Short History of Epilepsy1

Ayurveda refers to epilepsy in the Charaka Samhita (1000–500 BC) as “Apasmara” and mentions several kinds of seizures, which are comparable to the present day clinical description. The cause of epilepsy is traced to the vitiation of three basic factors “Vata, Pitta, and Kapha” and the treatment consists in correction of these “Doshas”. Hippocrates of Kos (460–370 BC) referred to as the “Father of Medicine” made major contributions for understanding of epilepsy. At his time, epilepsy was considered a “sacred disease” probably because famous people like Alexander the Great and Julius Caesar had this disease in spite of their great military and leadership qualities. Hippocrates, in his treatise on “Sacred Disease”, declared epilepsy as a natural disease and traced its origin to the brain. He mentioned “it is thus with regard to the disease called sacred. It appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from the originates like other affections. Men regard its nature and cause as divine from ignorance and wonder because it is not at all like other diseases. And, this notion of its divinity is kept up by their inability to comprehend it”.¹

Hippocrates examined the skulls of people with epilepsy (PWE), which had holes in them probably to drive away the evil spirits. After examining the brains of such people, he came to the conclusion that the brain must be the organ responsible for seizures. However, Hippocrates believed that the disturbance of bodily (and brain) humors was responsible for causing2 seizures and the treatment he suggested was correction of this humoral imbalance.

Several centuries after Hippocrates, the Greek Physician Claudius Galen (130–210 AD), who founded his school in Rome, accepted the Hippocratic concept of brain as the seat of epilepsy. Galen's theory on pathophysiology of diseases including epilepsy rested on the basis of bodily humors and the treatment consisted of their correction with diet, bloodletting, and other procedures. Galen classified epilepsy as “idiopathic” meaning caused by brain humors and “sympathetic” referring to other irritating factors. Both the schools of Hippocrates and Galen considered epilepsy as a major disease and called it “morbus sacer” and “morbus divus”. The influence of these schools of ancient Greek medicine lasted for several generations but lost their significance over the succeeding centuries probably because of the lack of treatment against epileptic seizures. For centuries, PWE were at the mercy of faith healers and sorcerers of various kinds. Probably because of this situation, there is practically no mention on epilepsy in the history of medicine for the next 1,500 years.²

The modern history of epilepsy can be traced to the early 19th century in West European countries, which more or less coincided with the Industrial Revolution and then spread rapidly to North America and other countries. A French Physician, Dominique Esquirol (1772–1840), classified epilepsy into “grand mal and petit mal” and differentiated epilepsy from psychiatric conditions. Two British neurologists, William Richard Gowers (1845–1915) and John Hughlings Jackson (1835–1911), made significant contributions toward understanding epilepsy as a functional disorder of the cerebral cortex. Around the first part of 19th century, neurology evolved itself into a separate medical discipline, away from psychiatry and internal medicine, depending upon the situation of the medical practice.

The clinical and scientific work of John Hughlings Jackson paved the way for the understanding of seizures as excessive neuronal discharge of brain hemisphere corresponding to the contralateral extremities, also in the form of “March of spasm”. His work on the “Study of Convulsions” was a pathbreaker in the direction of “Epileptology” becoming a subspecialty of neurology.

Jackson devoted a major part of his professional career of over 40 years for the study of epilepsy, which formed the basis for further studies by his contemporaries and neurologists3 of succeeding generations of 19th and 20th centuries. His definition that “epilepsy is the name for occasional, sudden, excessive, rapid, and local discharges of gray matter” holds good, particularly for focal epilepsies even today.³ The beginning of the 20th century noticed further publications related to epilepsy from several distinguished neurologists.

William Richard Gowers published in 1881 a monograph “epilepsy and other chronic convulsive diseases”. In 1907, he published his second book “The Borderland of Epilepsy” in which he referred to the differential diagnosis of other seizure-like conditions such as vertigo, vasovagal attacks, migraine, and narcolepsy. Gowers was known for his clinical accuracy and pathophysiology of epilepsy. His concept of “seizures beget seizures” has some clinical significance even today.

In 1924, Hans Berger (1873–1941), a German psychiatrist from the University of Jena, succeeded in recording the first human electroencephalogram (EEG), with which he had hoped to detect “the correlation between objective activity of the brain and subjective psychic phenomenon”. After initial disappointment, he published his paper “recording the electrical activity of the human brain from the surface of the head” in 1929.²

The medical profession, to begin with, was somewhat skeptical of Berger's invention, but after it was certified by American and British neurophysiologists, EEG was technically improved and fully accepted as the method of investigation in the diagnosis/differential diagnosis of epilepsy, which continues even today, however, in a much sophisticated form.

