Epilepsy & Behavior 115 (2021) 107704

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Epilepsy & Behavior

journal homepage: www.elsevier.com/locate/yebeh

Epilepsy in the Hippocratic collection: Seizures and syndromes

William H. Theodore
Clinical Epilepsy Section, NINDS NIH Building 10 Room 7D-43, Bethesda, MD 20892, USA

a r t i c l e i n f o a b s t r a c t

Article history: Despite extensive scholarship, several questions on the view of seizures and epilepsy in the Hippocratic
Received 31 August 2020 collection have not been answered. The book ‘On the Sacred Disease’ contains descriptions of focal and
Revised 9 December 2020 generalized tonic-clonic seizures, understands the stigma attached to epilepsy, its association with
Accepted 9 December 2020
depression, and probably describes auras. Remarkably, the collection presents a physiologic theory of
Available online 10 January 2021
‘mental’ disease. Other parts of the collection suggest recognition of syndromes such as childhood febrile
seizures. Non-motor seizures are not clearly described. There may be a distinction between ‘acute symp-
Keywords:
tomatic’ and recurrent seizures or ‘epilepsy.’ Analysis of the relative occurrence of terms related to ‘epi-
Hippocrates
Seizures
lepsy’ or ‘spasms’ in an online text collection shows a significant difference: ‘epilepsy’ terms are more
Epilepsy frequent when seizures are described alone, while ‘spasm’ terms are more frequent in the context of sys-
Melancholy temic diseases or injuries. This dichotomy suggests, in contrast to previous accounts, possible under-
Ancient Greek Medicine standing of the distinction between ‘idiopathic’ and ‘symptomatic’ seizure disorders.
Published by Elsevier Inc.

1. Introduction pocrates’ disparages and attempts to confute popular and supersti-

The Hippocratic work ‘‘on the Sacred Disease” (De morbo sacro),
written in the last half of the 5th century BCE is not only the first
extant medical treatise to describe epilepsy in purely naturalistic
terms but also considered a paradigmatic defense of naturalistic
and rational as opposed to ’magic-religious’ approaches to under-
standing disease [1–3]. Although Assyrian and Babylonian medical
texts contain clinical descriptions of seizures, they are ascribed to
supernatural causes [4 pp 315–322, 5]. Despite cultural interac-
tions and some degree of conceptual overlap, evidence of Ancient
Near Eastern influence on specific texts in the collection is hard
to find [6 pp 42–44,7 pp xxx-xxxii].
De morbo sacro is generally agreed to have been written by a
physician, probably for a mixed ‘professional’ and lay audience,
and for public recitation [7–9]. The author provides a physiologic
explanation of the disease based on the regulation of flow of
phlegm throughout the body. Epilepsy affects phlegmatic, but
not bilious individuals.
The author recommends treatment with diet and drugs,
although detail is limited. The assertion that the disease is caused
by dysfunction in the brain, and that in fact the brain is responsible
for all our cognitive and emotional experience, a theory that may
have been derived from Alcmaeon of Croton, is striking [10]. More-
over, a physiologic theory of some aspects of what we would call
psychiatric disorders is presented. Throughout the work, ’Hip-
E-mail address: theodorw@ninds.nih.gov
tious views of epilepsy as ’sacred,’ caused by malign influences of
one or another deity, and only treatable by ritualistic measures.
Other works in the collection, written over several centuries
(Table 1), also discuss clinical characteristics of events consistent
with seizures. Although chronologic range, variations in style, sci-
entific outlook, and of course authorship complicate uncovering a
unified ‘Hippocratic’ understanding of epilepsy, the collection does
represent a discrete period of ancient medical thought [1,9].
In this study, I attempt to ask how closely discussions in the col-
lection parallel current clinical concepts, and to address some
issues raised in the literature, such as whether De morbo sacro dis-
tinguished between ‘acute’ and ‘chronic’ seizure disorders, and
between what used to be called ‘idiopathic’ and ‘symptomatic’
epilepsies [1 p 28,11].
For the purpose of this essay, I focused on clinical descriptions,
rather than physiology, and treated Hippocratic writings apart
from De morbo sacro together, rather than attempting a chronolog-
ical analysis that would require expert textual knowledge; classical
scholars disagree on dating of some of the texts (table).
2. Methods
I reviewed descriptions of symptoms related to seizures in the
Hippocratic collection. To supplement printed sources, I searched
the Loeb Classical Library Online [12] for ‘epilepsy’ terms
(ἐpίkgpso1) and ‘spasm’ terms (rparlὸ1) and their associated
grammatical forms. I also searched for the English words ‘spasms,’

