenomenon of intense pleasure, joy, and contentmentand is seen in two forms . The first form occurs in patientswho have a sudden lapse of consciousness with the feel-ing of intense, inexplicable pleasure not followed byother seizure manifestations. The second form occurs asan aura of ecstasy before a generalized or grand malconvulsive episode .

Ecstatic seizures and auras of ecstasy are unusual epi-leptic phenomena. Most modern neurology textbooksdo not mention the subject and case reports are rare .Penfield and Kristiansen [14] alluded to ecstatic epilepsy

Address reprint requests to: Howard Morgan, M.D ., 3802 21st Street,Suite A, Lubbock, Texas 79410.

Received June 26, 1989 ; accepted January 30, 1990 .

© 1990 by Elsevier Science Publishing Co ., Inc .

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but documented only one case. Less than a dozen caseshave been reported in the medical literature[1,11,14,16] . I n 1980 Cirignotta et al [1), from Bologna,Italy, reported a well-documented case of ecstatic epi-lepsy complete with an electroencephalographic record-ing during one of the seizures in their patient demon-strating a temporal lobe focus . It is of note that in themedical literature ecstatic epilepsy is usually termedDostoevsky's epilepsy . In reviewing the few reportedcases of ecstatic epilepsy the author has found no in-stance of ecstatic epilepsy caused by a brain tumor .

DostoevskyFedor Mikhailovich Dostoevsky was born in 1821 in theMoscow Hospital for the Poor where his father, an ex-army surgeon, was an attending physician . Although thefamily had an hereditary title of nobility, their social andeconomic position was one of the lower middle class .After his early education in Moscow boarding schools,Dostoevsky attended the St. Petersburg Military Engi-neering Academy, and graduated in 1843 . Following ashort stint in the army, Dostoevsky devoted his life towriting and between 1844 and 1849 published two nov-els and several short stories . In 1849 Dostoevsky wasarrested, tried, and convicted of treason and was sen-tenced to death for outlawed political activities. He wastaken before a firing squad and at the last minute hissentence was commuted by the tsar . Dostoevsky wasexiled to Siberia where he served 4 years shackled inprison and 6 years in the army as a soldier . After hisrelease from the military, Dostoevsky resumed his liter-ary career, publishing during the remainder of his life-time 10 more novels, many short stories, and scores ofnonfictional articles in various periodicals . His life wastroubled by financial and family problems as well as illhealth. He suffered with tuberculosis and, in 1881, diedfollowing recurrent pulmonary hemorrhage .

During his entire adult life Dostoevsky was plaguedby epilepsy [3,6,8,10,15] . His seizures were frequentlynocturnal and grand mal . Those seizures that occurredduring waking hours were often preceded by an ecstaticaura, which led neurologists to theorize that he hadtemporal lobe epilepsy with secondary generalized orgrand mal epilepsy [10,16] . Dostoevsky said that for

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several short moments before a fit he felt a contentmentthat was unthinkable for those who had not experiencedit. He felt in perfect harmony with himself and with theentire universe. The perception was so clear and theepisode so pleasurable that he expressed that he wouldgive 10 years of his life and perhaps all of it for a fewseconds of such bliss [3,10,16] . Dostoevsky's grand malseizures were often quite violent and he usually sufferedfor several days after an attack with postictal confusion,lethargy, and inability to work [10,16] . Although Dos-toevsky's fits averaged one per month over a course of35 years, the frequency ranged from twice daily to oneevery 4 months [161 .

The IdiotDostoevsky uses epileptic characters in 4 of his 12 nov-els, Kirillov in The Possessed, Smirdyakov in The BrothersKaramazov, Nellie in the Insulted and Injured, and PrinceMyshkin in The Idiot . As Gide [9] states about Dostoev-sky, "his persistence in making epilepsy intervene asa factor in his novels sufficiently indicates the role heassigned to this disease in moulding his ethical concep-tions and directing the course of his thought ." Only inThe Idiot does epilepsy serve as a central motif, and inthis novel Dostoevsky portrays the epileptic mode ofbeing through the protagonist, Prince Myshkin [2] . Mo-chulsky [13] states, "Dostoevsky bestowed upon his be-loved hero (Prince Myshkin) that which was most inti-mate and holy in him : his ecstasy and his epilepsy ." Frank[6] suggests that the Prince is a noncomic, self-sacrificingDon Quixote . The Prince, at first an impoverished no-bleman and later in the novel the beneficiary of a largeinheritance, is a simple-minded but pure Christ-like fig-ure . In his notebooks Dostoevsky [5] clearly stated thathe intended Prince Myshkin to be a beautiful, innocentman. The Prince is unassuming, sincere, and compas-sionate. He is a friend of little children and a championof the sick and fallen . The Prince may be seen as an idiotsavant or as a holy fool, a theme recurrent in Russianliterature [2] . Who else but an epileptic himself wouldcreate such a character? Another of Dostoevsky's pur-poses in the novel is to show symbolically the uneven,unpredictable life of an epileptic through the flow ofthe novel itself. Some literary critics view The Idiot ascontrived and so disjointed that the plot is difficult tofollow . However, as Dalton [2] suggests, if one standsback and looks at the structure of The Idiot, one realizesthat the flow of the novel is a description of an epileptic'slife. The action seems to progress unevenly in waves ofaction that gather and erupt like an epileptic fit followedby collapse and lethargy like the postictal state after aconvulsion .