William Gordon Lennox (1884–1960) was an American neurologist and a leading personality in the further development of Epileptology. He is widely known because of his intensive clinical and EEG work on childhood encephalopathy known as “Lennox-Gastaut syndrome” described later by another pioneer Henri Gastaut. Lennox developed interest for epilepsy during his service as a missionary Doctor in China and after returning to USA, he intensified his work on the severe form of childhood epilepsy syndrome making widespread EEG studies along with his colleagues Stanley Cobb, Erna, and Frederic Gibbs.

Wilder Graves Penfield (1891–1976) was a famous Canadian neurosurgeon with multi-sided interest involving medicine, philosophy, and literature. In Epileptology, he is known for his pathbreaking work for surgically removing “epileptic neurons” where the seizures originate. Penfield operated patients on local anesthesia and before the operation he electrically stimulated the brain to observe the focus of origin of seizures in conscious patients. Along with Herbert Jasper, he published his leading book “Epilepsy and the Functional Anatomy of the Human Brain”. Penfield's work has provided considerable service for the succeeding generation of neurosurgeons, neurologists, and epileptologists. Penfield has published several books on neuroanatomy, neurosurgery, epilepsy, psychology, and philosophy.⁴

Henri Jean Pascal Gastaut (1915–1995) was a French neurologist who devoted his professional career in the service of Epileptology. He is widely known for the presentation of the Lennox–Gastaut syndrome, which he wished to publish in the name of William Lennox only, but the ILAE considering the efforts of Gastaut named the syndrome Lennox-Gastaut syndrome, under the initiative of Lennox's daughter Margaret Buchtal. Gastaut was actively involved in the activities of ILAE. He was the secretary general (1957–1969) and president (1969–1973) of ILAE. Gastaut is also known for the early classification of epileptic seizures and epilepsies by the ILAE, which has helped considerably in the clinical and EEG diagnosis/differential diagnosis of epilepsy.

Another important development was the foundation of the ILAE as early as in 1909, with the initiative of eminent neurologists like John Hughlings Jackson. The goal of ILAE is to promote worldwide research in the field of epilepsy for improving the lives of PWE. ILAE gives frequent guidelines for medical professionals like offering International Classification of epileptic seizures and epilepsies. It also runs the medical journal “Epilepsia”, which updates on epilepsy research and management. Much later in 1961, a second important organization, the International Bureau for Epilepsy (IBE), was founded by the initiatives of people like George Burden for the purpose of coordinating the social needs of PWE—on a worldwide basis. IBE has in its membership both medical professionals and the general public. IBE and ILAE work along with the World Health Organization (WHO) for a “Global Campaign against Epilepsy”.

Epileptology took strong roots in Europe and North America after World War II and spread rapidly to other countries. In 1912, a second important drug, phenobarbitone, was introduced, which considerably improved the prospects of antiepileptic therapy. Around the late 1960s, there were three more effective antiepileptic drugs—(1) phenytoin, (2) carbamazepine, and (3) sodium valproate. With these four drugs, about 70% of the PWE can be made seizure free. With the availability of more drugs, the quality of life can be improved with reduction of side effects and better seizure control. Medical technology made rapid advances with long-term videos—EEG, CT, MRI, and positron emission tomography (PET), which help in better diagnosis. Along with drug treatment, neurosurgery is helping PWE for further improvement of life. From an “incurable” condition of earlier centuries, epilepsy today is an eminently treatable neurological disorder, which, however, still carries a totally unjustifiable social prejudice.

During the recent history on epilepsy, much work is being done worldwide through the initiative of the two premier organizations, ILAE and IBE both in view of medical research and social aspects. The European Association of Epilepsy Centers (EAECs) started functioning in 1988 in Zurich and spread to other parts of Europe under the initiative of people like Christoph Pachlatko (1956–2015), Harry Meinardi (1932–2013), and others.

The purpose of this association is to emphasize the unique structure and function of these centers differentiating them from the usual neurological and neuropediatric hospitals/departments in way of offering comprehensive care to the PWE.⁶6

The European Forum on Epilepsy Research (ERF 2013), which started in Dublin, under the auspicious of ILAE and IBE, has identified the following projects on epilepsy research: (1) epilepsy in the developing brain, (2) novel targets for innovative diagnostics and treatment of epilepsy, (3) what is required for prevention and cure of epilepsy? and (4) epilepsy and comorbidities with focus on aging and mental health, with the motive to: (i) strengthen epilepsy research, (ii) reduce treatment gap, and (iii) reduce the burden and stigma associated with epilepsy.⁷

The IEA was affiliated to IBE in December 1974. Since then IEA chapters have grown all over India. The Bangalore chapter increased its membership rapidly with regular monthly meetings. Thanks to the dynamic leadership of KS Mani (1928–2001), whose inspiration leads the Bangalore chapter even today.