https://doi.org/10.1016/j.yebeh.2020.107704
1525-5050/Published by Elsevier Inc.
W.H. Theodore Epilepsy & Behavior 115 (2021) 107704

Table 1 happening, insensible to pain, and foam at the mouth. The seizure
Titles, abbreviations, and proposed dates for Hippocratic books mentioned in the text. stops when bodily movements warm the blood and end its
English name Corpus Medicorum Date [6] Date [2] congestion.
Graecorum [29] name Patients ‘habituated’ to the disease (ἐhάde1 eἰrὶ sῇ moύrῳ) often
(abbreviation) know (pqocimώrjotrim) when an attack is coming [XII,1]. Chil-
Airs, waters, places De aere, aquis, locis (De 450–400 450–400 dren run to their mother out of terror, when they feel about to have
aere aquis locis) a seizure. This passage strongly suggests recognition of ‘warnings’
Aphorisms Aphorismi (Aphor.) Around After 400
400
or auras although they are not described in detail. Several other
Coan prenotations Coa praesagia (Coac. Around After 300 passages suggest descriptions of auras as well (1 pp 37–40).
praenot.) 400 rjosodimίg (dizziness or vertigo) may precede a seizure [Coac.
Epidemics 1,3 De morbis popularibus I,III Around Around praenot.157]. Symptoms may begin in the head, hand, or foot
(Epid I,III) 410 410
[Prorrh. 2.9].
Epidemics 2,4,6 De morbis popularibus II, Around 350–300
IV,VI Epid II, IV, VI) 400 Focal seizures are described as well [VII,1]. A young girl suffered
Epidemics 5,7 De morbis popularibus V, Around 400–350 a right-sided penetrating head injury followed by pus, fever,
VII (Epid V, VII). 350 spasms of the left hand, and death [Epid. V.28]. De cap. vuln. [13]
Breaths or winds De flatibus (De flat) 420–400 425–400 indicates that spasms can occur contralateral to the side of incision
Places in man De locis in homine (De Around 4th
of the temple, but it is safe to incise in other parts of the head. Con-
locis in hom.) 450 century
On the sacred De morbo sacro (De morbo 450–400 450–400 tralateral spasms can also occur if a wound becomes purulent [ De
disease sacro) cap. vuln.19].
Diseases of women De mulierum affectibus Late 5th- End of 5th De morbo sacro does not appear to describe urinary as opposed
(De mul. affect.) early 4th century
to fecal incontinence, but a later text [Coac. praenot. 587] states
Prognostic Prognosticon (Progn) End of 4th 450–400
Prorrhetic 1 Praesagia I (Prorrh. I) Around Around that in people with epilepsy (ἐpikgpsijoὶ) urine passed ‘against
400 450 custom without fullness’ indicates a seizure. There is no explicit
Prorrhetic 2 Praesagia II (Prorrh. II) End of 5th Around discussion of seizure frequency, although intermittent attacks are
450 recognized.
Wounds in the De capitis vulneribus (De Late 5th Late 5th
Postictal confusion is not prominent in De morbo sacro or De
head cap. vuln.) early 4th early 4th
Girls De virginum morbis (Virg.) Late 5th- 4th flat, but described in other texts: When the epileptic spasms
early 4th century (ἐpikgpsijoῖri rparloῖ1) stopped ‘‘he gazed about; he was
Use of liquids De humidorum usu (De Around 4th not with himself. . .[Epid. VII.46].”
liquid. usu) 400 century
Focal onset seizures with automatisms and impaired awareness
(‘complex partial’) or ‘non-motor’ generalized (absence) seizures
probably are not recognized clearly in the collection [16]. Events
occurring at night including crying out, choking, ’suffocating’ or
‘epilepsy,’ ‘seizures,’ and ‘convulsions’. To investigate whether the leaping up, and running outside (more consistent with parasom-
collection distinguished between seizures occurring independently nias than seizures) are used rhetorically in De morbo sacro to illus-
or in association with other illnesses, I coded descriptions as either trate phenomena that are just as strange as those occurring in ‘the
independent (if mentioned alone) or associated with another dis- sacred disease,’ but are not considered divine [1.3]. However, in
