Cureus. 2021 Mar; 13(3): e13953.
Published online 2021 Mar 17. doi:
10.7759/cureus.13953
PMCID: PMC8051941
PMID: 33880289
The History of Epilepsy: From
Ancient Mystery to Modern Misconception
Monitoring Editor: Alexander
Muacevic and John R Adler
Christian M Kaculini,1 Amelia J
Tate-Looney,2 and Ali Seificorresponding author1
Author information Article notes
Copyright and License information PMC Disclaimer
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Abstract
Epilepsy is an ancient disease,
which has fascinated and frightened scientists and laymen alike. Before the
working knowledge of the central nervous system, seizures were shrouded in
mystery. In antiquity, this disease was accredited to gods and demonic possession,
causing those with epilepsy to be feared and isolated. Epilepsy patients
continued to face discrimination through the mid-20th century. This
discrimination ranged from lack of access to health insurance, jobs, and
marriage equality to forced sterilizations. Despite the strides that have been
made, there are still many misconceptions globally regarding epilepsy. Studies
show that patients with epilepsy in communities that understand the pathology
and cause of seizures are generally more successful in social and educational
environments. While there has been progress, there is more work which needs to
be done to educate people across the globe about the pathology of epilepsy.
Keywords: epilepsy, historical
medicine, social stigma, seizure, babylonia, ancient greece
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Introduction and background
Epilepsy as defined by the
International League Against Epilepsy (ILAE) is a disease of the brain that
results in at least two unprovoked seizures at least 24 hours apart. A person
may also be diagnosed with epilepsy if they have one unprovoked seizure and
have a high chance (>60%) of having another seizure within the next 10 years
or if they have an epilepsy syndrome [1]. Epilepsy is a disease historically
associated with evil spirits and mystery, and still to this day often carries
social stigmas [2]. Its long history, along with its social implications, makes
epilepsy a unique disorder. This review will discuss epilepsy’s extensive
history as well as how societal perceptions of people with epilepsy have
evolved over time.
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Review
Ancient history
The Akkadian Empire (/əˈkeɪdiən/)[4] was the first known ancient empire of Mesopotamia, succeeding the long-lived civilization of Sumer. Centered on the city of Akkad (/ˈækæd/)[5] and its surrounding region, the empire would unite Akkadian and Sumerian speakers under one rule and exercised significant influence across Mesopotamia, the Levant, and Anatolia, sending military expeditions as far south as Dilmun and Magan (modern United Arab Emirates, Saudi Arabia, Bahrain, Qatar and Oman) in the Arabian Peninsula.[6][page needed]
The Akkadian Empire reached its political peak between the 24th and 22nd centuries BC, following the conquests by its founder Sargon of Akkad. Under Sargon and his successors, the Akkadian language was briefly imposed on neighboring conquered states such as Elam and Gutium. Akkad is sometimes regarded as the first empire in history, though the meaning of this term is not precise, and there are earlier Sumerian claimants.[7][8]
Epilepsy's long history can be
traced back to a 4000-year-old Akkadian tablet found in Mesopotamia; inscribed
on it is a description of a person with "his neck turning left, hands and
feet are tense, and his eyes wide open, and from his mouth froth is flowing
without him having any consciousness" [2]. Nearly a millennium later, the
Late Babylonians wrote a diagnostic manual entitled, Sakikku, which included
texts describing epilepsy (Figure (Figure1).1). In this guide, the Babylonians
describe several seizure types and categorized them based on their
presentation. They also had some understanding of prognostics, as the text
detailed different outcomes depending on the type of seizure, including poor
outcomes in status epilepticus, as well as post-ictal states in other seizure
types. This tablet further described terms relating to epilepsy such as miqtu
(fall), hayyatu (fit), and sibtu (seizure) [3]. This rudimentary nomenclature
further underlines that the ancient world had some understanding of epilepsy.
Due to the belief that these episodes of rapid contractions were caused by evil
spirits invading the body, the treatment often involved spiritual intervention
[4].
Figure 1
An external file that holds a
picture, illustration, etc.
