Dr MAS Ahmed
Queen's University Hospital, London, United Kingdom

Ridhwan Bin Hassan
London School of Medicine and Dentistry, London, United Kingdom

Early civilizations

 

Dr. Guertin's nerve syrup, c. 1910

Since ancient times epileptic seizures have been subject to paranormal and superstitious beliefs, ranging from demonic causes to divine intervention. Some of the earliest observations were made by the Babylonians, who among their stone slabs on medical diagnostics (1067 – 1046 BC) had one known as Sakkikumiqtu, which literally translates into “falling sickness."1 They thought seizures were caused by demons and ghosts; and described several clinical forms: generalized, nocturnal, gelastic (i.e. laughter), chronic convulsions, and also post-ictal states.1

In Avesta, the Persian text on health (600 BC), there is mention of the prophet Zoroaster’s advice to prevent convulsions by offering sacrifices.1 In Ayurveda mental diseases were broadly classified as insanity, amnesia, and loss of consciousness - attributed to mental or psychological disease.6 The Charaka Samhita (400 BC) book on Ayurveda practice refers to convulsions as apasmara , defining them as sudden abhorrent bodily activities (vibhatsa-cheshta) along with momentary blackouts or loss of consciousness (tama-pravesha) owing to disturbance in mental faculties such as intelligence (dhi), retention (dhriti), and memory (smriti).1,6 Acharya Sushruta (600 BC), regarded  as the father of surgery, described various causes of apasmara  such as poor hygiene, diet, and conduct, repression of any natural urging of the body, or psychological factors i.e. anxiety, anger, and fright. All would lead to a maddening of bodily humours (doshas), ultimately leading to convulsive fits or episodes of unconsciousness and at last give rise to apasmara.6

Chinese physicians practicing the traditional Chinese Wade system (770 – 221 BC) also described Tíen-Hsíen, which is comparable to generalized convulsions.1 The first known citation of epilepsy in Chinese traditional medicine was in Ling Su, in a chapter entitled "Epilepsy and Madness of Huang Di Nei Jing." In that chapter, Zhu Danxi theorized that “epileptic seizure resulted from blockage of acupoint channels by phlegm and by salivation.” For treatment they recommended acupuncture, to balance the Yin and Yang and quench convulsion by opening up acupoint channels and modifying life energy, blood, and waking the brain.5 Compared to the other civilizations, the Chinese Wade and the Ayurveda were quite sophisticated in how they viewed epilepsy. Despite a degree of superstition and presumption, they did not regard demons as a cause of epilepsy, and understood that the cause of epilepsy resided in the brain.

Greco-Roman period

Greeks first coined the term epilepsy, meaning “to seize” or “to attack”, because they thought it was caused by an attack from a demon or god. The Sacred Disease (400 BC) was one of the Hippocratic collection of manuscripts (460 – 377 BC).1,2,7,8

Hippocrates wrote:

I am about to discuss the disease called “sacred”. It is not, in my opinion, any more divine or more sacred than any other diseases, but has a natural cause … Its origin, like that of other diseases, lies in heredity … the fact is that the cause of this affection … is the brain … 9

Although the “sacred” disease may also have included non-epileptic disease, some of the descriptions by Hippocratic physicians would nowadays be recognized as epilepsy.

If he foam at the mouth and kick, Ares has the blame. When at night occurs fears and terrors, delirium, jumping from the bed and rushing out of doors, they say Hecate is attacking.9

Hippocratic physicians thought that convulsions were due to an excess of phlegm entering the blood. Plato (428 – 348 BC) also agreed with this theory, but Aristotle (384 – 322 BC) believed that vapours from the food entered the vein, ascended to the brain and descended during sleep, causing epilepsy. Erasistratus (304 – 250 BC) thought that epilepsy resulted from having too much blood in the vein, whereas Soranus (98 – 138 AD) mentions that mechanical factors, meninges, and contusions as causes for epilepsy. Galen (129 – 199 AD)believed that the brain was responsible for convulsions: idiopathic epilepsy resulted from obstruction of the cerebral ventricles by phlegm and melancholic humours, while sympathetic epilepsy originated from other parts of the body, which subsequently involved the brain.1 It was largely thought during this age that epilepsy was hereditary, possibly due to abstinence from food or sex, digestive troubles, and much more.1