ease or injury. For analysis of the frequency of ‘mentions,’ I relied [I.11], similar symptoms are listed directly after those ascribed to
only on the Loeb online search, excluding nonspecific occurrences ‘the disease,’ in the context of the author’s polemic against the
of ἐpikalbάmeim (the common word meaning to ‘grasp’ or ‘seize’ common notion that epilepsy has a particularly divine nature.
from which ‘epilepsy’ terms derive) and its grammatical forms. The wife of Delearees in Thasos developed fumbling, plucking
I used Jouanna’s texts for De morbo sacro (also consulting edi- hairs, scratching, laughing, and weeping after grief and a febrile ill-
tions of Littre, Jones, and Grensemann), Airs-Waters-Places (De ness, without loss of consciousness [Epid. III.17 case 15]. An
aere aquis locis), and Breaths (De flat.), and the Loeb Classical intriguing passage [XIV.3], interpreted as describing a ‘sentiment
Library for others [9,12–16]. Abbreviations are listed in the table. of strangeness before the habitual” in the context of a discussion
Bracketed text references are to De morbo sacro unless otherwise not of epilepsy per se but of the brain’s responsibility for all mental
indicated. phenomena, is the subject of several alternative textual variants
and interpretive approaches, and probably should not be given
3. Results specific meaning. [9 p 111 note 2,12–14].
De morbo sacro does contain a striking account of the stigma
3.1. Clinical manifestations attached to seizures. Patients when an attack is coming run to hide
where they cannot be seen by others, and cover their faces from
De morbo sacro provides a coherent description of generalized shame, not for fear of the Gods [XII.1].
convulsive seizures. The patient becomes speechless, chokes, saliva
flows from the mouth, teeth gnash, hands draw together or con- 3.2. Epilepsy and melancholy
tract. Consciousness is lost. Spasms can occur on right, left, or both
sides of the body [VII.1]. Particular symptoms are mentioned to One of the most interesting aspects of the discussions of epi-
deride popular beliefs; if the patient imitates the noises of a goat lepsy in the collection is the association with ‘psychiatric’ disor-
or has spasms on the right side, the Mother of the Gods is blamed ders. It is remarkable in presenting a physiologic theory of brain
[I.11] Sharp or frequent ’thin’ cries like birds are due to Apollo. The function and ‘mental illness in the 5th century B.C.E. In De morbo
feet kick. Fecal incontinence often occurs. The eyes roll or diverge sacro phlegm chilling, the brain can cause loss of memory, and
[I.11; VII.1]. Leg pain may accompany spasms and kicking [VII.10]. ‘quiet’ madness, while bile heats the brain and causes restlessness
De flat. [XIV] describes similar symptoms in a discussion of the and bad deeds [XV.1]. Memory loss occurs in madness due to
cause of the ‘sacred disease.’ Due to the irregular passage of the phlegm [XV.3]. Since only the phlegmatic get seizures, the implica-
blood, the body is drawn or stretched in all directions, shaken tion is that people with epilepsy suffer from the former sort of
and distorted; patients are unconscious, deaf and blind to what is mental disturbance [V.1]. In later texts, the association between
2
W.H. Theodore Epilepsy & Behavior 115 (2021) 107704

‘melancholics’ and ‘epileptic’ (lekacvokijoὶ jaὶ ἐpikgpsijoὶ) is

described explicitly. The diseases tend to develop into one another.
Epilepsy occurs if the underlying ‘weakness’ ‘inclines’ more toward
the body, and melancholy if toward the ‘‘intelligence (diάmoia).‘‘
[Epid VI 8.31]. People (particularly women), afflicted by the ‘sacred
disease’ are at risk of hanging themselves [Virg. 1]. Mandrake root
can be used to treat both suicidality and spasms [De locis in hom.
39].

