epilepsy may well be one of mankind's oldest diseases. Hippocrates (
c.450–377 bce) wrote
On the sacred disease, which is usually interpreted as being epilepsy, arguing that it could be treated by regular attention to a healthy way of life, especially by the proper and moderate use of food and drink, which would correct the causative physiological blockages. That is, the Hippocratic tradition regarded epilepsy as a disease as natural as any other, and not due to supernatural influences, whilst prior to the Hippocratic corpus a range of disturbed gods had been invoked to account for epilepsy's signs and symptoms.
Further, Hippocrates argued that the disease was inherited and was caused by a disturbance in the
brain, and thus firmly fixed epilepsy as a natural disease, treatable by doctors and not by priests, an important development for both market and medical practices. This view was long held by learned doctors: the influential physician Alexander of Tralles (525–605), however, recommended treatments that included making the nail of a wrecked ship into a bracelet, which was to be decorated with ‘the bone of a stag's heart taken from its body whilst alive’, adding that this should be worn on the left arm, for ‘astonishing results’. Somewhat earlier, the Roman physician Pliny (
c.23–79) had also reported that epileptic patients could be cured by drinking blood, especially of gladiators. Throughout the Middle Ages, the view that epilepsy was a medical problem continued to coexist with causative theories of demonic
possession and spiritual imbalances. Treatments including Christian prayer (St Christopher was drafted in as a patron saint with special responsibility), pagan ritual, and humoral medicine all emerged. A prominent medieval surgeon, Guy de Chauliac (1298–1368), prescribed magic and prayer for epileptics — they were to write the names of the Three Wise Men in their own blood on parchment, and daily recite three Pater Nosters and Ave Marias for three months. It was at this time that mistletoe acquired a special association with epilepsy — mistletoe was hung around children's necks in Central Europe as a protective against seizures, and in Scandinavia knife handles were cut from oak mistletoe, for the same purpose. By the sixteenth century epileptics could be branded as
witches, and little medical progress had been made. In the middle of the seventeenth century, Robert Boyle, a founder member of the Royal Society of London, was still advocating crushed mistletoe to be taken during the days of a full moon.
Gradually however, some effort was made to classify the different types of seizures, and by the beginning of the nineteenth century epileptics were often hospitalized. One advance occurred in 1838, when epileptic children in Paris were provided with education, rather than being completely hospitalized, although often epileptics were separated from the insane because of the growing belief that epilepsy was infectious. Thus epileptics were increasingly confined in separate wards, and soon in separate institutions.
By 1860 special hospitals for epileptics had been founded in Germany, France, and Britain. One of these was the Hospital for Epilepsy and Paralysis in Queen Square, London (later the National Hospital for Nervous Diseases). This meant that epileptics were increasingly seen and treated by physicians attached to such institutions, who became particularly experienced in the diagnosis and treatment of the disease. This led in particular to a more detailed differentiation and classification of epilepsy, including terms still in use today, such as
grand mal, petit mal, absence seizures, and
status epilepticus. By the latter part of the nineteenth century, the theories of the British neurologist, John Hughlings Jackson (1835–1911), and his French counterpart Jean Charcot (1825–93) began to define the neurological basis of the disease and its complex symptomatology. W. R. Gowers (1845–1915) authoritatively described the ‘aura’ that preceded a
grand mal attack (although Hippocrates had not been ignorant of it).
In terms of treatment,
bromides were the first successful medicine for epilepsy, from the 1850s onwards, abolishing attacks in some, and diminishing them in number or violence in most others; they started to be displaced only after the introduction of
phenobarbital, first prescribed in 1912. Barbiturates continue to be one of the effective treatments, although further understanding of the underlying mechanisms have led to the development of alternative modern anticonvulsant drugs: those that potentiate or imitate the inhibitory
neurotransmitter GABA, or stabilize the neuronal cell membrane, and thus prevent excessive firing.
It may seem obvious in the present day that the origin of the
convulsions that characterize epilepsy lies in the brain — but this was not in fact established until the latter half of the nineteenth century. Indeed, there had been at that time a belief that they originated as abnormal
reflexes from the
spinal cord. This, together with the notion that there was not any localization of function in the
cerebral cortex, was based on faulty interpretation of experimental studies. Broca initiated the concept of localization in the 1860s, with his description of the part of the left hemisphere responsible for
speech function, followed by Hughlings Jackson's conclusion from his studies that convulsions on one side of the body are due to discharge from certain convolutions of the cortex on the opposite side of the brain. ( Hippocrates had noted this association somewhat earlier in his writings on injuries to the head, but the knowledge had been submerged.) Studies on electrical stimulation of the brain of animals in the 1870s supported Hughling Jackson's suppositions. Anaesthesia and antisepsis followed by asepsis allowed the beginnings of modern brain surgery, and another historic event was in 1886, when Victor Horsley in London operated on the brain and cured a young man's fits by removing scarring resulting from a head injury in childhood.
The next landmark in the history of epilepsy was the
electroencephalogram (EEG) — the first demonstration in the late 1920s that the electrical activity of the brain could be recorded through the intact skull, and that abnormal patterns appeared during an epileptic attack. In subsequent decades, electroencephalography advanced the diagnosis of epilepsy, and the localization of its site of origin in the brain. Meanwhile, exploration of the effects of electrical stimulation of the human brain, with relevance to the site of onset of focal seizures, culminated in the detailed mapping of functional localization of the parts of the body in the motor and sensory regions of the cortex, by the Canadian neurosurgeon Wilder Penfield and his colleagues in the 1930s.
Deliberate induction of epileptic seizures was used during the twentieth century in attempts to treat mental illness. Camphor, which had been observed to precipitate attacks in epileptic patients, was introduced to induce shocks, but it produced such violent convulsions that bones were broken, and symptoms remained unaffected.
Insulin shock therapy inducing seizures by the lowering of
blood sugar was used with some success in schizophrenics. Electroconvulsive therapy (ECT), first applied in the late 1930s, and nowadays performed under anaesthesia, remains in use and is effective in the treatment of depressive illness.
Epilepsy would now be defined as a paroxysmal and transitory disturbance of the functions of the brain, involving repetitive discharges in large groups of brain cells, and commonly causing convulsions. The disturbance develops suddenly, ceases spontaneously, and is subject to recurrence. The current understanding of epileptiform activity in the brain, its types, nature, and mechanisms, is described under ‘
convulsions’.
E. M. Tansey, and Sheila Jennett
See also
convulsions;
craniotomy;
EEG;
magnetic brain stimulation.