Object name is
cureus-0013-00000013953-i01.jpg
Tablet 26 of a series of 40 which
compose the ancient Babylonian diagnostic manual entitled Sakikku which
translates to "all diseases".
Sakikku is organized into six
chapters and tablet 26 is the first in the chapter about epilepsy. It describes
the symptoms of epilepsy and the different types of epileptic presentations
[5].
Tablet BM47753. Neo-Babylonian
Period. Courtesy of the British Museum, London.
Evidence of epilepsy has also been
found in ancient Egypt, as indicated by the Edwin Smith Surgical Papyrus
written circa 1700 BC. It describes several accounts of epilepsy, one of which
is of particular interest. The Egyptians documented a case in which direct
stimulation of the brain resulted in a physiologic response. The case described
a man with "a gaping wound in his head" and when the wound was
palpated, the man would "shudder exceedingly" [6]. Distinguishing
themselves from the Mesopotamians, who believed spirits and gods were the cause
of seizures, the Egyptians proved that seizures can be caused by cortical
disruption. Documentation of epilepsy is also found in Chinese texts, dating to
approximately 770-221 B.C. A group of physicians published The Yellow Emperor’s
Classic of Internal Medicine, Huang Di Nei Ching, which outlined generalized
seizures. In 610 A.D, Cao Yuan Fang was thought to have classified and
categorized epilepsy. Traditional principles of Yin Yang Wu Xing were employed
to treat epilepsy, consisting of herbs, massage, and acupuncture [7].
Epilepsy's spiritually based
pathophysiology remained largely unchallenged until around the 5th century BC,
when the School of Hippocrates in Greece hypothesized that the brain might be
the root cause of epilepsy. Hippocrates believed that the Sacred Disease
(epilepsy), was no more divine than other diseases, but was named
"sacred" due to its unique and inexplicable characteristic
appearance. He also hypothesized that epilepsy could be cured like other
diseases, though once it becomes chronic, it was no longer curable [6].
Hippocrates was also one of the first to introduce the concept of
post-traumatic epilepsy; through his observations of head trauma, he observed
convulsions which were always contralateral to the head wound [6].
In essence, Hippocrates was among
the earliest to attribute epilepsy to the brain and to suggest that it is
hereditary rather than contagious. He described its clinical presentation as
unilateral motor signs with an aura, which could serve as a warning signal that
allowed them to immediately leave the public to convulse. During this time, it
was widely accepted that epilepsy was caused by spirits, which played a role in
the social stigma surrounding epilepsy [6]. He attributed society's
misunderstanding and reaction to epilepsy as a result of divine fear which
society had built around this disease [6]. Hippocrates was one of the first to
explain a non-spiritual basis for epilepsy, but unfortunately, his hypothesis
had little influence over the supernatural belief for many centuries to come.
This stigma surrounding seizures,
and the misunderstanding of their origins, caused noteworthy impacts on
society’s view of epilepsy throughout history. Aristotle, a notable philosopher
of the 4th century BC, hypothesized that epilepsy and sleep were due to similar
mechanisms. In his work, On Sleeping and Waking, he theorized that sleep was
caused by the evaporations resulting from consuming food, which would
subsequently rise and fall in the veins. He extended this hypothesis to the
process occurring when one convulsed and thought this was the mechanism that
caused epilepsy to affect levels of consciousness [8]. In later years, his
ideas were considered indisputable by the Catholic Church and would influence
the scientific community for centuries. Even famous physicians like Galen
included Aristotle's ideas of vapors in his works [6].