In part 2, chapter 5 of The Idiot, Dostoevsky [4},

Morgan

speaking through Prince Myshkin, describes the onsetof a seizure with an ecstatic aura :

He was thinking, incidentally, that there was a momentor two in his epileptic condition almost before the fititself (if it occurred during his waking hours) when sud-denly amid the sadness, spiritual darkness and depres-sion, his brain seemed to catch fire at brief mo-ments. . . . His sensation of being alive and hisawareness increased tenfold at those moments whichflashed by like lightening. His mind and heart wereflooded by a dazzling light . All his agitation, all his doubtsand worries, seemed composed in a twinkling, culminat-ing in a great calm, full of understanding . . . .

Contemporary CaseA 38-year-old right-handed white man was admitted tothe Methodist Hospital, Lubbock, Texas, in the fall of1985 with a nocturnal grand mal seizure . He had beenin excellent health. He was treated with anticonvulsantmedication and his epilepsy was temporarily controlled .Four months later he was again admitted to the hospitalwith further convulsions . At that time he was also havingepisodes that the author labels as ecstatic epilepsy . Theseepisodes occurred multiple times daily over the courseof 2 months . A typical fit began suddenly with a feelingof irritation followed promptly by a sense of detachment .He would see a bright but not glaring light . He sensedthat the light was the source of knowledge and under-standing. He occasionally heard soft music. In about halfof these episodes a young bearded man would appear .The man did not identify himself, although the patientassumed that this somewhat vague appearing individualwas Jesus Christ . The entire episode lasted only a secondor two, but to the patient it seemed much longer . Hisfamily reported that during these fits he seemed in an-other world and would not respond normally to them .At first the patient was frightened after these episodesbut gradually came to see them as joyful and pleasurable .During the fit he felt at ease with himself and his environ-ment . He sensed an ineffable contentment and fulfill-ment. Occasionally these ecstatic seizures were followedby a grand mal convulsion .

The patient was found to have a brain tumor in theright temporal lobe as seen on the computed tomogra-phy scan (Figure 1) . At surgery an anterior temporallobectomy was done with resection of the amygdala andthe anterior hippocampus. The pathological diagnosiswas high-grade astrocytoma (grade III/IV) . After sur-gery the patient had no further seizures . He receivedradiation therapy and did fairly well for 9 months . I low-ever, the tumor recurred, and the patient died 15 monthsafter surgery .

Dostoevsky's Epilepsy

Figure 1 . Computed tomographl, roan of the brain in this patient withecstatic epilepsy demonstrating a tumor in the nondominant right temporallobe (arrorobead) .

In this case the exact site of the pathological lesioncausing the ecstatic epilepsy was localized radiographi-cally in the anterior nondominant temporal lobe, provenpathologically in the surgical specimen, and further con-firmed when the seizures did not recur after surgery .This is the first case of ecstatic epilepsy in which theexact site of the brain abnormality has been preciselylocalized . In other cases of ecstatic epilepsy reported inthe medical literature the localization of the cerebraldisturbance was assumed to be the temporal lobe and,in one report already mentioned, was confirmed on elec-troencephalogram to be in the temporal lobe [I). How-ever, further localization within the temporal lobe hasnot been proven . The present case is unique in the pre-cise localization of the brain disturbance responsible forecstatic epilepsy .

DiscussionThe ecstatic epilepsy of Prince Myshkin has similaritieswith that of my patient . In both the ecstatic episode cameon suddenly and was heralded by light . In the case ofPrince Myshkin, the light was a sensation described byDostoevsky as follows: "A wonderful inner light illumi-nated his soul," and "His mind and heart were flooded

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by a dazzling light" [4,8} . My patient actually saw a lightand felt that the light was the source of unattainableunderstanding. Both Prince Myshkin and my patientwere unaware of their surroundings during the ecstaticepisode. Dostoevsky describes Prince Myshkin's ecstaticepisode lasting only a few seconds and adds that, "Maho-met refers to the same moment when he says that hevisited all the dwellings of Allah in less time than heneeded to empty his pitcher of water" [4,8] . My patient,too, knew chat the time span of his ecstasy was very briefbut it seemed longer . Much seemed to happen duringthese episodes as if time were expanded . Prince Myshkinwas plagued by self-doubt, considered himself an invalid,called himself an idiot, and felt that in society he wassuperfluous [4,10] . My patient, too, was tormented bypsychological problems during his illness . He could notwork or drive an automobile . He had doubts about hisworth as a husband and as a provider for his family .As suggested by Rice [15}, the ecstatic auras of PrinceMyshkin have religious overtones . The Prince speaks ofprayer and refers to Mahomet, the prophet of Islam [4] .My patient felt as though he had been visited by JesusChrist during some of his ecstatic episodes and heardmusic like he might hear in church . It is of note that heinfrequently attended church during his adult life but didattend regularly as a child . During their ecstatic episodes,both Prince Myshkin and my patient felt a oneness orcontentment with the universe . According to Dalton,this sense appears to be the "oceanic feeling" of Freudin which the boundaries of the ego are dissolved, andthere is regression to the primordial state of the infantat the breast [2,7] .

Contemporary physicians specializing in neurologicaldisease consider themselves well trained in dealing withthe organic aspects of epilepsy-the diagnosis, evalua-tion, and treatment. However, many of us may feel inad-equately trained in dealing with the nonorganic aspectsof epilepsy-the emotional, psychological, moral, andmetaphysical enigmas of those so afflicted . Dostoevskyignores the organic side of epilepsy but lets us see intothe mind and emotion of the epileptic patient throughhis character Prince Myshkin as well as several others inhis works who are in a large part autobiographical . AsMiksanek [12] states, "Dostoevsky's The Idiot is anexample of how art can reinforce and elaborate scientificobservation ." By reading The Idiot and several other ofDostoevsky's works, we can sense in part what it is liketo be an incurable epileptic . Such insight is not offeredin even the best neurology or neurosurgery textbooks .

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