3.3. Etiology

Epilepsy occurs when excess phlegm is not cleansed in child-

hood, and then can block the flow of air to the brain [V.4, VII.1].
The brain becomes excessively moist, as is shown by cutting open
the heads of goats suffering from the disease [XI.3]. It is, like all
other diseases, genetic, due to inheritance of a phlegmatic physiol-
ogy, and begins at the embryonic stage [II.2, V.1]. The disease
occurs only rarely after the age of 20, unless present from infancy Fig. 1. ‘Epilepsy’ terms were much more likely to be found in contexts where
seizures alone were described, while ‘spasm’ terms were more likely to be found
[X.6]. Later texts suggest slightly different age ranges [Prorrh. II 9;
associated with other diseases, or in cases such as tetanus.
Aphor.V.7].
Secondary factors include heating of brain by sun or fire, then a
sudden chill particularly in the elderly; or coming from cold into lus, my study suggests that, in contrast to previous views, the col-
heat. A sudden change from north to south wind may ‘loosen’ lection, and particularly De morbo sacro does distinguish between
the brain [X.1–5]. In cities exposed to hot winds, hot in summer isolated seizures and a tendency to repeated events, or ‘epilepsy’ [1
and cold in winter, people’s heads are particularly moist and full p 28,9].
of phlegm, and children likely to suffer from epilepsy (as well as
asthma) [De aere aquis locis III.3]. When children have fear of
3.4. Prognosis
the mysterious, are afraid of a shout, or cannot catch their breath
while crying a seizure may occur (this passage is the only instance
Epilepsy is no less curable than other diseases unless it has been
of an ‘epilepsy-related’ term (ἐpikήwiό1) in De morbo sacro [X.5].
present for a long time [I.1, XI.4, XVIII.2]. Treatment should con-
Other passages [Aphor.III.16, 20, 22] mention the effect of weather
sider the factors that may augment or diminish the disease, partic-
and season.
ularly moisture, dryness, heat and cold, without recourse to magic
Several passages describe probable seizures in association with
or religion [XVIII 1–4]. Particularly for the young, epilepsy is cured
systemic disease. An infant had fatal seizures in association with
by changes in climate, place, and mode of life [Aphor. II.45]. Young
red swellings on legs, back, and lower abdomen, but no fever [Epid.
children are likely to die during seizures (particularly if there is a
VII.106]. Chills of the neck and back, as well as delirium in fever
heavy flow of phlegm during a south wind). Children attacked by
can be associated with rparlὸ1 [Coac. praenot. 81-5]. Apellaeus
the disease usually die, but if they survive, have sequelae such as
of Larissa had a chronic illness associated with vomiting bile for
distortion of the mouth, eyes, or hand, perhaps suggesting a stroke
about two years before developing severe chills, fever, and spasms
[VIII.2]. Children who recover without sequelae are more likely to
first on the right, then the left, and dying [Epid. V.22]. rparlὸi
have future attacks. Several passages suggest recognition not only
but not ἐpikgpsijoὶ are described after wounds in the context
of seizures in infectious disease but also of childhood febrile sei-
of tetanus [eg Epid. V.74, VII.36]. The observation that patients
zures: rparlὸi after a fever are mortal, but less so in children
with quartan fevers, typically due to the most benign form of
[Coac. praenot. 350]; seizures occurring after a fever are lethal after
malaria, Plasmodium malariae, do not suffer from the ‘great dis-
the age of 7 [Coac. praenot. 351]. Fever starting after a spasm is less
ease (epilepsy)’ is interesting {Epid. VI.6.5].
dangerous than the reverse [Aphor. II.26]. In a patient with fever, it
Disorders of the uterus, thought to be able to suffer upward dis-
is a bad sign if a rparlὸ1 lasts beyond the hour when it started
placement and exert pressure on the liver, could produce symp-
[Coac. praenot. 153]. Other observations are hard to interpret
toms of the ‘Heraclean [De mul. affect. VIII 1.7]’ or ‘sacred [De
[Coac. praenot. 152].
mul. affect. II.151]’ disease.
Adults, because the veins of the latter are larger and full of hot
Overall, non-specific ‘fever’ is the most common specific con-
blood that the phlegm cannot congeal, are at less risk, except for
text for rparlὸi mentioned, appearing in 16.1% of cases. Peri-
the very old (especially in winter) who, if they do not die, may
