Sidiropoulou Et Al. 2010 - Epilepsy in Scientific Era2

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ARTICLE IN PRESS
YEBEH-02232; No. of pages: 12; 4C:
Epilepsy and Behavior xxx (2010) xxx–xxx
Contents lists available at ScienceDirect
Epilepsy and Behavior

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y e b e h
1 Review
2 Hallmarks in 18th- and 19th-century epilepsy research

3 K. Sidiropoulou, A. Diamantis, E. Magiorkinis ⁎
4 Office for the Study of History of Hellenic Naval Medicine, Naval Hospital of Athens, Athens, Greece
5
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a r t i c l e i n f o a b s t r a c t
6
7 Article history: The purpose of this study was to reveal the major views of the early scientific period (18th and 19th 23
8 Received 18 March 2010 centuries) on epilepsy as both a disease and a symptom. The shaping of thought about illness and medicine 24
9 Received in revised form 30 March 2010
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as a science, which began in the Renaissance and progressed into the Enlightenment, intensified during the 25
10 Accepted 2 April 2010
18th and 19th centuries. During this period of increasingly methodical investigation, researchers undertook a 26
11 Available online xxxx
thorough study of epilepsy. Renowned doctors of this period from the Dutch and German medical schools, 27
13
12
14
15 Keywords:
the “golden era” of French medicine, and British medicine, including, of course, John Hughlings Jackson, all 28
16 Epilepsy left their mark in this era of epilepsy research. Epidemiological studies using large patient data sets were 29
17 French medicine conducted for the first time, as was systematic research on the pathophysiological, pathological, neurological, 30
18
19
20
21
22
Dutch medicine
British medicine
John Hughlings Jackson
Convulsions
Epileptic fits
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and psychiatric aspects of the disease.
© 2010 Elsevier Inc. All rights reserved.
31
32
36 34
33
35
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38
37 Contents
39 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
40 2. The work of 18th-century physicians on epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
41 3. The 19th century: The “golden era” of French medicine and the contribution of the English school of physicians . . . . . . . . . . . . . . . 0
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42 3.1. The French medical school of the 19th century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

43 3.2. The British medical school of the 19th century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
44 3.3. The Dutch and German medical schools of the 19th century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
45 3.4. Therapies for epilepsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
46 4. The age of John Hughlings Jackson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
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47 5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
48 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
49
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50 1. Introduction large hospital facilities in France provided large patient data sets that 59
facilitated their research. 60
51 Important advances were made in epilepsy during the 18th and
52 19th centuries, when the science of medicine became emancipiated 2. The work of 18th-century physicians on epilepsy 61
53 from the restrictions of the Catholic Church and evolved from the
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54 theories developed during the Renaissance and Enlightment periods. The beginning of the 18th century is marked by the work of doctors 62
55 These advances would form a scientific basis on which medical of the Dutch medical school founded by Herman Boerhaave and his 63
56 research advanced during the next centuries. The main driving force in pupil Gerard van Swieten. Herman Boerhaave (1668–1738) (Fig. 1), 64
57 the area of epilepsy was the work of famous French doctors in the 19th doctor, botanist, and humanist, regarded as the founder of clinical 65
58 century in the fields of neurology and psychiatry; the establishment of teaching and the modern academic hospital, was the first to establish a 66
scientific basis for epilepsy. In his Institutiones Medicinae, published in 67
1708, for example, he provides a rather strict definition of epilepsy: 68
⁎ Corresponding author. Leoforos Aianteiou 3- PB 1541, Salamina, 18900, Greece.

“Epilepsy is the sudden abolishment of all vital functions with 69
Fax: +30 210 7486382. accompanying increase of mobility and convulsions in all body 70
E-mail address: mayiork@med.uoa.gr (E. Magiorkinis). muscles.” In his Praelectiones de morbis nervorum, published after his 71
1525-5050/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.yebeh.2010.04.004
Please cite this article as: Sidiropoulou K, et al, Hallmarks in 18th- and 19th-century epilepsy research, Epilepsy Behav (2010), doi:10.1016/j.
yebeh.2010.04.004
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2 K. Sidiropoulou et al. / Epilepsy and Behavior xxx (2010) xxx–xxx
belief that masturbation could cause epileptic seizures [7] or sexual 108
excesses or excessive continence [8]. Tissot suggests as a therapy 109
trephining, among others, for all cases where the symptoms point to a 110
seat of the disease accessible to the trephine, even if there were no 111
conspicuous previous injury [9]. 112
During this period, the French medical school took the first steps 113
toward understanding the disease, especially in the growing fields of 114
neurology and pscyhiatry. One of the early figures of the French 115
medical school, Jacques–Louis Doussin Dubreuil (1762–1831), in his 116
De l'épilepsie en général, et particulièrement de celle qui est déterminée 117
par des causes morales, first published in 1797, tried to explain the 118
influence of various emotional states on epilepsy. He believed that 119
through the contraction of the heart, emotions affect the flow of blood 120
and other humors, and can thus impede the excretion of substances 121
through sweating, impeding, thus, the excretion of substances 122
through sweating [10]. Jean Maisonneuve, a pupil of Philip Pinel 123
(1745–1826), in his Recherches et observations sur l'épilepsie présentées 124
F
à l'école de médecine de Paris, states that “epilepsy like all chronic 125
diseases can be studied well only in hospital,” stressing the variety of 126
OO
clinical manifestations of epilepsy [11]. He considered violent 127
passions as a cause of epileptic seizures. Maisonneuve accepted the 128
initial division of epilepsy into idiopathic and sympathetic; idiopathic 129
epilepsy can be congenital, spontaneous, plethoric, humoral, or 130
caused by strong emotions, whereas the sympathetic form can be 131
produced by “irradiation” from external parts, the stomach, the
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132
intestines, or uterus, to which “vaporous or hypochondric epilepsy” is 133
the fifth category of epilepsy [12]. Maisonneuve described the so- 134
Fig. 1. Herman Boerhaave (1668–1738). called sensitive aura of sympathetic epilepsy and its expansion to the 135
brain preceding the epileptic seizure, connecting the sensitive aura 136
72 death in 1761, he seems to follow the Galenic classification of epilepsy, with partial epilepsy [13]. 137
73 distinguishing between epilepsia idiopathica and epilepsiae deutero- This period is also marked by the work of eminent British physicians. 138
ED
74 pathicae [1]. In his Aphorisms (1708), regarding the epileptic attack and Thomas Beddoes (1760–1808), physician, scientific writer, reforming 139
75 its variations, he says: practitioner, teacher of medicine, and associate of leading scientific 140
figures, in his Essay on the Nature and Prevention of Some of the Disorders, 141
76 But all those varieties consist only in changing the motions of the
Commonly Called Nervous, states that the disposition toward epilepsy is 142
77 moveable parts, and therefore of the muscular; wherefore they
widespread. He pays particular attention to the changes developing 143
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78 only suppose various contractions of the muscles; hence various

before the onset of an attack, noting that these preepileptic states are 144
79 influxes of the nervous liquid, and thence the various distribution
similar to the manifestations of the hysteric and other nervous 145
80 of it from the common sensory organs to the nerves; and lastly
complaints. According to Temkin, his essay is one of the most 146
81 before various causes in the medulla of the brain producing these
comprehensive studies on incipient epilepsy [13]. William Cullen 147
82 distributions, etc., which are best known from the historical
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(1712–1790), one of the greatest physicians in Scotland and also a 148

