**1. Introduction**

130 Novel Aspects on Epilepsy

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#### **1.1 First reports on epilepsy**

The history of epilepsy is intervened with the history of humanity. One of the first descriptions of epileptic seizures can be traced back to 2,000 B.C. in ancient Akkadian texts, a language widely used in the region of Mesopotamia. The author described a patient with symptoms resembling epilepsy:

> *his neck turns left, his hands and feet are tense and his eyes wide open, and from his mouth froth is flowing without having any conciousness.*

The exorciser diagnosed the condition as *'antasubbû'* (the hand of Sin) brought about by the god of the moon (Labat, 1951).

Later reports on epilepsy can also be found in Ancient Egyptian medical texts. The Edwin Smith surgical papyrus (1700 B.C.) refers to epileptic convulsions in at least five cases (cases 4, 7, 29, 40, 42). Descriptions of epilepsy can also be found in ancient babylonian texts; epileptics are thought to be afflicted by evil spirits. (Longrigg, 2000). The *Sakikku,* one of the oldest Babylonian medical texts (1067-1046 B.C.), refers to epilepsy with the terms *'antasubba'* and *'miqtu'1*. The translated babylonian text describes unilateral and bilateral epileptic fits, the epileptic cry, the incontinence of feces, the description of simple and complex epileptic seizures, the epileptic aura and narcolepsy (Eadie & Bladin, 2001). The Hamurabbi code (1790 B.C.) also refers to epilepsy. The code states that a slave could be returned and the money refunded, if *bennu*, another word for epilepsy (Stol, 1993), appeared within the month after the purchase. In Indian medicine, Atreya attributed epilepsy to a brain dysfunction and not to divine intervention. In the *Caraka Saṃhitā Sutra*  (6th century B.C.), he defines epilepsy as:

*"paroxysmal loss of consciousness due to disturbance of memory and [of] understanding of mind attented with convulsive seizures"* (Pirkner, 1929).

In the Indian text, four different kinds of epilepsy are descibed along with a description of premonitory symptoms and a type of epilepsy called '*Abasmara*', in which the patients lose their memories.

<sup>1</sup> One can easily note the similarity between the Akkadian word *antasubbû* and the Babylonian *antasubba*

Hallmarks in the History of Epilepsy: From Antiquity Till the Twentieth Century 133

*unless by long lapse of time it be so ingrained as to be more powerful than the remedies that are* 

Hippocrates was also the first who attempted a scientific approach toward the study of epilepsy by suggesting possible etiology and therapy for the disease. He was the first to attibute the etiology of epilepsy to brain disfunction (Hippocrate, 1849a), stressing the role of heredity in the disease. Among others, Hippocrates will describe the disease accurately, including its unilateral nature and the symptoms of aura (Hippocrate, 1849d). Hippocrates calls epilepsy the "great disease", the originator of the term 'grand mal.' He also describes symptoms reminiscent of psychomotor epilepsy and temporal lobe fits (Hippocrate, 1849e). The view of Hippocrates for the origin of epileptic convulsions and their association with life in utero is also interesting. He states unequivocally that "its birth begins in the embryo while it is still in the womb" (Hippocrate, 1849h). Among the predispositionary factors that can lead to a epileptic fit are: (a) the changes of the winds and of temperature, (b) the exposition of the head to sun, (c) crying, and (d) fear. Prognosis is also worse, when the disease is manifestated in early age (Hippocrate, 1849g), but, for older people, the prognosis is better (Hippocrate, 1849f). In his other treatise, *Injuries of the Head,* Hippocrates notes that head injuries often lead

Medicine in the post-Hippocratic era did not make important achievements as far as the treatment of the disease is concerned. Diocles of Carystus employed the use of various remedies such as phlebotomy, whereas Praxagoras of Cos prescribed extreme remedies such

On the other hand, Plato (428/427 BC - 348/347 BC), in his *Laws*, suggests specific punishment for people selling slaves with epilepsy, in parallel with the Hamurabi code of the Babylonians (Plato, 1871).During the Roman period, the proceedings of the Senate were interrupted or postponed, whenever a senator was struck by epilepsy during a session because epilepsy was considered a bad sign from the Gods. For that reason Romans called epilepsy *morbus comitialis*, since an epileptic attack tended to spoil the day of the *comitia,* the

to convulsions, introducing the idea of traumatic epilepsy (Hippocrate, 1849i).

Fig. 1. Hippocrates of Kos (460 BC – ca. 370 BC)

as the cauterization (Drabkin, 1950).

assembly of the people.

