**2. Epilepsy in the dark ages**

#### **2.1 Medieval times and medicine**

The Medieval times is characterized by a domination of mysticism and dogmatism in all fields of science, including Medicine. Physicians tended to believe that diseases such epilepsy, hysteria and psychoses were the result of demonic possession; for that reason epileptics were treated as witches and warlocks. Many medieval mosaics, frescoes, miniatures and paintings depic the exorcism of a particular disease/devil by a particular saint. Beyerstein suggests that the curious behavior of the possessed people described in the classic *Malleus Maleficarum* (15th century AD) is likely symptoms of epilepsy or Tourette's

Various philosophers will refer to epilepsy such as the Pliny the Elder, in his *Naturalis Historia,* suggesting magical remedies such as the rubbing of patient's feet with menstrual blood (Pliny, 1856), Pedanius Dioscorides (40-90 A.D.) describing 45 different substances used as remedies for epilepsy (Temkin, 1971a) and Aurelius Cornelius Celsus who calls epilepsy, in his writings, *morbus comitialis* and suggests as a cure sexual intercourse for boys

One of the most important works of this period is that of Aelius Galenus or Claudius Galenus (131-201 AD) who systemized nosology and described epilepsy with accuracy in his classic treatise *Medical Definitions* (Galen, 1821c). He was able to discern three forms of epilepsy: (1) idiopathic, attributed to primary brain disorder (an analogue to grand mal epilepsies), (2) Secondary forms, attributed to disturbance of cardiac function transmitted through the flow of liquids secondarily to the brain (epilepsy by sympathy), and (3) a third type attributed to disturbance of another part of human body which is secondarily transmitted to the brain (probably Jacksonian epileptic seizures). Galen accurately sets the brain as the organ afflicted by the disease , and, most importantly, he described the aura, a greek word which originally means 'breeze', in his *De locis affectis* referring to the symptoms of a case of a 13-year-old boy (Galen, 1821a). Galen also differentiates epilepsy from tetanus because with epilepsy the whole

Aretaeus of Cappadocia (1st/2nd century AD) was the first to describe premonitionary symptoms of epilepsy, such as hallucinations that occasionally precede epileptic seizures; he noted that fetid odors, luminous circles of diverse color, noises from the ears, tremors and sensations in the hands or feet may occur before the seizure. He also noted the tendency of seizures to recur, once established, and the phenomenon of epileptic insanity (Aretaeus, 1856a). After the fall of the epileptic to the ground, Aretaeus, distinguished three main periods: manifestation, abatement, cessation. The manifestation is characterized by insensibility and tonic and clonic convulsions. At the end of the abatement stage, patients appear to suffocate, with its concomitant signs including erection of the genital. During the abatement stage, the patients unconsciously discharge urine, excrement, and semen, a hallmark symptom that discerns epilepsy from hysteria. Then, a flow of froth ends the suffocation. At the end of the abatement stage, they arise with the seizure having ended. During cessation period, patients still have various signs of physical and mental discomfort (Aretaeus, 1856c). Aretaeus gives an excellent description of 'grand mal' epilepsy in his text (Aretaeus, 1856c), as well as the first description of the so-called 'epileptic personality'

Soranus of Ephesus (1st/2nd century AD) also referred to epilepsy without making any

The Medieval times is characterized by a domination of mysticism and dogmatism in all fields of science, including Medicine. Physicians tended to believe that diseases such epilepsy, hysteria and psychoses were the result of demonic possession; for that reason epileptics were treated as witches and warlocks. Many medieval mosaics, frescoes, miniatures and paintings depic the exorcism of a particular disease/devil by a particular saint. Beyerstein suggests that the curious behavior of the possessed people described in the classic *Malleus Maleficarum* (15th century AD) is likely symptoms of epilepsy or Tourette's

or the warm blood of slain gladiators in obstinate cases (Celsus, 1935).

body participates with a loss of consiousness (Galen, 1821b).

contribution to the understanding of the disease.

**2. Epilepsy in the dark ages 2.1 Medieval times and medicine** 

(Aretaeus, 1856b).

syndrome (Beyerstein, 1988). Beginning at age 13, Joan d'Arc experienced moments of ecstasy with light, heard voices of saints, and claimed to see visions with angels, all probably symptoms of epileptic seizure (d'Orsi & Tinuper, 2006).