83 account of them [2].
professor of medicine, wrote Of Neuroses or Nervous Disorders, in which 149
84 he includes epilepsy as one of the spasmodic affections without fever, 150
85 Enumerating the causes of epilepsy, Boerhaave accounts for together with tetanus and chorea or St. Vitus dance [14]. Both the 151
86 hereditary causes and the effect of imagination of the mother while London practitioner William Heberden (1710–1801) and John Cooke 152
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87 pregnant and being shocked at the sight of a person having an (1756–1838), in his Treatise on Nervous Disease, make extensive 153
88 epileptic fit [3], and the mother's prolonged retention of urine [4]. The references to epilepsy [15,16]. 154
89 Dutch–Austrian Gerard Van Swieten (1700–1772), who was Boer- Finally, the first experimental provocation of convulsions was 155
CO
90 haave's pupil and, from 1745, personal physician to the Austrian done in Italy. The Italian naturalist Felice Gaspar Ferdinand Fontana 156
91 Empress Maria Theresa, wrote a chapter on epilepsy in which he (1730–1803), in a series of experiments on stimulation of the cerbral 157
92 describes extensively the clinical characteristics of various forms of cortex with electricity, demonstrated that convulsions could be 158
93 the disease and discusses epilepsy in comparison with apoplexy and produced by pressure on the brain, but not by irritation of the dura, 159
94 hysteria. He also attempts to explain the various symptoms, such as as commonly believed [17,18]. 160
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95 the initial cry, the swelling of the veins, and frothing, on the basis of
96 the physiological facts known in his time, while he also refers to the 3. The 19th century: The “golden era” of French medicine and the 161
97 ancient literature of Hippocrates, Aretaeus, Galen, and Caelius contribution of the English school of physicians 162
98 Aurelianus. Van Swieten, being a student of Boerhaave, also agrees
99 with the view that the thoughts of the mother can affect the fetus, During the 19th century, neurology was elevated as a new science, 163
100 admitting, however, that he cannot give a reasonable explanation [5]. separate from psychiatry, and epilepsy was widely considered as a 164
101 The first major treatise on epilepsy was written by the Swiss brain disturbance. The French medical school seemed to predominate 165
102 physician Simon August André David Tissot (1728–1787). Published in the field of epileptology, as a result of the establishment of the first 166
103 in 1770, the Traite de l’ epilepsie is considered to be a milestone in large hospital facilities in France. In 1857, the first hospital for the 167
104 scientific research on epilepsy. Tissot completely rejects the influence crippled and people with epilepsy was founded. At the same time, 168
105 of the moon on epileptic seizures, accepts the hereditary forms of humanitarian approaches to address the social problems that epilepsy 169
106 epilepsy, and states that it is the duty of the person with epilepsy to creates led to the foundation of centers for the care and professional 170
107 remain unmarried [6]. Among his extreme views about epilepsy is the orientation for people with epilepsy. Among the countries in which 171
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K. Sidiropoulou et al. / Epilepsy and Behavior xxx (2010) xxx–xxx 3
172 such institutions were founded were Germany, The Netherlands,

173 England, Switzerland, Denmark, and Norway.
174 3.1. The French medical school of the 19th century
175 Marie-Jean-Pierre Flourens (1794–1867) (Fig. 2), one of the most

176 important figures in physiology in French medicine, published his
177 Recherches physiques sur le propriétés et les fonctions du systême
178 nerveux dans les animaux vertébrés in 1823. In it, he established the
179 basic rules regarding the irritability and sensibility of the central
180 nervous system, noting that different functions can be attributed to
181 different parts. Flourens found that the cerebral hemispheres and the
182 cerebellum were not irritable; irritability pertained to the spinal cord,
183 its continuation (medulla oblongata), and its end (the corpora
184 quadrigemina). These parts had the property of immediately exciting
185 muscular contractions, whereas the cerebral hemispheres were the
186 exclusive site of volition and sensation, just as coordination of
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187 movement was placed in the cerebellum. His contribution is decisive
188 for the research on epilepsy, as the loss of consciousness and the
189 voluntary movements in epileptic attacks would imply the involve-
190 ment of the cerebral lobes were it not for the participation of the
191 medulla described by Flourens [19].
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192 In 1815, French psychiatrist Jean-Étienne Dominique Esquirol
193 (1772–1840) distinguished severe from light epileptic seizures
194 (grand mal and petit mal) (Fig. 3). Along with his pupils Bouchet
195 and Cazauvieilh, he studied epilepsy and insanity in parallel,
196 publishing a series of 385 cases of women hospitalized in the epileptic
197
198
199
200
ward, 46 of whom were finally diagnosed with hysteria. Four-fifths of
the remaining 339 women were seriously affected mentally. A later
study by Bouchet and Cazauvieilh revealed a high frequency of
epileptic attacks among patients considered to be insane [20].
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201 Examining the postmortem data, Esquirol admits that “pathological Fig. 3. Jean-Étienne Dominique Esquirol (1772–1840).
202 anatomy has shed little light on the immediate seat of epilepsy” [21].
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203 Esquirol divides epilepsy into three kinds: (1) idiopathic, (2)
sympathetic, and (3) symptomatic. Idiopathic and sympathetic 204
epilepsy can be further subdivided; idiopathic epilepsy can be 205
produced by an external force causing fracture of the skull; a disease 206
of the skull, the meninges, or the brain; or even fright. On the other 207
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hand, sympathetic epilepsy includes epilepsia plethorica, polyposa, 208

humoralis, metastatica, scorbutica, syphilitica, uterina, and others 209
[22]. Bouchet and Cazauvieilh also tried to establish a anatomical 210
relationship between insanity and epilepsy by placing insanity in the 211
gray substance of the brain and epilepsy immediately underneath 212
213
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[23]. The problem of epilepsy classification is also discussed by Louis