partum seizures are mentioned in 6.5%, gastrointestinal complaints
develop hemiparesis [IX.1–2; Prorrh II.9]. ἐpikgpsijὰ in ‘dropsy’
in 5.2%, bleeding in 4.5%, head wounds in 3.2%, other wounds and
are fatal [Coac. praenot. 445].
‘phrenitis’ (an acute brain disease associated with delirium and
fever caused by over-heated blood) each in 2.6%. Three patients
had seizures after taking hellebore, which has prominent CNS tox- 4. Discussion
icity [Aphor.V.1, Coac. praenot. 556] [17]. Cold water applied to
sores may lead to spasms [De liquid. usu. 6]. De morbo sacro presents descriptions of generalized tonic-
The word-search revealed that there was a significant difference clonic and focal clonic seizures. The denial that the ‘disease’ is
between contexts in which ‘epilepsy’ words and ‘spasm’ words any more sacred than others, and assertion that the brain is the ori-
appeared (Fig. 1). The former were more likely to be used in inde- gin of conscious experience, is striking. Perhaps most remarkable, a
pendent contexts, and the latter in association with other disor- physiologic theory of mental illness is presented. De morbo sacro
ders, or in non-seizure contexts such as tetanus (chi- and other works in the collection include insights into the associ-
square = 33.9; p < 0.001 two-sided). ation of epilepsy with depression and stigma. It is possible that
Taken together with the descriptions of seizures occurring in auras, childhood febrile seizures, and remission of some
the context of acute disease, or provoked by some external stimu- childhood-onset epilepsies were recognized. The approach to
3
W.H. Theodore
treatment, depending mainly on changes in diet and environment
is conservative.
Several scholars have suggested that the collection does not dis-
tinguish between epilepsy occurring by itself or in association with
other disorders [1,7]. The disjunction between the context of ‘epi-
lepsy’ and ‘spasm’ terms suggests that some authors at least, gen-
erally later than De morbo sacro did recognize ‘idiopathic’ epilepsy,
as opposed to ‘symptomatic’ seizures.
rparlὸ1 are described in a variety of ‘non-epilepsy’ conditions
in the collection, including tetanus, complicating interpretation.
Moreover, it is used in a wide variety of other contexts [18]. For
example, in Aristophanes [Lysistrata 1089], it describes persistent
erections. However, the term seems to denote seizures in the
majority of instances in the collection.
Several tragedies of Euripides use language extremely close to
De morbo sacro to describe symptoms associated with divinely
provoked altered mental states and aberrant behavior (Bacchae,
Herakles) or poisoning (Medea). In Bacchae Agaue is tearing her
son Pentheus to pieces, ’spewing foam and rolling her twisted eyes’
[Bacchae 1122-23]. This might suggest that ’Hippocrates’ was
drawing on a conventional set of descriptors for altered mental
states, not necessarily specific to seizures. However, the overall
depiction in De Morbo Sacro fits these symptoms into the context
of a seizure. Moreover, since texts (or public readings of texts) like
De morbo sacro were available to a general audience, Euripides
himself might have adapted medical descriptions to dramatic
purposes.
The opinion that ‘the disease’ can be ‘cured’ [I.1, XI.4, XVIII.2}
may imply a stand-alone condition in the ancient medical context,
when treatment for illnesses that cause seizures, such as CNS infec-
tion, was not available. In the MESS trial, seizure recurrence over
two years in untreated patients varied from 39% for patients with
a single seizure to 61% for those with multiple seizures [19]. These
data suggest that it is wrong to consider it unreasonable for a Hip-
pocratic physician to give a patient a good prognosis [3 p 57].
The distinction between epilepsy as an illness characterized by
recurrent seizures and single attacks often is unclear [9]. ‘Epilepsy’
terms as well as ‘disease’ (moῦro1) terms were used to describe
both individual attacks and the chronic illness. However, De morbo
sacro’s descriptions do seem to imply the author did have a con-
ception of the illness as a whole as opposed to single seizures.
The assertion that the disease can be cured unless it has grown
too strong over time certainly suggests understanding of epilepsy
as a chronic condition characterized by recurrent attacks. However,
specific terms were not yet available, and the author used ‘sacred