Fig. 2. Malleus Maleficarum (Lyon edition, 1669)

Another aspect on epilepsy during the Medieval times, was the theory that epilepsy was a contagious disease. The epileptics, considered to be possessed, were excused from oblation and Eucharist because they would desecrate the holy objects and would infect the common plate and cup (Dolger, 1933). Epilepsy was also included in the infectious diseases enumerated in the verse of the so-called *Schola Salernitana*, where it was named *pedicon* (Martin, 1922). Berthold of Regensburg, attributed the infection of the 'falling evil', as epilepsy was commonly called during this period, to the contagious character of the patient's evil breath. A connection of epilepsy with astrology was also a very popular theory in medieval times. Pagans believed that epilepsy was a vengeance of the goddess of the moon. The waxing moon supposedly heated the atmosphere surrounding the earth, which in turn melted the human brain and provoked the attack (Temkin, 1971c).

#### **2.2 Epilepsy and the catholic church**

Inevitably, many saints of the catholic church dealt with epilepsy. For example, St. Hildegard of Bingen (1098-1179 AD) distinguished between two kinds of epilepsy: a vengeful wrath sets the blood in motion causing one type of epilepsy while patients with unstable or low morals suffered the a second type (Hildegard, 1903). Saint Valentine, whose name in German originates from the phrase 'fall net hin' (Valentin) ('do not fall down'), was considered as patron of the epileptics (Kluger & Kudernatsch, 2009). Saint John the Baptist, was also connected with the disease, probably because his head fell to the ground after his decapitation by Herod (Budrys, 2007). St John was originally the patron of the dancing mania, and later, St. Vitus, a christian martyr of Sicily, became the specific saint of this neurosis and St. John of

Hallmarks in the History of Epilepsy: From Antiquity Till the Twentieth Century 137

terms: primitive, antecedent and conjoint (Savonarola, 1547), as well as Matthaeus Platearius in his *Practica brevis* adding two clinical varieties that are distinguised as 'maior and 'minor'

The end of the Medieval times and the beginning of the European Renaissance (14th-17th century) is marked with an exceptional production of literature regarding epilepsy. Science, emancipated from the restrains of the Catholic Church will undoubtly make important progress; in the field of epilepsy, almost all the prestigious and famous physicians of the era

Various theories will be proposed regarding the mechanism that causes the epileptic fits as well as new classifications of the disease will come forth. For example, Petrus Forestus (1522-1597 AD), a Dutch physician, notes that the part of the body that epilepsy originates, leads to different manifestations. There is also a tedency to differentiate epilepsy and daemonism; in his *Daemonum investigatio peripatetica* (Peripatetic investigation of demons) Andreas Caesalpinus (1519-1603 AD), an Italian natural philosopher, tries to differ epileptic

One of the most famous physicians of this period, Paracelsus (1493–1541 AD), dealt with epilepsy. He agrees that epilepsy may originate from the brain or the liver, the heart, the intensines and the limbs. Paracelsus views about the human nature and the construction of the human body from mercury, sulfur and salt led him to a different model for the causes of epilepsy (Paracelsus, 1922-1933a). However, in his essay he clearly sets God above all, and stresses that the physician should ask for divine help in the treatment (Paracelsus, 1922- 1933b). Ioannes Marcus Marci (1595-1667 AD), a Bohemian physician and scientist, broadened the definition of epilepsy 'to any affection of the body where the victims are disordered in their minds, while the members [of the body], be it all, or some, or only one, are moved against their will.' Thus, he tied cases of epileptic convulsions with mental manifestations (Marci a Kronland, 1678). Levinus Lemnius (1505-1568 AD), famous Dutch physician and student of Vesalius, all stressed the natural origin of the disease and rejected

Other physicians who also dealth with epilepsy include Charles Le Pois (1563-1636 AD), consultant physician to Charles III of France, who rejected previous theories such as those postulated by Petrus Forestus suggesting that peripheral organs led to epilepsy (Le Pois, 1733), Joannes Ambianus Fernelius (Jean François Fernel) (1497-1558), a French astrologist and physiologist, who supported the theory that poisonous vapors affected the brain and led to epileptic fits, and rejected the medieval belief about the contagious nature of epilepsy