Jean François Delasiauve (1804–1893) in his Traité de l'épilepsie, in 214
which he classifies epilepsy into three categories: essential or 215
idiopathic, symptomatic, and sympathetic [24]. 216
In 1827, Antoine Baron de Portal (1742-1832) published his 217
classic Observations sur la nature et le traitement de l'epilepsie, in which 218
CO
he presented his clinical experience based on a large amount of 219

clinical data and postmortem reports. Portal admits that in many cases 220
of epilepsy, dissection does not reveal any lesions in either the brain or 221
other parts of the body [25]. He also makes important notes on the so- 222
called furor epilepticus. He noted that this clinical status occurs before 223
UN
the onset of the epileptic seizure, as well as after; a patient in this 224
condition could even commit murder [26]. 225
The same year, a less well known French physician, Louis François 226
Bravais (1801–1843), published his thesis Recherches sur les symptômes 227
et le traitement de l'épilepsie hémiplégique, in which he defines epilepsy 228
on a new basis, that of “hemiplegic epilepsy,” during which convulsions 229
attack one side of the body followed by paralysis. His description is 230
literally the forerunner of what was later called Jacksonian convulsions: 231
In the majority of cases the patients know that their hands, their 232
forearms are initially affected, either by spasms or by a particular 233
aura…. Many amongst them are subject to incomplete attacks in 234
Fig. 2. Marie-Jean-Pierre Flourens (1794–1867). which the arm alone is affected; they complain to their physician 235
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236 of experiencing jerking, numbness, nervous twitching in the malaise, whereas in 54 cases there was complete “loss of the feeling of 301
237 affected limb, either during the day or at nightfall. If the attacks existense” at the very beginning and the patients did not recall the 302
238 return at regular periods, or if by a happy chance the physician is a episode [34]. Herpin also describes epilepsies with intellectual 303
239 witness, these are the symptoms observed: First are convulsions disturbances and with immediate loss of consciousness. “The trouble 304
240 of the arm and forearm, then of the muscles of the lower limb, of is purely intellectual,” one of Herpin's patient says. “I am neither 305
241 the face, of the neck and finally of the wall of the chest of the dazed nor giddy; I can still read words, but I no longer grasp their 306
242 abdomen.... Do the convulsions begin with the muscles of the meaning. This is a most distressing condition; it seems to me that one 307
243 shoulder and of the arm, or with those of the hand and the flexors part of my intellect witness the disorders of the other” [35]. Herpin 308
244 of the fingers? The attack is too prompt and observation too also believed that the etiology of epilepsy was in the brain and not the 309
245 difficult for me to have been able to solve this question. Which is peripheral parts [36] (Fig. 4). 310
246 the order in which the muscles of the lower limb, of the head and Around the same period, French psychiatrists also elaborated on 311
247 the neck of the wall of the great cavities of the trunk contract? It psychomotor epilepsy and the psychiatric symptoms of epileptic fits. 312
248 seemed to me that the flexor, extensor and rotator muscles of the The French–Austrian physician and influential psychiatrist Bénédict 313
249 head convulse before the muscles which move the mouth Augustin Morel (1809–1879), in his Etudes cliniques, noted that 314
250 sidewards, the patient inclining the head towards the shoulders irritability and anger are the salient features of the epileptic 315
251 before the mouth is split to the ear on the same side [27]. personality [37]. The epileptic anger could last 1 or 2 hours and 316
would repeat itself during the day. Epileptic fury, according to Morel, 317
F
252
appears in two forms: either before or after the epileptic attack or 318
253 An important contribution in the delineation of psychic manifesta- indepedently “like lightning and being condensed in terrible deeds” 319
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254 tions of epilepsy is the work of French physician and expert in forensic [38]. In 1860, Morel published the article D'une forme de délire, suite 320
255 medicine Francois-Emmanuel Foderé (1764–1835). In his Les lois d'une surexcitation nerveuse se rattachant à une variété non encoe 321
256 éclairées par les sciences physiques, one of the most influential works décrite d'épilepsie (Épilepsie larvée), in which he describes an atypical 322
257 on legal medicine of the 19th century, Foderé discusses what he calls form of epilepsy diagnosed primarily by symptoms of insanity, and 323
258 periodic delirium, which is clearly epileptic mania, as one can deduce gives a list of symptoms constituting the epileptic character [39]. 324
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259 from his description: “These paroxysms do not come suddenly. The very same year, another French psychiatrist of the same era, 325
260 Usually the patient feels their approach; they are preceded by a noise Jules Falret (1824–1902), in his article entitled De l’ état mental des 326
261 in the head and frightening dreams; then the patient feels something épileptiques, divides the mental disorders found in persons with 327
262 ascending from the lower parts of the body to the uppermost, almost
263 as in the aura epileptica. He loses conciousness; he falls down; he is
264 raised up again and is now raging” [28].
265 Charles-Édouard Brown-Séquard (1817–1894), a well-known
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266 Mauritius-born physiologist and neurologist, while experimenting on
267 the spinal cord of animals, managed to provoke epileptiform
268 convulsions by transverse section of the lateral half of the spinal
269 cord [29]. He noted that epileptic attacks could be provoked in many
270 ways, and he concluded that “it is in the cutaneous ramifications of
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271 certain nerves of the face and the neck where the faculty of producing
272 convulsions in the animals resides.” Based on those experiments,
273 Brown-Séquard contended that epilepsy could be provoked by any
274 part of the nervous system, either central or peripheral, and that in
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275 any form epilepsy is a reflex phenomenon [30]. His theory also
276 included such vasomotor manifestations of epilepsy as pallor of the
277 face (contraction of blood vessels through the irritation of sympa-
278 thetic fibers) and loss of consciousness (contraction of the arteries of
279 the brain through the same mechanism); convulsions were connected
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280 to a decrease in oxygen concentration in the blood and a concomitant

281 increase in carbon dioxide [31].
282 The book Des accés incomplets d'épilepsie by the French neurologist
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283 Théodore Herpin (1799–1865), published 2 years after his death, is

284 based on 300 cases. Herpin describes half of them as having mild
285 symptoms, such as cramps, visceral spasms, and vertigo. Major attacks
286 occurred after 5 years of follow-up [32]. According to Herpin,
287 recognition of early symptoms of epilepsy is the key to treatment.
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288 Herpin's study therefore focused on the symptoms preceding the