disease’ or ‘this disease’ for the chronic condition [14].
The collection had many authors over several hundred years.
Scholars agree that Aphor.and Epid. are later than De morbo sacro,
suggesting an evolution in ‘Hippocratic’ thinking about the relation
of ‘melancholy’ and epilepsy [2,7,9,19]. De morbo sacro does not
present the reciprocal relation of later texts. It shows some ambi-
guity concerning symptoms that would probably now be described
as a sleep disorder [I.3, I.11] [9 p 37 note 5]. The author might be
suggesting that similar events could occur in patients with or with-
out ‘the sacred disease.’ However, the Hippocratic concept of the
sacred disease may have been much broader than our identifying
it with epilepsy suggests. [8 p 140].
In Aphor. VI.56, a melancholic illness could lead to ‘apoplexy of
the body,” ‘rparlόm,’ madness or blindness, a wider range than in
Epid. Vi.8.31, which mentions only epilepsy and melancholy. Hip-
pocratic physicians explored a range of terms in developing a
vocabulary to describe the phenomena of ’mental illness,’ that do
not always correspond to modern concepts and can create problem
in translation even for philologists [20]. Overall, however, the col-
lection appears to use the term ‘melancholia’ to describe a ‘dys-
thymic disorder’ rather than acute depression [21].
4
Epilepsy & Behavior 115 (2021) 107704
Identification of ancient descriptions of ‘illnesses’ with modern
‘diseases’ is difficult [22]. On the other hand, the dramatic clinical
features of generalized tonic-clonic seizures have always been easy
to recognize. The author of De morbo sacro may well have included
in the concept of the ‘sacred disease’ features of epilepsy, stroke,
and other disorders [7,8]. It is possible that complete loss of con-
sciousness was a defining characteristic of the ‘sacred disease’ as
opposed to conditions like apoplexy [23]. Repetition of events con-
sistent with parasomnias probably was a rhetorical device. The
popular concept of the ‘sacred disease’ may have been broader
than that held by the physicians [1]. Later writers in the collection
suggest that similar symptoms may herald the onset of ‘apoplexy’
or ‘epilepsy’ [eg Coac. praenot. 157]. The list of symptoms associ-
ated with childhood epilepsy [Prorrh. II.10] include abdominal
varicose veins, enlarged testicles as well as mono- or hemiparesis.
Ancient terminology can also cause confusion. Symptoms iden-
tifiable with what we call epilepsy were named ἐpίkgpso1,
rparlὸ1, the sacred disease, the great disease, and sometimes
the Heraklean Disease (itself open to varying interpretations)
among others [24]. It is interesting, however, to consider that epi-
lepsy is increasingly defined as encompassing a wide spectrum of
clinical features and comorbidities [25]. Hippocratic physicians
might well be considered to have a surprisingly contemporary ’pa-
tient’ or ’illness’ centered’ as opposed to ’disease-centered’ view in
describing the symptoms and signs in people with epilepsy.
In Hippocratic medicine, clinical observations were used to jus-
tify prior theoretical constructs [3,8]. Anatomico-pathologic and
physiologic data available to physicians were very limited. It is
not clear, for example, whether any specific clinical observations
led to De morbo sacro’s phlegm-bile distinction. Did the emphasis
on genetic factors in the etiology of the sacred disease derive from
family history records or prior theory about phlegm? The author
thought all disease began in heredity. Clinical descriptions could
be influenced (just as today of course) by concepts of what should
be found; the assertion that children who recover without sequelae
are more likely to have future seizures may be an example of the-
oretical considerations driving clinical observations. De morbo
sacro (as well as De flat) was a sophistic work designed for public
presentation to a general audience; one tradition has the Sophist
Gorgias as Hippocrates’ teacher [2,8,9]. This rhetorical approach
may have influenced the uncertainty over whether ‘night terrors’
were being used as an example of an illness just as strange as
the sacred disease but not considered divine, or as a manifestation
of the disease itself [9,26].
Magico-religious and ‘scientific’ medical concepts still over-
lapped; the author of De morbo sacro strongly approves of tradi-
tional purification practices, although not specifically for treating