An important treatise of the period is that of Jean Taxil's *Traicté de l'épilepsie,* that summarize the knowledge around epilepsy, including its causes and various remedies; he was the first

William Harvey (1585-1657 AD) will be the first who will make important advances for the establishment of neurology as clinical speciality with his descriptions of various neurological disorders including epilepsy (Brain, 1959; R. Hunter & MacAlpine, 1957). An interesting theory on epileptic convulsions is that of Thomas Willis Thomas Willis (1621 – 1675) who assumed the existence of a '*spasmodic explosive copula'*. For Willis 'The convulsive disease for the most part, takes its origin from the head (Willis, 1684). In his *De morbus* 

Renaissance doctor who seriously doubted demonic possession (Taxil, 1602).

epilepsy (i.e., grand mal and petite mal) (Serapion, 1530).

seizures and daemonic possesion (Caesalpinus, 1593).

any theological superstitions (Lemnius, 1658).

deal with the disease.

(Fernelius, 1577).

**3. Views on epilepsy in renaissance and enlightment** 

epilepsy. The three wise men from the biblical tale of Jesus' birth also had a reputation as patrons of epilepsy mainly because they fell down before the divine child and offered gifts (Kerler, 1905). On the other hand, the Greek Orthodox Church has the example of St. Tychonas of Cyprus who was considered to have cured many possessed people.

#### **2.3 Byzantine and Arab physicians**

Once should also note the views of famous byzantine physicians such as Oribasius of Pergamum, Aetius Amidenus, Alexander of Tralles and Paulus of Aegina on epilepsy. Overall, byzantine doctors recapitulate the theories of Ancient Greek physicians and further systemize the nosology of the disease by reporting interesting cases of epileptic patients. It is of note, though, that Alexander of Tralles (525-605 AD), in his treatise *Twelve books on Medicine*, takes an orthologic approach considering epilepsy a brain disturbance and reject extreme procedures such as trephinization (Tralles, 1878). Paulus of Aegina (7th century AD), according to Economou and Lascaratos, was the first Byzantine doctor who provided a clinical description of the epileptic fits, and also described a clinical condition that resembles *status epilepticus* (Economou & Lascaratos, 2005).

Arab doctors seem also to recapitulate the theories of Galen and Hippocrates without making any significant progress. Interesting descriptions of epileptic seizures can be found in the texts of Rhazes (Temkin, 1942) and those of Abulcasis (936 - 1013 AD) who also refers to cases of epilepsy due to daemonic possession (Abulcasim, 1519). He will also make important observations on traumatic epilepsy, correctly associating fractures of the skull and brain compression with the malady (Africanus, 1536-1539). Masoudi (late 10th century AD) refers to epilepsy of traumatic origin by noting that an obstruction of the brain may be the result of a compression from a fracture of the skull accompanied by severe pain (Abbas, 1523), whereas Avicenna (981-1037 AD), one of the most influential scientists in the Middle ages, supports the theory of blockage of humors as a possible mechanism of epileptic convulsions (Avicenna, 1999).

Constantinus the African (1020–1087 AD), a translator of Greek medical and Islamic texts, advises the parents of epileptics to take the patient to church during the second week following Whitsuntide (Pentecost) and expose them to the Friday or Saturday Mass (Temkin, 1971d).

#### **2.4 Physicians of the Western Europe**

Among the most influential physicans are Arnold of Villanova, famous physician, alchemist and magician, Bernard of Gordon, a teacher in Montpellier from 1285 to 1307, and John of Gaddesden, physician to Edward II of England. Arnold of Vilanova (1240 - 1311), perpetuates superstitious views emphasizing the depedence of the disease on the star constellations and especially the moon. (Vilanova, 1585b). He also notices that 'the true epilepsy is engendered with phleghm; spurious epilepsy by black bile mixed with phlegm' (Vilanova, 1585a). Bernard of Gordon (1303) suggested as therapy that a priest should recite a Gospel passage, which it should be written down to be carried by the patient as an amulet (Gordon, 1542). John of Gaddesden (1280-1361 AD) distinguishes three forms of epilepsy: minor, medium and major assigning the synonyms true, truer and truest. Minor epilepsy is attributed to the obstruction of arteries, medium epilepsy to the obstruction of the nerves and major to an obstruction of the ventricles of the brain (Gaddesden, 1595). Giovanni Michele Savonarola of Padova (1385 – 1466 AD) adopts a similar classification with different