The Hippocratic idea that epilepsy
was a brain disorder finally began to gain traction in Europe beginning in the
17th century and continuing through the millennium [4]. Samuel Tissot
(1728-1797), a prevalent Swiss physician, published Traité de l’épilepsie in
1770 [9]. A decade later he published a four-volume text entitled Traite des
Nerfs et du leurs Maladies, which cemented him as a prominent medical figure in
the enlightenment period. William Cullen (1710-1790), a Scottish physician,
outlined the fact that seizures could occur in parts of the body, and did not
inherently have to result in loss of consciousness [10,11]. During the same
era, French physician Maisonneuve (1745-1826) began emphasizing the need to
hospitalize patients with epilepsy [12,13]
In 1849, Dr. Robert Bentley Todd
introduced the idea that the brain functions through an electrical force and
hypothesized that “electrical discharges” in the brain may be the cause of
seizures [4,14]. He later confirmed his hypothesis using Michael Faraday's
magnetoelectric rotation machine on rabbits [15]. John Hughlings Jackson
(1835-1911) laid the scientific foundation for epileptology, as well as studied
the localization of lesions which could produce seizures [12,16]. He published
the influential text, “Study of Convulsion” which was the culmination of his
scientific findings. Around 80 years later, Hans Berger invented the human
electroencephalogram, which allowed him to confirm that convulsions were the
result of abnormal electrical activity in the brain [4]. In 1935, William Lenox
demonstrated that there was no change in cerebral blood flow in patients during
a seizure, finally dismantling the pervasive belief of a vascular etiology for
epilepsy. He also demonstrated abnormal electrical changes before convulsions
which increased during a seizure, which he proposed as the new etiology for
epilepsy [17].
Societal perception of epilepsy
Clinically, the presentation of a
seizure can be sudden and dramatic, which may elicit fear in people. The
mystery behind the cause of seizures has been debated for millennia, and many
theories and misconceptions have led to profound social consequences for people
with epilepsy. Throughout most of history, seizures were thought to be caused
by evil spirits invading the body, which required exorcism or other religious
and spiritual remedies (Figure (Figure2)2) [4].
Figure 2
An external file that holds a
picture, illustration, etc.
Object name is
cureus-0013-00000013953-i02.jpg
Saint Severin curing a woman of
the 'falling sickness demon'.
Meister des Heiligen Severin.
Circa 1300. Courtesy of the Museum Horne Foundation, Florence.
From ancient to relatively modern
times, people with epilepsy have been disenfranchised and the subject of
discrimination. Until the mid 20th century, in the United States of America,
many states prohibited people with epilepsy to get married, and some even
encouraged eugenic sterilization [4,18]. Many public facilities, including
restaurants, had the right to deny service to people with epilepsy until the
1970s [19]. These discriminatory laws further stigmatized people with epilepsy.
Even in recent years, many developing countries continue to perceive epilepsy
to be a result of evil or ancestral spirits. In these areas, it is common for
the patient and their family to usually see a traditional healer first and
follow their treatment recommendations. Epileptic patients often face stigma,
which may discourage them from seeking the treatment they need [4]. In some
countries, a patient can have symptomatic epilepsy for 6-14 years before
seeking modern medical care [4]. Finally, in the late 20th century, several international
societies were formed to promote both the scientific and social knowledge of
epilepsy. In 1997 the International League Against Epilepsy, the International
Bureau of Epilepsy, and the World Health Organization focused their objectives
on addressing political and public awareness of epilepsy to reduce stigma and
to improve treatment [4].
Modern day patients with epilepsy
often face civil rights violations. One example is the unequal access to health
and life insurance they may encounter. Another is how people with epilepsy
often are discriminated against by employers, frequently causing them to choose
a different occupation altogether. This is often seen in "hands-on"
professions, such as firefighters or construction workers, despite the fact
that accommodations from employers should be available under the Americans with
Disabilities Act [20]. An epilepsy diagnosis can impact employment options and
the number of employers which will hire them, even when the individual is fully
capable of the job. People with epilepsy are often dissuaded from pursuing
certain professions because of the speculated consequences of epilepsy. Several
countries in Europe still have job restrictions based on a diagnosis of
epilepsy despite many worldwide reports of low accident rates in people with
epilepsy [21]. These civil rights violations extend to their autonomy,
resulting in limitations in legal agreements, such as marriage, in some
countries. Until the passage of the Affordable Care Act, many health insurance
companies in the United States could deny coverage based on pre-existing
conditions, and in 2005 as many as 36% of people diagnosed with epilepsy were
refused one or more types of insurance because of their epilepsy [22].