289 onset of major seizures, the initial symptoms with which major
290 attacks began, and the minor attacks occurring in the intervals
291 between complete attacks. He thus rejected the dualistic categoriza-
292 tion of epilepsy into idiopathic and symptomatic and returned to the
293 ancient division of epilepsy as originating (1) from external parts; (2)
294 from the uterus, mouth, stomach, and so on; and (3) from the head or
295 brain. Herpin focuses on epileptic vertigo and the description of the
296 psychomotor attacks, but he also deals with Jacksonian convulsions
297 [33]. Of the 300 cases described in Herpin's book, 183 experienced
298 short and frequent episodes (what Herpin calls accés), 49 of whom
299 had initial symptoms beginning from the sense organs. Fifty-four had
300 attacks or vertigo that began with mental trouble or some cerebral Fig. 4. Théodore Herpin's Des accès incomplets d'épilepsie.
yebeh.2010.04.004
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328 epilepsy into three categories. First is the category of a passing trouble his treatise The Modern Practice of Physic, summarizes the existing 391
329 before, during, or after a convulsive attack, in relation to which the knowledge on epilepsy: 392
330 trouble stood as a mere epiphenomenon. This category includes many
The predisposing causes are a hereditary disposition, intemperance 393
331 premonitory symptoms: “The same idea, the same reminiscence or
and great mobility of the system in the early periods of life. The 394
332 the same hallucination arises spontaneously at the moment of the
occasional or exciting causes are tumours pressing upon the brain, 395
333 invasion of every attack and infallibly precedes its appearance.... This
irregularity in the arrangement of the bones of the cranium, mal- 396
334 reminiscence, this idea or this image are the reproduction of the idea
conformation of the cranium, sharp-pointed ossifications within 397
335 or the sensation which has provoked the first attack in this patient.”
the cranium, splinters or depression of the bones of the cranium 398
336 The second category is of disorders ordinarily met in perons with
from fracture, serous or other effusions into the ventricles, or upon 399
337 epilepsy during the intervals between the attack, that is, epileptic
the membranes of the brain, an abscess formed in the tuberculum 400
338 personality. The third mental disorder is a more or less prolonged
annulare, or its neighbourhood, violent joy and anger, pressure 401
339 delirium assigned as folie épileptique (epileptic insanity) [40]. Falret
upon the medulla oblongata and medula spinallis, worms, denti- 402
340 was also able to identify intellectual disturbances during the epileptic
tion, derrangement of the primae viae, suppression of any habitual 403
341 attack in cases where the patient did not lose consciousness. During
haemorrhage or accustomed evacuation, syphilis, over-distension 404
342 those attacks, patients “utter certain incomprehensible sounds or
of the blood-vessels of the brain, the eruptive fever in certain 405
343 articulate a few incoherent words which seem to indicate a painful
exanthemata, as the variola and scarlatina, nervous sympathy, 406
344 anxiety or deep fright.” Also, some convulsions are mouvements
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profuse haemorrhages, terror, horror, pungent odours, certain 407
345 automatiques, including swallowing and chewing. After the attacks
poisons, difficult patrutition, a diseased state of the liver, the aure 408
346 some of the patients “have retained a more or less vague memory of
epileptica and external irritations. The proximate cuase is supposed 409
347 the ideas that preoccupied them while the attacks lasted” [40]. Falret
to be an involuntary and irregular exertion of the energy of the 410
348 divided the mental disorders of the third type into petit mal intellectuel
brain and nervous system [43]. 411
349 and grand mal intellectuel [40]. The types of epileptic delirium could
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412
350 either follow or precede the convulsive attacks or, less commonly,
The physician and ethnologist James Cowles Prichard (1786–1848) 413
351 could occur during the intervals between the attacks. Falret found that
(Fig. 5), in his Treatise on Diseases of the Nervous System, notes that the 414
352 The epileptic delirium, with the psychic characteristics proper to “epileptic delirium” occurs when the patient revives from the comatose 415
353 it … occurs in patients who are not considered as presently state consequent to a seizure, but it can also occur without any previous 416
354 affected by epilepsy. In this case either vertigo or nightly attacks fit. He describes the typical symptoms of epileptic mania: 417
355
356
357
358
which have passed unnoticed are demonstrated; or on the
contrary, these somatic symptoms do not exist at the time when
the patients are observed but have taken place before or will show
up later in the course of their life. Under these circumstances, the
DP The face is flushed, and the aspect of the patient is like that of a man
under intoxication; he attempts to start from bed and run about, and
on being withheld, vociferates and endeavours to overcome
418
419
420
resistance. Sometimes an appearance of maniacal hallucination 421
359 epileptic delirum substitutes somehow for the epileptic convul-
displays itself, but more generally the disorder resembles phrenitic 422
360 sions and is, so to speak, but another manifestation of the same
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361 disease in a different form [40].
362
363 Falret also distinguished between petit mal intellectuel and grand
364 mal: “The calm of the movements, the partial lucidity of the ideas, in
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365 short the semblance of reason which are observed in epileptics

366 suffering from petit mal intellectuel contrast in the highest degree
367 with the manic agitation, the extreme disorder of their actions, and
368 the incessant loquacity of those affected by the grand mal” [40]. Falret
369 also strongly believed that the seat of epilepsy was the brain and not
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370 the medulla oblongata, though he admitted, however, the inability to

371 explain sensory loss and motor manifestations [41]. Falret noticed
372 exceptionally various automatisms in epileptic attacks. During the
373 petit mal intellectuel, the patient could leave his home and work, be
374 absentminded, and have dulled thinking; he had fits of despair and
375 unprovoked anger, with various impulses followed one another at
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376 brief intervals; he had a desire to destroy himself and the things that
377 passed through his hands; he was forgetful, with complete lapses of
378 memory; and experienced headaches, giddiness, sparks in the sphere
379 of sight, visions or frightening objects. Regarding automatisms, Falret
380 noticed in particular that “they strike mechanically [machinalement],
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381 without motivation, without interest, without knowing what they do

382 or, at least, with a very vague consciousness of their actions” [42]. In
383 some rare cases their automatic acts have a motive: “Sometimes,
384 indeed, an attack of petit mal intelectuel suddenly arouses in the heart
385 of an epileptic a feeling of jealousy, of vengeance, or of anger towards
386 a definite person and then pushes him immediately into action, while
387 in his normal state he had succeeded in suppressing this feeling” [42].
388 3.2. The British medical school of the 19th century
389 The British medical school seemed to have followed the French
390 closely during this period. The physician Edward Goodman Clarke, in Fig. 5. James Cowles Prichard (1786–1848).
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423 delirium. It commonly continues one, two or three days, during case, we might expect that lesion of the cineritious substance 454
424 which the patient requires confinement in a straight waistcoat, and would produce disordered action in that part; and that such 455
425 then gradually subsides, and the patient returns into his previous action might be transferred to the distant parts of the body, 456
426 state [44]. producing disordered and involuntary motions: whereas, if the 457
427 great injury were done in the substance of the brain, the means of 458
428 Prichard describes other states of mental confusion, suggesting communication with the active part being cut off, paralysis might 459
429 they are like somnambulism or epileptic ecstasy: “A more unusual result, more or less mingled with convulsion, in proportion as the 460
430 circumstance in the history of epilepsy is the appearance of a species cineritious substance is more or less involved [48]. 461
431 of somnambulism, or of a kind of ecstasis, during which the patient is 462
432 in an undisturbed reverie, and walks about, fancying himself occupied The physician and physiologist Marshall Hall (1790–1857) 463
433 in some of his customary amusements or avocations. This takes place suggested that epilepsy was due in part to anemia of the medulla 464
434 during the waking as well as the sleeping hours” [45]. and that paroxysmal discharges arose from the brain [49,50]. 465
435 His observations are the forerunners of the concept of “psychic According to Hall, “epilepsy is plainly of two kinds: the first has a 466
436 equivalents of epilepsy.” Prichard was also the first to establish the centric origin in the medulla itself; the second is an affection of the 467
437 term partial epilepsy in the literature, devoting to the topic an entire reflex function, the exciting cause being eccentric, and acting chiefly 468
438 chapter in his treatise: “Of Local Convulsion or Partial Epilepsy” [46]. upon the nerves of the stomach or intestines, which consequently 469
439 In his study of epilepsy, Richard Bright (1789–1858) (Fig. 6), one
F
form the first part of the reflex arc” [51]. Robert Bentley Todd (1809– 470
440 of the most famous English physicians, attempted to combine 1860), physician at King's College Hospital, in an experiment to 471
441 anatomical data with clinical cases. Bright was able to show changes determine the seat of epilepsy, observed discrete movements on the 472
OO
442 in the cortex of the cerebral hemispheres. In his classic treatise Reports face of a rabbit on stimulation of the cerebral hemispheres, but he did 473
443 on Medical Cases, published in 1831, he describes various cases of not appreciate the significance of his experiments, for he maintained 474
444 epilepsy in detail. He concludes that “epilepsy generally depends upon that movement was the concern of structures from the corpora 475
445 irritation on the surface of the brain, and that it is often connected with striatum rostrally (Fig. 7). He used the term epileptiform for epileptic 476
446 unusual thickness of the skull” [47]. Bright supported the theory that attacks of the following description: 477
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447 the gray matter of the brain was the main functional part of the
One arm, or both arm and leg on one side, become seized with 478
448 cerebral hemispheres, referring to the discoveries of Foville:
convulsive movements, quite of the clonic or epileptic kind. These 479
449 The cineritious is the more active part of the brain generally, with come in paroxysms; the paroxysm lasts a variable time, and then 480
450 regard to all its functions; and the medullary part is more subsides, leaving more or less general exhaustion and disposition 481
451 particularly employed in the conveyance of the motions and to sleep; but consciousness is not impaired. Yet there can be no 482
452 sensations, or whatever else may be acted upon or produced in doubt that such fits may pass into the true epileptic fit; for it is not 483
ED
453 the cineritious part. And supposing for a moment this to be the derangement of sensation or motion or both. 484
485
During his experiments he noticed a “slight convulsive twitching 486
of the muscles of the face” when he irritated electrically the 487
hemispheric lobes, suggesting that “a disturbed state of the 488
CT
hemispheric lobes ... may in some degree at least, contribute to the 489
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Fig. 6. Richard Bright (1789–1858). Fig. 7. Robert Bentley Todd (1809–1860).
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490 development of convulsions” [52]. To explain both uremic convul-