epilepsy. The three wise men from the biblical tale of Jesus' birth also had a reputation as patrons of epilepsy mainly because they fell down before the divine child and offered gifts (Kerler, 1905). On the other hand, the Greek Orthodox Church has the example of St. Tychonas

Once should also note the views of famous byzantine physicians such as Oribasius of Pergamum, Aetius Amidenus, Alexander of Tralles and Paulus of Aegina on epilepsy. Overall, byzantine doctors recapitulate the theories of Ancient Greek physicians and further systemize the nosology of the disease by reporting interesting cases of epileptic patients. It is of note, though, that Alexander of Tralles (525-605 AD), in his treatise *Twelve books on Medicine*, takes an orthologic approach considering epilepsy a brain disturbance and reject extreme procedures such as trephinization (Tralles, 1878). Paulus of Aegina (7th century AD), according to Economou and Lascaratos, was the first Byzantine doctor who provided a clinical description of the epileptic fits, and also described a clinical condition that resembles

Arab doctors seem also to recapitulate the theories of Galen and Hippocrates without making any significant progress. Interesting descriptions of epileptic seizures can be found in the texts of Rhazes (Temkin, 1942) and those of Abulcasis (936 - 1013 AD) who also refers to cases of epilepsy due to daemonic possession (Abulcasim, 1519). He will also make important observations on traumatic epilepsy, correctly associating fractures of the skull and brain compression with the malady (Africanus, 1536-1539). Masoudi (late 10th century AD) refers to epilepsy of traumatic origin by noting that an obstruction of the brain may be the result of a compression from a fracture of the skull accompanied by severe pain (Abbas, 1523), whereas Avicenna (981-1037 AD), one of the most influential scientists in the Middle ages, supports the theory of blockage of humors as a possible mechanism of epileptic

Constantinus the African (1020–1087 AD), a translator of Greek medical and Islamic texts, advises the parents of epileptics to take the patient to church during the second week following Whitsuntide (Pentecost) and expose them to the Friday or Saturday Mass

Among the most influential physicans are Arnold of Villanova, famous physician, alchemist and magician, Bernard of Gordon, a teacher in Montpellier from 1285 to 1307, and John of Gaddesden, physician to Edward II of England. Arnold of Vilanova (1240 - 1311), perpetuates superstitious views emphasizing the depedence of the disease on the star constellations and especially the moon. (Vilanova, 1585b). He also notices that 'the true epilepsy is engendered with phleghm; spurious epilepsy by black bile mixed with phlegm' (Vilanova, 1585a). Bernard of Gordon (1303) suggested as therapy that a priest should recite a Gospel passage, which it should be written down to be carried by the patient as an amulet (Gordon, 1542). John of Gaddesden (1280-1361 AD) distinguishes three forms of epilepsy: minor, medium and major assigning the synonyms true, truer and truest. Minor epilepsy is attributed to the obstruction of arteries, medium epilepsy to the obstruction of the nerves and major to an obstruction of the ventricles of the brain (Gaddesden, 1595). Giovanni Michele Savonarola of Padova (1385 – 1466 AD) adopts a similar classification with different

of Cyprus who was considered to have cured many possessed people.

**2.3 Byzantine and Arab physicians** 

*status epilepticus* (Economou & Lascaratos, 2005).

convulsions (Avicenna, 1999).

**2.4 Physicians of the Western Europe** 

(Temkin, 1971d).

terms: primitive, antecedent and conjoint (Savonarola, 1547), as well as Matthaeus Platearius in his *Practica brevis* adding two clinical varieties that are distinguised as 'maior and 'minor' epilepsy (i.e., grand mal and petite mal) (Serapion, 1530).