**1.4 Epilepsy in Alexandrian and Roman medicine** 

*applied"* (Hippocrate, 1849b)

### **1.2 Epilepsy in ancient Greece: the era before Hippocrates**

The nosological entity of epilepsy is found under many names in Ancient Greek texts: seliniasmos (*σεληνιασμός*), sacred disease, Herculian disease (because it affected the semi-god Hercules) or demonism. After all, the word 'epilepsy' (επιληψία) originates from the Greek verb "epilambanein" (*επιλαμβάνειν*), which means 'to seize, possess, or afflict'. The disease was initially called sacred, because of the belief for its divine origin. In his work *Lithica,*  Orpheus describes eloquently the vengeance of Mene, goddess of the Moon, in the form of epilepsy (Gottfried et al., 1805):

> *".... to prove them sufferers from the sacred ill For quickly will they bend and forwards tilt, As to earth it draws them. Smeared by froth From their own mouths, hither and tither will they turn, And wallow on the ground. For filled with anger towards them She laughs to see their woe, Mene, the horrid and swift"*

Ancient Greeks considered epilepsy to be a *'miasma*'2 (*μίασμα*) which was cast upon the soul. Considered a divine punishment for sinners, an aura of mysticism and superstition surrounded epilepsy; the disease was connected with *Selene* (*Σελήνη*), the goddess of the Moon, since people who offended her were afflicted with epilepsy. Depending on the special symptoms of the epileptic seizure, the Greeks would attribute the fits to a different deity such as Cybele, Poseidon, Mars, Hekate, Hermes or Apollo. According to the Hippocratic texts, for example, if the symptoms included teeth gnashing or convulsions on the right side, then epilepsy was attributed to Cybele, whereas if the patient screamed like a horse, then god Poseidon was to blame (Hippocrate, 1849c).

According to Plutarch (50-120 A.D.), all babies in ancient Sparta were examined by the '*Lesche*' (*Λέσχη*), a council of the elder of Sparta; epileptic babies were left to Apothetae, a short chasm of the mountain Taygetus (Plutarch, 1914). Heracletus of Ephesus (535–475 B.C) makes the first reference to the term 'sacred disease', however, not for describing epileptic seizures (Laertius, 1853). Alcmaeon of Croton (6th B.C.) was the first of the Greek physicians to ascertain that the brain was the organ where '*hegemonicon*' (*ηγεμονικόν*)3 is founded, the source of memory and thoughts (Diels, 1906). Democritus of Abdera (5th B.C.) wrote a book on epilepsy (*Περί επιληψίας*) which now is extinct, suggesting that the brain is the center of the soul and that cognition and senses were one and the same, originating from the same force (Plutarch, 1888). Herodotus of Hallicarnassus (484 - 425 B.C.), the father of history, in the third book of his work *The Histories* (Thaleia) indirectly refers to epilepsy afflicting the Persian King Cambyses II, whose erratic behavior, according to Herodotus, could be attributed either to the retribution of an aggrieved god or to the so-called 'sacred disease'. Herodotus also noticed the hereditary nature of the disease (*εκ γενεής*) (Herodotus, 2000).

#### **1.3 Epilepsy in the Hippocratic corpus**

The first formal description of epilepsy as a disease should be attributed to the father of medicine, Hippocrates of Kos, in his classic treatise *On the sacred disease* (Περί ιερής νούσου). In this book, Hippocrates disputes the divine origin of epilepsy by saying:

*"This disease is in my opinion no more divine than any other; it has the same nature as other diseases, and the cause that gives rise to individual diseases. It is also curable, no less than other illnesses,* 

<sup>2</sup> Miasma: a greek word for pollution, a noxious form of 'bad air'

<sup>3</sup> Hegemonicon comes from the word hegemon which means sovereign.

The nosological entity of epilepsy is found under many names in Ancient Greek texts: seliniasmos (*σεληνιασμός*), sacred disease, Herculian disease (because it affected the semi-god Hercules) or demonism. After all, the word 'epilepsy' (επιληψία) originates from the Greek verb "epilambanein" (*επιλαμβάνειν*), which means 'to seize, possess, or afflict'. The disease was initially called sacred, because of the belief for its divine origin. In his work *Lithica,*  Orpheus describes eloquently the vengeance of Mene, goddess of the Moon, in the form of

*".... to prove them sufferers from the sacred ill For quickly will they bend and forwards tilt, As to earth it draws them. Smeared by froth From their own mouths, hither and tither will they turn, And wallow on the ground. For filled with anger towards them She laughs to see their woe, Mene, the horrid and swift"*  Ancient Greeks considered epilepsy to be a *'miasma*'2 (*μίασμα*) which was cast upon the soul. Considered a divine punishment for sinners, an aura of mysticism and superstition surrounded epilepsy; the disease was connected with *Selene* (*Σελήνη*), the goddess of the Moon, since people who offended her were afflicted with epilepsy. Depending on the special symptoms of the epileptic seizure, the Greeks would attribute the fits to a different deity such as Cybele, Poseidon, Mars, Hekate, Hermes or Apollo. According to the Hippocratic texts, for example, if the symptoms included teeth gnashing or convulsions on the right side, then epilepsy was attributed to Cybele, whereas if the patient screamed like a