seizures. De morbo sacro’s claim that all diseases are equally divine
has led to varied interpretations; ‘divinity’ may refer at least in part
to all the natural processes with a rational pattern, such as climate,
that influence illness, but they are not identical [2]. If only for the
sake of avoiding charges of atheism (potentially leading to unfortu-
nate consequences even in ‘enlightened’ Athens) ‘Hippocrates’ sup-
ports traditional religion and in fact attacks magico-religious
healers as impious for their claims that Gods can cause disease
[8,9]. The author may have conceived of natural forces, particularly
‘air,’ as ‘divine’ in a philosophical sense current in 5th century
thought, perhaps derived from Diogenes of Apollonia [XVIII.1]
[26–28].
There appears to have been little concept of nonepileptic
events, in the current sense of being without an understood phys-
iologic basis. The physiologic explanations of ‘mental events’ pro-
posed in De morbo sacro and generally echoed (though differing
in detail) by other writers in the collection strongly imply that
any behavior can be explained by physical perturbations in flow
of phlegm, bile, blood, or air. Other ancient authors, such as
W.H. Theodore
Herodotus [III.33], thought that somatic disease, particularly pre-
sent from birth, (giving as an instance ‘”the disease some call
sacred”) would have strong effects on mental function.
It is clear that a rational view of epilepsy, as well as associ-
ated mental illness, was common to all ‘Hippocratic’ physicians.
They did not conduct (and had limited, if any, facilities for) ‘clin-
ical investigation,’ and their empirical observations tended to
support preexisting theories, rather than test alternatives. How-
ever, they did emphasize the importance of clinical observation,
careful examination, and history taking, and attempts to estab-
lish the course of the disease [3]. Ironically, their untested theo-
ries of the pathophysiological role of phlegm, bile, and other
factors, supported by clinical experience, led to a view of epi-
lepsy and mental disorders that was more ‘advanced’ than would
appear until at least the 19th century. A relatively restrained
approach to treatment suggests that patients with epilepsy
attended by a ‘Hippocratic’ physician would have received good
advice.
5. Limitations
Variation in manuscript texts and ambiguity about the mean-
ing of words limit certainty about interpretation of some pas-
sages. Interpretation of others such as Epid. [2.6.2] remains
obscure even to medical historians [24]. It very important not
to assign modern meanings to ancient terms: descriptions of
symptoms in women ‘resembling the Heraklean Disease’ or the
‘sacred disease’ [De mul. affect. I.7; II.152] appear ascribed to
physical disorders of the uterus rather than to a purely psychic
process. It is unclear if these passages are meant to describe sei-
zures or simply symptoms reminiscent of seizures [1]. There is
disagreement over whether lekacvokijά and associated terms
indicate a clear disease more or less equivalent to depression; just
as with seizures a common vocabulary of mental disease was in
evolution, tied to physiologic conceptions themselves in flux, such
as the identification with black bile [12,22]. Even the terminology
used by some historians of medicine can lead to confusion when
considered in the context of current epilepsy concepts. I am a
neurologist interested in epilepsy, not a classical scholar. I proba-
bly missed some incidences of the search terms. My judgement of
the context in which ‘epilepsy’ or spasm’ terms were used was
not blinded.
Nevertheless, this study shows that the collection provides
descriptions of several seizure types, describes auras, understands
the stigma attached to epilepsy, its association with depression,
and probably recognizes syndromes such as childhood febrile
seizures.
In contrast to previous accounts, it suggests that the collection
makes a distinction between seizure disorders independently and
in the setting of other diseases, as well as a related one between
‘acute symptomatic’ seizures and ‘epilepsy.’
Epilepsy & Behavior 115 (2021) 107704
Funding
This Research was supported in part by the NINDS Division of
Intramural Research.
Declaration of competing interest
The author have no conflicts of interest to report.
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