491 sions and convulsions during poisoning, Todd developed a “humoral
492 theory of epilepsy,” which was not a novelty in medical literature. He
493 also used the term epileptic hemiplegia, like Bravais, for epileptic
494 attacks combined with weakening or paralysis of the affected side,
495 which now are known as Todd's paralysis [52].
496 William B. Carpenter (1813–1885), physiologist and naturalist, in
497 his Principles of Human Physiology, clearly establishes contemporary
498 knowledge regarding the function of the cerebral cortex:
499 It has usually been considered that the cerebrum acts directly
500 upon the muscles, in the virtue of a direct continuity of nerve-
501 fibres from the grey matter of its convolutions, through the
502 corpora striata, the motor tract of the medulla oblongata, the
503 anterior portion of the spinal cord, and the anterior roots of the
504 nerves; and that in the performance of any voluntary movement,
505 the will determines the motor force to the muscles or set of
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506 muscles, by whose instrumentally it may be produced [53].
507
508 Carpenter introduced the theory of the sensorimotor ganglia,
509 according to which
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510 The thalamus is the organ of conscious sensibility, to which all
511 impressions made on peripheral sensory nerve-fibres must be
512 transmitted in order to be recognized as sensations, and the
513 corpus striatum, the organ or instrument of voluntary motion,—
514 the downward starting point of volitional motor impulses, or it
515 might be said of all cerebral motor impulses. These two ganglia
516
517
518
519
are again associated … in sensori-motor action, impressions
reaching the thalamus being passed to the corpus striatum, and
giving rise to automatic movements differing from those which
have their centre in the cord, only in being accompanied by
DP
520 sensation [54]. Fig. 8. John Russell Reynolds (1828–1896).
521
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522 In 1836, Astley Cooper (1768–1841), surgeon and anatomist, previously, which appeared in 1858, it is considered to be a milestone in 554
523 reported his findings on provoking epileptic seizures by temporary English epileptology. 555
524 anemia, without the loss of blood. He tied the carotid arteries of a Reynolds suggested that even if “we were compelled to recognise 556
525 rabbit and then compressed with his thumbs the cerebral arteries. the existence of many, or even a few, cases distinct from any more 557
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526 “Respiration almost directly stopped: convulsive struggles succeeded; general condition or systemic or local disease, we must employ the 558
527 the animal lost its consciousness, and appeared dead. The pressure term epilepsy in a restricted sense, implying only those cases which, 559
528 was removed; and it recovered with a convulsive inspiration. It laid in the present state of medical science, are irreducible” [63]. [[AU: The 560
529 upon its side, making violent convulsive efforts; breathed laboriously; preceding quote is identical to the quote a few lines down. Two 561
530 and its heart beat rapidly. In two hours it had recovered; but its different sources. OK?]] He defines epilepsy as an episodic loss or 562
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531 respiration was laborious” [55]. impairment of consciousness, associated or not with muscle spasms 563
532 In 1850, John Simon (1816–1904), a physician famous for reforming or convulsing. As far as the seat of epilepsy, he also supported the 564
533 the British health system, noted in his General Pathology that the loss of theory of the medulla oblongata and that the change was of a 565
534 consciousness during epileptic seizures can be attributed to the functional and not of an anatomical nature. Idiopathic epilepsy was, to 566
535 “convoluted surface of the cerebrum” and that general clonic convul- him, a disease of unknown etiology [64]. In general, he suggests that 567
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536 sions implied “the excitement of some aggregative centre of motion” epilepsy has its own right as a disease, but its pathological basis is still 568
537 [56]. The physician Sir Edward Henry Sieveking (1816–1904), in 1858, not known. In his Diagnosis of Diseases of the Brain, Spinal Cord and 569
538 raised doubts about the distinction between idiopathic and symptom- their Appendages (1855), he states that: 570
539 atic epilepsy. He also rejected the distinction between epilepsy,
If we can succeed in distributing all the cases hitherto known as 571
540 eclampsia, and children's convulsions, which he considered to be all
epilepsy among the several classes of better defined diseases, we 572
541 variations of the same disease [57]. John Russell Reynolds (1828–1896)
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ought to reject the term epilepsy from our nosology: but if we 573
542 (Fig. 8), an influential physician and neurologist, president of the Royal
cannot accomplish this distribution, and are compelled to 574
543 College of Physicians of London and of the British Medical Association,
recognise the existence of many, or even of a few, cases distinct 575
544 was the first to identify “epilepsy proper” with idiopathic epilepsy, to
from any more general condition of systemic or local disease, then 576
545 which, he believed, “the name of epilepsy ought to be applied” [58]. His
we must employ the term (epilepsy) in a restricted sense, 577
546 work in epilepsy is considered to be pioneering. His first article on
implying only those cases which, in the present state of medical 578
547 epilepsy was published in 1855, on the interictal abnormalities that
science, are irreducible [65]. 579
548 characterize patients with epilepsy [59,60], and, a year later, he
549 presented a series of cases illustrating what was regarded as the 580
550 rational treatment of epilepsy [61]. His major account on epilepsy was Reynolds employs the terms epileptiform and epileptoid for seizures 581
551 published in 1861 and is entitled Epilepsy: Its Symptoms, Treatment and resembling epilepsy, rejecting , in that way, the existence of renal or 582
552 Relation to Other Chronic Convulsive Diseases [62] With the exception of uterine epilepsy and epilepsy from tumor of the brain; he claims that we 583
553 Sieveking's monograph On Epilepsy and Epileptiform Seizures, referred to “find these confounded together with simple or idiopathic affection” [63], 584
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585 adopting indirectly Delasiauve's theories about idiopathic epilepsy [66]