According to Plutarch (50-120 A.D.), all babies in ancient Sparta were examined by the '*Lesche*' (*Λέσχη*), a council of the elder of Sparta; epileptic babies were left to Apothetae, a short chasm of the mountain Taygetus (Plutarch, 1914). Heracletus of Ephesus (535–475 B.C) makes the first reference to the term 'sacred disease', however, not for describing epileptic seizures (Laertius, 1853). Alcmaeon of Croton (6th B.C.) was the first of the Greek physicians to ascertain that the brain was the organ where '*hegemonicon*' (*ηγεμονικόν*)3 is founded, the source of memory and thoughts (Diels, 1906). Democritus of Abdera (5th B.C.) wrote a book on epilepsy (*Περί επιληψίας*) which now is extinct, suggesting that the brain is the center of the soul and that cognition and senses were one and the same, originating from the same force (Plutarch, 1888). Herodotus of Hallicarnassus (484 - 425 B.C.), the father of history, in the third book of his work *The Histories* (Thaleia) indirectly refers to epilepsy afflicting the Persian King Cambyses II, whose erratic behavior, according to Herodotus, could be attributed either to the retribution of an aggrieved god or to the so-called 'sacred disease'. Herodotus also noticed the hereditary nature of the disease (*εκ γενεής*) (Herodotus, 2000).

The first formal description of epilepsy as a disease should be attributed to the father of medicine, Hippocrates of Kos, in his classic treatise *On the sacred disease* (Περί ιερής νούσου).

*"This disease is in my opinion no more divine than any other; it has the same nature as other diseases, and the cause that gives rise to individual diseases. It is also curable, no less than other illnesses,* 

In this book, Hippocrates disputes the divine origin of epilepsy by saying:

2 Miasma: a greek word for pollution, a noxious form of 'bad air' 3 Hegemonicon comes from the word hegemon which means sovereign.

**1.2 Epilepsy in ancient Greece: the era before Hippocrates** 

horse, then god Poseidon was to blame (Hippocrate, 1849c).

**1.3 Epilepsy in the Hippocratic corpus** 

epilepsy (Gottfried et al., 1805):

*unless by long lapse of time it be so ingrained as to be more powerful than the remedies that are applied"* (Hippocrate, 1849b)

Hippocrates was also the first who attempted a scientific approach toward the study of epilepsy by suggesting possible etiology and therapy for the disease. He was the first to attibute the etiology of epilepsy to brain disfunction (Hippocrate, 1849a), stressing the role of heredity in the disease. Among others, Hippocrates will describe the disease accurately, including its unilateral nature and the symptoms of aura (Hippocrate, 1849d). Hippocrates calls epilepsy the "great disease", the originator of the term 'grand mal.' He also describes symptoms reminiscent of psychomotor epilepsy and temporal lobe fits (Hippocrate, 1849e). The view of Hippocrates for the origin of epileptic convulsions and their association with life in utero is also interesting. He states unequivocally that "its birth begins in the embryo while it is still in the womb" (Hippocrate, 1849h). Among the predispositionary factors that can lead to a epileptic fit are: (a) the changes of the winds and of temperature, (b) the exposition of the head to sun, (c) crying, and (d) fear. Prognosis is also worse, when the disease is manifestated in early age (Hippocrate, 1849g), but, for older people, the prognosis is better (Hippocrate, 1849f). In his other treatise, *Injuries of the Head,* Hippocrates notes that head injuries often lead to convulsions, introducing the idea of traumatic epilepsy (Hippocrate, 1849i).

Fig. 1. Hippocrates of Kos (460 BC – ca. 370 BC)

#### **1.4 Epilepsy in Alexandrian and Roman medicine**

Medicine in the post-Hippocratic era did not make important achievements as far as the treatment of the disease is concerned. Diocles of Carystus employed the use of various remedies such as phlebotomy, whereas Praxagoras of Cos prescribed extreme remedies such as the cauterization (Drabkin, 1950).

On the other hand, Plato (428/427 BC - 348/347 BC), in his *Laws*, suggests specific punishment for people selling slaves with epilepsy, in parallel with the Hamurabi code of the Babylonians (Plato, 1871).During the Roman period, the proceedings of the Senate were interrupted or postponed, whenever a senator was struck by epilepsy during a session because epilepsy was considered a bad sign from the Gods. For that reason Romans called epilepsy *morbus comitialis*, since an epileptic attack tended to spoil the day of the *comitia,* the assembly of the people.

Hallmarks in the History of Epilepsy: From Antiquity Till the Twentieth Century 135

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

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

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

in turn melted the human brain and provoked the attack (Temkin, 1971c).

probably symptoms of epileptic seizure (d'Orsi & Tinuper, 2006).

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

**2.2 Epilepsy and the catholic church** 

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

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

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' (Aretaeus, 1856b).

Soranus of Ephesus (1st/2nd century AD) also referred to epilepsy without making any contribution to the understanding of the disease.