People with epilepsy can be
subjected to social ostracism, both directly and indirectly. There is a growing
body of evidence that a strong social support system is directly correlated
with well-being [23]. According to the Epilepsy Foundation, parents often felt
that their journey after their child’s diagnosis was a challenge to navigate,
citing difficulties seeing a specialist, financial strain due to medical care,
and lack of opportunities for their children due to challenging behavior [24].
Often, those with epilepsy tend to be more isolated than those without,
resulting in diminished well-being. Even as early as childhood, people with
epilepsy begin showing signs of social issues, stemming from lack of inclusion
[25]. This social isolation after a childhood diagnosis can negatively impact
self-esteem and academic performance [4]. An example of how those with epilepsy
become unintentionally isolated is how social gatherings require
transportation, and in areas where public transportation is limited, patients
with epilepsy can be excluded socially due to their ineligibility to obtain a
driving license. There is evidence that people with epilepsy suffer from higher
rates of depression, anxiety, psychosis, and attention-deficit hyperactivity
disorder (ADHD) than the general population, indicating that this disconnect
from society can lead to harmful downstream effects [26,27]. According to a
longitudinal study by Berg et al. seizure course (akin to severity of seizure
examine from childhood to young adulthood) influenced completion of college,
employment, and driving, which further impacts employment opportunities [28].
This may cause socioeconomic impact, due to a combination of diminished access
to the job market, and in the United States of America, lack of health
insurance due to joblessness. Due to increased risk of mental health
conditions, compounded with the issues discussed above, those with epilepsy
were more likely to have a lower annual income and were more likely to be
unemployed [29,30]. The more direct effects of ostracism can be seen in
developing countries, where there are commonly held misconceptions that
epilepsy is contagious. Some believe contact with saliva or the person during a
seizure can cause transmission. This leads to social isolation and further
abandonment during a seizure, which increases the likelihood of a
seizure-related injury [31].
Societal knowledge and perception
of epilepsy have been directly correlated to the successful treatment of
epilepsy. Hirfanoglu et al. found a correlation between familial understanding
of the disease after their child’s diagnosis and fewer depressive symptoms and
the better use of anti-epileptic drugs (AEDs) [32]. A similar effect was
observed in urban secondary schools in northern India, where the more
knowledgeable students were about epilepsy, the less discrimination students
with this condition face [33]. These studies (and beyond) indicate that the
more that is known about epilepsy and what causes it, the better patients with
the disease are incorporated into society, and outcomes and seizure management
improve. In essence, the more that is understood about epilepsy by the public,
the better the lives are for people with epilepsy.
Modern treatment of epilepsy
At the turn of the 19th century,
pharmacologic treatment of epilepsy began to gain traction. In 1912, Alfred
Hauptmann discovered the anticonvulsant properties of phenobarbital, one of the
most commonly prescribed medications for epilepsy worldwide today [34].
Numerous AEDs were introduced in the following decades including ethosuximide,
carbamazepine, valproate, and several benzodiazepines. Today, AEDs are usually
the first-line treatment for epilepsy and selected based on the type of seizure
one has as well as the patient’s other pertinent medical history. For seizures
that are refractory to AEDs, patients can be offered alternative treatments
including trying a ketogenic diet, vagus nerve stimulation, or surgery [4].
These modern advancements in the treatment of epilepsy have undoubtedly helped
patients with epilepsy live a more normal life.
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Conclusions
While the pathophysiology,
diagnostics, and treatment have evolved over the last 3000 years, globally, the
societal perceptions have largely remained the same. Due to modern medicine and
the work of scientists and physicians for millennia, epilepsy can be safely
managed, and most patients with the disease can live full and normal lives.
There is a direct correlation between society's understanding of epilepsy, and
outcomes and wellbeing of patients who have it. Unfortunately, there is still
much to be done in regard to the global public perception of the disease, as
well as public access to resources.
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Notes
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organizations. Cureus is not responsible for the scientific accuracy or
reliability of data or conclusions published herein. All content published
within Cureus is intended only for educational, research and reference
purposes. Additionally, articles published within Cureus should not be deemed a
suitable substitute for the advice of a qualified health care professional. Do
not disregard or avoid professional medical advice due to content published
within Cureus.
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Footnotes
The authors have declared that no
competing interests exist.
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