Middle Ages
Opinions on epilepsy during the medieval ages (400 – 1400 AD) were dominated by the symbolism, demonology, and religious belief inherited from the Greco-Roman period. As with all other sciences, medicine was ridden with superstitions. The views of the Catholic Church led to the public beliefs that convulsions were a form of possession or witchcraft, requiring exorcism and religious rituals.2 Much of this was based on passages from the New Testament such as Jesus casting out evil spirits and curing a boy from epilepsy in the gospels of Mark (9:14-16).1,3,4 Interestingly, there are references in  Mark (9:17-29) and Matthew (17:14-21) of epileptics responding to fasting, suggesting that fasting and a ketogenic diet were then recognized as a form of treatment for convulsions.3

Iranian medicine was thought to be the foundation of the 13th century European medicine. The two most outstanding Iranian scholars were Rhazes (Al-Râzi) and Avicenna (Ibn-Sinâ). The Continent (Kitab al-hawi of Râzi) and The Cannon (Qanoon fel teb of Avicenna) were used as medical textbooks in education from the 13th to the 18th centuries.10 During that period, scholars furthered the transmission of ancient knowledge to the West by translating Latin works into Arabic, but the invasion of the Mongols in the early 12th century put an end to scientific progress in medieval Iran.1

In the context of epilepsy, medieval Iranian texts denoted convulsions as sare, meaning the falling sickness. Omm-ol-sabyan was used when it comes to convulsions in a child. Rhazes states that as the convulsion starts, the patient falls to the ground and cries and froths at the mouth, occasionally accompanied by the occurrence of urinary and bowel incontinence. On the other hand, Avicenna defines epilepsy as a convulsive disorder that begins abruptly, with prodromal symptoms such as epigastric pressure, pain, depression, tongue paraesthesia, spreading extremities paraesthesia, incoherent speech, nightmares and sadness.10 Avicenna mentions that his approach to the diagnosis of epilepsy relies heavily on the pulse and urine, where the pulse of epileptics is irregular, protracted with varied strength and rate. The urine of epilptics contains bubbles and glass-like materials. Avicenna also makes mention of a post-ictal state, in which  where he notices patients regaining consciousness complain of headaches and depression, muscle pain in the lumbar and sacral region, hiccups, and tremors. The etiology of epilepsy was also heavily discussed, including endogenous factors (i.e. in pregnancy or what is known today as eclampsia), epileptogenic factors that increase the risk of developing epilepsy (i.e. trauma, diphtheria, pleuritis, etc), and also precipitating factors that may trigger a convulsion (such as psychological and physical stress).

To prevent convulsions, both Rhazes and Avicenna agreed on the need to avoid extreme weather, swimming, prolonged bathing, exhaustion, long exposures to bright and shiny objects, and euphoria. They also believed that diet helped prevent convulsions, as Avicenna wrote, “Most illnesses arise due to long-continued errors of diet and regimen” - common practice in Iran that mirrored what the Christians at the time believed. Interestingly, Abu Al-Faraj (1286 AD), an avid Avicennian physician was the first to advocate electrical-shock therapy by using a fish called torpedo.10 Similar to the Greeks, Iranian physician treated convulsions by phlebotomy, and also with herbs, powders, leeches, and ointments. Although the medieval Iranian physicians were objective in their understanding of convulsions, the general public at the time believed they were the result of possession by Jinns, whose existence is an integral part of Islam, even though no such statement was made by the Prophet Muhammad (Hadith).11

The Renaissance and Enlightenment

The Renaissance era focused on new possible causes of epilepsy, such as various chemicals particles. Joannes Fernelius (1497 – 1558 AD), among others, stated that seizures were due to poisonous vapours affecting the brain. An Italian natural philosopher, Andreas Caesalpinus (1519-1603 AD) tried to distinguish between epilepsy and demonic possessions.12 By the late 16th century physicians began to consider head injuries, uraemia, and syphilis as etiological factors in convulsions.1 Notable physicians at the time such as Herman Boerhaave (1668 – 1738 AD) and Gerard Van Swieten (1700 – 1772 AD) emphasized a clinical approach in identifying factors provoking seizures. Samuel Tissot’s (1728 – 1797 AD) contribution was that he identified absence seizures as a variant of convulsions and dispelled superstition about the moon causing convulsions, insisting that convulsions involved the brain and motor nerves. He thought that excessive masturbation could cause epilepsy, and castration and clitoridectomy were performed in severe cases, a practice not stopped until 1881, when William Gowers (1845 – 1915 AD) disproved this theory. During this period, grand mal and petit mal seizures were discussed by William Cullen (1710 – 1790 AD), and epileptic seizures were distinguished from non-epileptic ones.1