586 as epilepsy of cerebral origin with uknown pathology. Reynold's
587 classification of epilepsy, although more rational, made his epidemio-
588 logical data hard to interpret for his contemporaries, who employed a
589 rather more broad definition for epilepsy. Reynolds also supported the
590 theory of positive and negative symptoms arising from brain pathology
591 [67], earlier than his successor, Jackson; negative effects are associated
592 with direct impact on structural pathology that damaged or destroyed
593 tissue, whereas positive symptoms are more remote effects of pathology
594 arising from “altered nutrition” that the pathology produced in surviving
595 tissue. Reynolds also refers to the epileptic aura without attempting to
596 explain its pathogenesis. His theory on epileptogenesis is rather a
597 mixture of Marshall Hall's [68] and Brown-Sequard's [69] concepts;
598 Reynolds adopts Brown-Sequard's hypothesis to explain the early stages
599 of an epileptic seizure and Hall's neck muscle spasm–cerebral venous
600 congestion mechanism to account for the continuation of the seizure
601 process. To that point, Reynold adds his own theory involving an increase
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602 in carbon dioxide concentration in the blood that converts the initial tonic
603 phase of the epileptic seizure into a clonic phase [70].
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604 The physician and biographer Samuel Wilks (1824–1911) wrote
605 about epileptic convulsions in 1866, and states clearly:
606 I have no hesitation in saying that for one such case fifty might be
607 found in which the morbid changes producing these symptoms
608 occupy the surface.… It appears to me that, from clinical and post-
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609 mortem observations, as well as from all analogy, we cannot but
610 conclude that the fons et origo mali is in the cineritious substance
611 of the brain. I believe that in this region a commotion occures
612 which would, perhaps, be analogous to a palpitation affecting the
613 heart, and that this irritates the ganglia below, which form the
614 summit of the motor tracts [71].
ED
615
616 William Richard Gowers (1845–1915) (Fig. 9), one of the most
617 emminent figures in British neurology and a contemporary of John
Fig. 9. William Richard Gowers (1845–1915).
618 Hughlings Jackson, also contributed substantially to the understand-
619 ing of the pathogenesis of the disease. In 1879, he was honored by the
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620 Royal College of Physicians by delivering the college's Goulstonian

blood flow in the hemispheres. He distinguished between “plethoric 648
621 Lectures [72], chosing epilepsy as his topic. During those lectures,
epilepsy,” where both the convex surface and the brain are congested 649
622 Gowers presented and reviewed the clinical features of a series of
with blood, and “anemic epilepsy,” where the collapse of hemispheres 650
623 1500 cases whom he observed and treated personally. Those cases
is the primary phenomenon leading to a subsequent turgor at the base 651
624 were published in some of the most prestigious contemporary
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[77]. 652
625 medical journals [72], and, then, he expanded further those findings
The same year, Adolf Kussmaul (1822–1902), a German 653
626 in his monograph entitled Epilepsy and Other Chronic Convulsive
internist, along with Adolf Tenner, published the classic treatise 654
627 Disorders (1881), including a series of 3000 cases of epilepsy that
on epileptiform convulsions. According to them, the main cause of 655
628 cover every possible clinical feature of epilepsy [73].
convulsions in animals is a “sudden interruption in the nutrition of 656
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the brain.” They assumed that nutritional alterations cause changes 657
629 3.3. The Dutch and German medical schools of the 19th century at the molecular level of the brain substance that can also be caused 658
by chemical agents such as poisons. In that way they not only 659
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630 Research into epilepsy was also advanced by the work of German included alteration of blood circulation in their model, but also the 660
631 and Dutch physicians of the era. Moritz Heinrich Romberg (1795– effect of various poisons [78]. In 1859, Höring, a German physician, 661
632 1873), in the section on motor diseases in his classic text A Manual of in his dissertation entitled Über Epilepsie, described a case of a 662
633 the Nervous Diseases of Man (1840–1846), describes at length young man who had grand mal attacks as well as many mild attacks 663
634 muscular spasms of various etiologies including epilepsy [74]. during which he had complete lapses of memory [79]. 664
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635 Romberg also mentions premonitory symptoms with sensitive, In 1868, the German neurologist and psychiatrist Wilhelm 665
636 motor, or psychic character [75]. Karl Friedrich Burdach (1776– Griesinger (1817–1868), in an article entitled “Ueber einige epilep- 666
637 1847), anatomist, physiologist, and embryologist, published a series of toide Zustände,” used the term psycho-motor symptoms (psycho- 667
638 1911 anatomical abnormalities observed in the brain. In his book Vom motische symptome) in epileptoid conditions. Among those symptoms 668
639 baue und leben des gehirus, he describes 476 epileptic cases, among he included “mild twitchings in the hands, bulbi around the mouth, 669
640 which the proportion of lesions in general convulsions and epilepsy to rigidity in the neck, tension in the abdominal muscles” [80]. 670
641 total brain lesions was 1:4 [76]. According to those data, the lateral The founder of Dutch neurology and psychiatry, Jacobus Schroe- 671
642 ventricles were most frequently affected, in 86 of 476 cases, 63 of der van der Kolk (1797–1862), in concordance with, in 1859, 672
643 whichconsisted of serous effusion. supported the reflex theory of epilepsy to which Brown-Séquard 673
644 The German anatomist and pathologist Friedrich Gustav Jacob subscribed. According to this theory, the seat of epilepsy is in the 674
645 Henle (1809–1895), writing in 1853, noted that epileptic convulsions medulla oblongata, and especially “in the ganglionic cells of the 675
646 are provoked by an increased turgor at the base of the brain, and that medulla oblongata, which, as reflex ganglia, possess the peculiar 676
647 the loss of consciousness depends on either increase or decrease in property that when once brought into an excited condition, may more 677
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678 or less suddenly discharge themselves and communicate their

679 influence to different nervous filaments” [81]. However, van der
680 Kolk further believed that that the excitability of the medulla
681 oblondgata can cause epilepsy, agreeing with Tissot on the effect of
682 masturbation as an irritant of epileptic seizures [82], a theory also
683 adhered to by Fournier (1832–1914) [83] and later Gowers [84].
684 3.4. Therapies for epilepsy
685 Different types of therapy for epilepsy have been suggested by

