Preface

Epilepsy is the most frequent neurological pathology in the world and affects individuals of all ages with important effects on neurodevelopment and cognitive and behavioral skills. Despite increasing prevalence and knowledge of the disease, epilepsy is still strongly burdened by social stigma. Treating epileptic pathology is possible thanks to the numerous and various therapeutic techniques now available, many of which do not involve the use of drugs.

The disease affects about 65 million people globally, 80% of whom live in developing countries. The management of epilepsy generally involves antiseizure drugs or surgery for those patients who are candidates. There are also numerous other therapeutic options to support drug therapy such as a ketogenic diet or stimulation of the vagus nerve, in addition to neuromodulation techniques.

Epilepsy has always been cloaked by a mysterious aura. Since ancient times, cultures and civilizations have attempted to understand why a person may appear normal and then suddenly present with intense and uncontrollable convulsions. The first hypothesis indicated a spiritual cause.

Among the oldest texts is one dating back to about 2000 BC written by a Mesopotamian. It describes a patient who has wide eyes and hands, tense feet, and a lack of consciousness. The text attributes the symptoms to the "hand of sin." In 1790 BC, the Hammurabi code listed a "return clause" for slaves who were purchased and subsequently found to experience epileptic crises. The clause was presumably written due to the fear about the cause of the disease. About 700 years after the Hammurabi code was decreed, a Babylonian text outlined a spiritual solution for epileptic patients said to be possessed by evil spirits.

The modern opinion that the etiology of epilepsy is physiological and not divine has its roots largely in the studies of Hippocrates of Kos of 400 BC, who argues that the etiology of epilepsy is precisely similar to that of any other disease, that is, based on physiological principles. This debate between divine and physiological causes would continue for another 2000 years.

Epilepsy is not curable but can be commonly controlled with modern anticonvulsants that prevent convulsions or reduce their intensity. However, more than 30% of people with epilepsy have uncontrolled convulsions even with the best drugs available. Throughout history, epilepsy was viewed with amazement, and uncontrollable convulsions were often attributed to the influence of spirits. It is thought that people in the Stone Age drilled into the skull to dissipate demons. In ancient Greek Hippocratic thought, convulsions were sometimes interpreted as a sign of a person possessing prophetic skills. Early Christian and medieval belief was that epilepsy was a punishment from God, and in early modern times epilepsy was viewed according to the concepts

of humoral pathology as a sort of imbalance among the four bodily fluids or humors: blood, phlegm, black bile, and yellow bile.

The first synthetic anticonvulsant, paraldehyde, was introduced in 1882. Subsequently, phenobarbital became the main drug prescribed for epilepsy, followed in 1938 by Difenilhidantoina (Dilantin, phenytoin). Before these drugs, people worldwide depended mainly on plants to treat epileptic convulsions.

Since epilepsy is a disease characterized by sudden and mysterious symptoms, it is not surprising that people have been looking to understand its cause since it was first encountered. The initial attempts to surgically treat epilepsy trace their roots back to Greek, Roman, Egyptian, and South American cultures. Despite the lack of scientific etiology for epilepsy, it was thought that these primitive procedures, which more commonly consisted of drilling, freed the demons that caused the disease. These first surgical concepts are captured in various works of art that span many centuries; the oldest of these artistic references to epilepsy surgery dates back to the late twelfth century.

Recent history shows that public opinion on epilepsy continues to evolve. The second half of the twentieth century, in particular, saw many changes in the treatment by the public of those who have epilepsy. Starting in the 1970s, the United Kingdom began to allow epileptic patients to marry and the United States began to allow them to go to public places such as restaurants and movie theaters. In addition, according to a Gallup survey of Americans from 1949 to 1979, the percentage of the public who said no to the belief that epilepsy is madness has increased from 59% to 92%. The percentage of the public that would allow their children to play with other children with epilepsy had increased from 57% to 89%.

Section 1

New and Old Perspectives

on Epilepsy

Modern medicine fixes a more physiological logic at the origin of the disease, but there remain critical questions about its mechanism and the most appropriate treatment strategies. This text was born with the idea of providing innovative contributions to epilepsy. Written by scholars on epilepsy worldwide, this book will help readers find new answers to ancient doubts about epilepsy.

> **Marco Carotenuto** Department of Mental and Physical Health and Preventive Medicine, University of Campania "Luigi Vanvitelli", Caserta, Italy

Section 1