Late 19th century to 20th century AD

During that age, the understanding of epilepsy grew swiftly. In Europe and America hospitals were built specially for epileptic patients. Among pioneers in the field was Robert Bentley Todd, who lectured on post-ictal paralysis (later named Todd’s paralysis), and John Hughlings Jackson (1835 – 1911 AD), whose contributions included a unifying theory for epilepsy. Jackson observed that the anatomical location of a lesion at different levels determined the clinical features. He divided epilepsy into local and generalized and based his theories on the work of Marshall Hall (1790 – 1875 AD) and Brown-Séquard (1817 – 1894 AD), who argued that peripheral gastrointestinal or uterine stimulus triggered an epileptic seizure and that the brain epileptic center was in the medulla or even the upper spinal column. This was largely based on Brown-Séquard renowned guinea-pig studies. Jackson also theorized that epileptic seizure was a discharge, of chemical rather than electrical nature due to vascular and nutritional disturbance. His paper "A Study on Convulsions" stated that convulsion is a symptom and that it was a disorder of the nerve tissue of the muscles, arising from the gray matter of the cortex. At the time (1860s), however, the cortex was thought to be unexcitable. He wrote in 1868 that the most important question to ask a patient is “How does the fit begin?” and in 1873 “There is nothing more important than to note where a convulsion begins, for the inference is, that the first motor symptom is the sign of the beginning of the central discharge.” He defined what is now known as ‘Jacksonian seizure’ – a cortical spreading of seizure. It is also sad and ironic that his wife died from a cerebral thrombophlebitis complicated by Jacksonian seizures. Nevertheless, Jackson’s theory on the localization of epilepsy was revolutionary, laying the groundwork for the later advances in diagnosis and therapy.11

References

  1. Chaudhary UJ, Duncan JS, Lemieux L. A dialogue with historical concepts of epilepsy from the Babylonians to Hughlings Jackson: persistent beliefs. Epilepsy Behav. Jun 2011;21(2):109-114.
  2. Diamantis A, Sidiropoulou K, Magiorkinis E. Epilepsy during the Middle Ages, the Renaissance and the Enlightenment. J Neurol. May 2010;257(5):691-698.
  3. DeToledo JC, Lowe MR. Epilepsy, demonic possessions, and fasting: another look at translations of Mark 9:16. Epilepsy Behav. Jun 2003;4(3):338-339.
  4. Obeid T, Abulaban A, Al-Ghatani F, Al-Malki AR, Al-Ghamdi A. Possession by 'Jinn' as a cause of epilepsy (Saraa): a study from Saudi Arabia. Seizure. May 2012;21(4):245-249.
  5. Xia Y. Acupuncture therapy for neurological diseases : a neurobiological view. Berlin ; London: Springer; 2010.
  6. Karam S, Bhavna V. An Ayurvedic Insight Towards Epilepsy. Internation Journal of Research in Ayurveda and Pharmacy. 2012;3(5):682 - 689.
  7. Devinsky O, Lai G. Spirituality and religion in epilepsy. Epilepsy Behav. May 2008;12(4):636-643
  8. Riggs AJ, Riggs JE. Epilepsy's role in the historical differentiation of religion, magic, and science. Epilepsia. Mar 2005;46(3):452-453.
  9. Jones WHS, Withington ET. Hippocrates. With an English translation by W. H. S. Jones (vol. 1, 2; vol. 3 by E. T. Withington; vol. 4 [including the text and translation of Heracleitus on the Universe] by W. H. S. Jones). 4 vol. William Heinemann: London; G. P. Putnam's Sons: New York; 1923.
  10. Gorji A, Khaleghi Ghadiri M. History of epilepsy in Medieval Iranian medicine. Neurosci Biobehav Rev. Jul 2001;25(5):455-461.
  11. Shorvon S. The Beginning and the End of the Falling Sickness: Epilepsy and its treatment in London 1860 - 1910. 1st ed. London: Simon Shorvon; 2012.
  12. Magiorkinis E, Sidiropoulou K, Diamantis A. Hallmarks in the history of epilepsy: epilepsy in antiquity. Epilepsy Behav. Jan 2010;17(1):103-108.

 


DR MAS AHMED is a consultant paediatrician at Queen’s University Hospital. His main areas of interest include paediatric neurology and childhood headaches. He is also an honorary senior Lecturer at University College London–UK and Associated Professor at the American University of Caribbean/University of Florida, Unit Medical Student Lead.  Active in research and teaching and development, he was awarded top teacher of the year and the Excellence of Education Award by the University College London.

RIDHWAN BIN HASSAN is from the Barts and the London School of Medicine and Dentistry, London.

 

 

 

 

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