686 various authors. Théodore Herpin suggests prescribing selinum
687 palustre and zinc oxide [85], whereas Achille-Louis-François Foville
688 (1799–1878) advises turpentine [86]. Armand Trousseau
689 (1801–1867) suggests administration of indigo and belladona [87],
690 John Russel Reynolds recommends misletoe and the inhalation of
691 chloroform [88]. Edward Sieveking, in 1857, introduced bromide
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692 potassium in the treatment of epilepsy [89], a treatment further
693 supported by Charles Locock (1799–1875) and especially Samuel
694 Wilks [90,91]. Locock described the anticonvulsant effect of
695 bromides, although the earliest studies on the effects of various
696 drugs as anticonvulsants were performed by Albertoni (1882), on
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697 animals with induced seizures [92]. Delasiauve wrote that the
698 process of causing “intermittent fever” as a remedy for patients with
Fig. 10. John Hughlings Jackson (1835–1911).
699 epilepsy was condoned by Selade [93]. Surgical intervention was
700 another popular intervention, especially for sympathetic epilepsy.
701 Trephining of the skull was supported by Charles-Édouard Brown-
the medical literature [103]. In 1863, he observed about unilateral con- 739
702 Séquard, Benjamin W. Dudley (1785–1870), John Saw Billings
703
704
705
706
(1838–1913), and Paul Broca (1824–1880), most of whom had
used surgical therapy in various cases [94–96]. Other surgical
procedures suggested were tracheoctomy, by Marsall Hall [97] and
cauterization of the larynx with nitrate of silver by Brown-Séquard
DP vulsions that:
In very many cases of epilepsy and especially in syphilitic
epilepsy, the convulsions are limited to one side of the body;
and, as autopsies of patients who have died after syphilitic
740
741
742
743
707 [98]. epilepsy appear to show, the cause is obvious organic disease on 744
the side of the brain, opposite to the side of the body convulsed, 745
TE
frequently on the surface of the hemisphere [104]. 746
708 4. The age of John Hughlings Jackson
747
The same year he published a pamphlet entitled Suggestions for 748
709 John Hughlings Jackson (1835–1911) (Fig. 10) inaugurated the
Studying Diseases of the Nervous System on Professor Owen's Vertebral 749
710 modern period in the scientific research of epilepsy. Working at the
750
EC
Theory, in which, based on Richard Owen's theory about the

711 British National Hospital for the Relief and Cure of the Paralysed and
segmental nature of the skull, he assumed that the vertebrae of the 751
712 Epileptic, he was able to deal with a large number of epileptic cases.
skull corresponded to a segmentation of bones, nerves, blood vessels, 752
713 Jackson was in contact with such famous neurologists as Charles-
and muscles [105]. 753
714 Édouard Brown-Sequard, Charles Bland Radcliffe (1822–1889), Russel
In 1864, Jackson published an important article entitled “Epileptic 754
715 Reynolds, Edward Sieveking, and Sir William Richard Gowers
755
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Aphemia with Epileptic Seizures on the Right Side,” in which he

716 (1845–1915), who was his assistant [99]. His clinical work led him
discusses the symptoms of aphasia [106]. In this article, Jackson refers 756
717 to disagree with the earlier theses of Marie-Jean-Pierre Flourens
to two cases, a patient with epileptic hemiplegia, loss of speech, and a 757
718 (1794–1867) and François Achille Longet (1811–1871). His clinical
valvular disease of the heart, and a patient with unilateral seizures 758
719 observations from 1861 to 1870, which came well before the
combined with temporary defects in speech. In the first case Jackson 759
720 experimental reports of Eduard Hitzig (1839–1907) and David Ferrier
assumed the involvment of emboli plugging the middle cerebral 760
CO
721 (1843 –1928), were confirmed ultimately by Hitzig and Ferrier. Some
artery, whereas, for the second case, he suggested a spasm in the 761
722 time after 1870, Gustav Theodor Fritsch (1837–1927) and Hitzig
middle cerebral artery. He specifically added: “when we further 762
723 published their investigations On the Electric Excitability of the
consider that the left middle cerebral artery supplies: (1) the roots of 763
724 Cerebrum, in which they published the discovery of the motor area
the olfactory bulb; (2) the corpus striatum; and (3) the hemispheres, 764
725 of the hemispheres in dogs [100]. In 1873 David Ferrier, in an article
we can readily understand how the three strangely associated 765
726 entitled “Experimental Researches in Cerebral Physiology and
UN
symptoms should occur together in plugging of that vessel; and I 766

727 Pathology,” confirmed Jackson's clinical findings anatomically and
submit that temporary spasm of the vessels in that arterial region 767
728 experimentally [101].
would account for the three temporary symptoms in epileptiform 768
729 Jackson studied epilepsy on a pathological and anatomical basis.
seizures” [107]. Jackson thus offered a new explanation of epileptic 769
730 He initially believed that focal convulsions were due to a discharging
seizures that differed from that of his predecessors who claimed the 770
731 lesion from damage to nerve cells. He also believed, at first, that the
seat of the disease lay in the medula oblongata. 771
732 part of the brain involved was the region of the corpus striatium or the
In the following years, Jackson's views regarding the involvement 772
733 convolutions near to it. According to Temkin, we can distinguish three
of the corpus striatum in the genesis of seizures evolved rapidly. In 773
734 periods of observations in Jackson's life: from 1861 to 1863, when he
1870, Jackson wrote: 774
735 formed the focus of his interest; 1864 to 1870, when his study on
736 convulsions appeared; and the period after that publication [102]. In Palsy depends on destruction of fibres, and convulsion on 775
737 1861, Jackson published his first article entitled “Cases of Epilepsy instability of grey matter. As the convolutions are rich in grey 776
738 Associated with Syphilis,” containing reports from hospitals and from matter I suppose them to be to blame, in severe convulsions at all 777
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778 events; but as the corpus striatum also contains much grey matter nutrition,” and those cells that are discharged lose their function and 843
779 I cannot deny that it may be sometimes the part to blame in temporarily form a “negative lesion” [117]. Sensory or/and motor 844
780 slighter convulsions. Indeed, if the discharge does begin in symptoms are present in each epileptic or epileptiform seizure; in 845
781 convolutions, no doubt the grey matter of lower motor centres, epileptic seizures paralysis is generalized, whereas in epileptiform 846
782 even if these centres be healthy, will be discharged secondarily by seizures it is located in certain parts of the body. 847
783 the violent impulse received from the primary discharge. Now To explain postepileptic states, Jackson suggests the four-layer 848
784 both these parts—the corpus striatum and many convolutions— theory of higher levels, though this theory was not supported by any 849
785 are supplied by one artery, the middle cerebral or Sylvian, and this anatomical data, as Jackson admits. He thought that discharges afflicting 850
786 artery circumscribes the region I speak of [108]. the first layer are responsible for impaired consciousness, the second for 851
a single loss of consciousness, as in the case of epileptic mania, and the 852
787
third for coma without affecting the vital operations [118]. 853
788 His Study of Convulsions is the high point of his work. Jackson Jackson also refers to the “dreamy state” some patients experience 854
789 distinguishes four factors involved in the final cause of convulsions. The before the onset of the epileptic fits. He mentions, writing in 1876, a 855
790 first is the “seat of the internal lesion,” the existence of a localized lesion number of expressions used by patients to describe those symptoms 856
791 in the cortex that is involved in the localized spasms; the functional of the so-called “intellectual aura,” some of which resemble states 857
792 cause of the change is the second stage [109]. The pathological process known in modern psychiatry and neurology as déjà vu: “Old scenes 858
793 that brought about the functional change (embolus, tumor, syphilis, or revert, I fell in some strange place, a dreamy state, a panorama of 859
F
794 other cause) is the third factor, and the fourth is the various something familiary and yet strange, if I were walking alone and had a 860
795 circumstances that trigger the paroxysm (provocative or exciting fit, I should think ‘Oh, I saw that before”’ [119]. 861
OO
796 cause) [110]. In 1873, Jackson gave the following definition for epilepsy:
797 “Epilepsy is the name for occasional, sudden, excessive, rapid and local
5. Conclusion 862
798 discharges of grey matter” [111]. By adopting this definition, Jackson
799 accepted many different clinical entities as “epilepsy.”
The 18th and 19th centuries constitute the most important period 863
800 In 1866 Jackson discussed the mechanisms of various forms of
in the formation of scientific thought on epilepsy as a disease and 864
PR
801 epilepsy in his article entitled “Clinical Remarks on the Occasional
symptom. Theories on epilepsy during this period are formulated on a 865
802 Occurrence of Subjective Sensations of Smell etc.” He notes that “in
803 cases of sudden and temporary loss of conciousness in which solid scientific basis, and people with epilepsy are, for the first time, 866
treated as patients and not as lunatics or possessed. During this 867
804 convulsive movements were slight, or perhaps absent, the disorder
period, experimental studies were conducted as well as advances 868
805 of function was chiefly in the range of the anterior cerebral artery”
made in the pathology of the disease and the connection of epilepsy 869
806 [112]. For cases of loss of conciousness, he believed the disorder to be
with various psychiatric symptoms. The work of John Hughlings 870
807 located “in the very highest nervous centres of the cerebral
ED
Jackson was preceded by a plethora of studies by Dutch, German, 871
808 hemisphere” [113]. As far as the mechanisms involved, genuine
English, and French physicians who evolved scientific thought and 872
809 epilepsy was not different from unilateral epilepsy. He later refined
performed thorough studies on epilepsy. 873
810 his definition of epilepsy, suggesting a scientific and an empirical
811 classification; in terms of anatomy and physiology, epileptic vertigo,
812 petit mal, and grand mal were due to differences of a discharge
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References 874
813 “beginning and spreading from the same parts of the brain” [114].
814 Empirically, he distinguished three classes of epilepsy proper from [1] Boerhaave H. Praelectiones academicae de morbis nervorum; 1761. p. 834. t. II. 875
Leiden. 876 Q1
815 which the epileptiform or epileptoid group, including convulsions [2] Van Swieten G. The commentaries upon the aphorisms of Dr. Herman Boerhaave 877
816 beginning unilaterally, unilateral dysesthesia (migraine), and epilep- [English translation], vol. 10; 1754. p. 343. London. 878
879
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817 tiform amaurosis, had to be differentiated [115]. [3] Van Swieten G. The commentaries upon the aphorisms of Dr. Herman Boerhaave
[English translation], vol. 10; 1754. p. 351. London. 880
818 In his lecture “On Convulsive Seizures,” as part of the Lumleian [4] Boerhaave H. Praelectiones academicae de morbis nervorum; 1761. p. 794. t. II. 881
819 Lectures, Jackson presented the most advanced form of his theory on Leiden. 882 Q2
820 epilepsy. According to Jackson, the central nervous system can be [5] Temkin O. Great systems and period of Enlightenment. The falling sickness: a 883
821 divided into three levels: (1) the lowest level, which consists of the history of epilepsy from the Greeks to the beginnings of modern neurology. 884
London: John Hopkins Univ. Press; 1971. p. 218. 885
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822 spinal cord, the medula oblongata, and the pons, representing the most [6] Tissot SA. Traité de l'épilepsie, faisant le tome troisième du traité des nerfs et de 886
823 rough and simple movements; (2) the “motor province,” consisting of leurs maladies; 1770. Paris. 887 Q3
824 the motor region of the cerebral cortex (rolandic region) and of the [7] Tissot SA. L' onanisme: dissertation sur les maladies produites par la masturbation 888
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(troisieme edition). Lausanne: Chez Marc Chapuis et Compagnie; 1764.

825 ganglia of the corpus striatum representing complex movements of all [8] Tissot SA. Traité de l'épilepsie, faisant le tome troisième du traité des nerfs et de 890
826 parts of the body; and (3) the highest level formed by the centers of the leurs maladies; 1770. p. 70–3. Paris. 891 Q4
827 prefrontal lobes (“the organ of mind”) [116]. Fits beginning at the lower [9] Tissot SA. Traité de l'épilepsie, faisant le tome troisième du traité des nerfs et de 892
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Epilepsy and Behavior

2 Hallmarks in 18th- and 19th-century epilepsy research

42 3.1. The French medical school of the 19th century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

⁎ Corresponding author. Leoforos Aianteiou 3- PB 1541, Salamina, 18900, Greece.

78 only suppose various contractions of the muscles; hence various

(1712–1790), one of the greatest physicians in Scotland and also a 148

172 such institutions were founded were Germany, The Netherlands,

174 3.1. The French medical school of the 19th century

175 Marie-Jean-Pierre Flourens (1794–1867) (Fig. 2), one of the most

hand, sympathetic epilepsy includes epilepsia plethorica, polyposa, 208

[23]. The problem of epilepsy classiﬁcation is also discussed by Louis

he presented his clinical experience based on a large amount of 219

280 to a decrease in oxygen concentration in the blood and a concomitant

283 Théodore Herpin (1799–1865), published 2 years after his death, is

288 Herpin's study therefore focused on the symptoms preceding the

365 short the semblance of reason which are observed in epileptics

370 the medulla oblongata, though he admitted, however, the inability to

381 without motivation, without interest, without knowing what they do

388 3.2. The British medical school of the 19th century

Fig. 6. Richard Bright (1789–1858). Fig. 7. Robert Bentley Todd (1809–1860).

490 development of convulsions” [52]. To explain both uremic convul-

585 adopting indirectly Delasiauve's theories about idiopathic epilepsy [66]

620 Royal College of Physicians by delivering the college's Goulstonian

678 or less suddenly discharge themselves and communicate their

684 3.4. Therapies for epilepsy

685 Different types of therapy for epilepsy have been suggested by

Theory, in which, based on Richard Owen's theory about the

Aphemia with Epileptic Seizures on the Right Side,” in which he

symptoms should occur together in plugging of that vessel; and I 766

(troisieme edition). Lausanne: Chez Marc Chapuis et Compagnie; 1764.

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