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Epilepsy in ancient Greek medicine---the vital step

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doi: 10.1053/seiz.1999.0332, available online at http://www.idealibrary.com onSeizure 2000; 9: 12–21

Epilepsy in ancient Greek medicine—the vital step

JAMES LONGRIGG

Formerly Reader in Ancient Philosophy & Science, University of Newcastle, UK

Correspondence to: Linden Lodge, High Hamsterley Road, Hamsterley Mill, Rowlands Gill, Tyne & Wear, NE39 1HD,UK

EPILEPSY IN ANCIENT GREEK MEDICINE:THE VITAL STEP

In the opening paragraph of his book,The Falling Sick-ness: A History of Epilepsy from the Greeks to the Be-ginnings of Modern Neurology1, Temkin writes as fol-lows:

Diseases can be considered as acts orinvasions by the gods, demons, or evilspirits, and treated by the invocation ofsupposedly supernatural powers. Or theywere considered the effects of naturalcauses and are consequently treated bynatural means. In the struggle between themagic and the scientific conception thelatter has gradually emerged victoriousin the western world. The fight has beenlong and eventful, and in it epilepsy heldone of the key positions. Showing bothphysical and psychic symptoms, epilepsymore than any other disease was open tointerpretation both as a physiological pro-cess and as the effect of spiritual influ-ences. . .

In this paper I propose to concentrate upon thestruggle mentioned here by Temkin and shall en-deavour to describe the social and intellectual influ-ences that brought about the vital step-forward that ledsome medical authors in fifth century Greece to regardepilepsy, notwithstanding its striking and alarmingsymptoms, as a disease due to purely natural causes.

Although our evidence of early medicine in ancientEgypt and Mesopotamia is in an incomplete and frag-mentary state, it is nevertheless possible to draw somegeneral conclusions from it. It is clear that the physi-cian in these societies considered diseases to be signsof divine displeasure and caused by the intrusion ofa demon. The primary purpose of the physician wasto appease the god or drive out the demon which had

‘possessed’ the sick man’s body. To do so he employedprayers, supplications, spells and incantations. Surviv-ing Egyptial medical papyri, like the Hearst and EbersPapyrus, consist largely of prescriptions of drugs in-terspersed with magical spells which were believed toimpart efficacy to the prescriptions they follow. Manyof the remedies prescribed contain noxious or offen-sive ingredients to make them as unpalatable as pos-sible to the possessing spirit and so give it no induce-ment to linger in the patient’s body.

The ancient Babylonians, too, lived in a worldhaunted by evil spirits. Whenever they fell ill they be-lieved that they had been seized by one of these spirits.Those afflicted sought for aid to bring about a return totheir previous condition. The healer’s function was tohelp them achieve this end by removing the cause oftheir illness. Patients were required to atone for theirsins and the angry god has to be placated. The treat-ment involved the employment of ritual involving sac-rifice and incantations.

A recently translated cuneiform text preserves in-valuable evidence of Babylonian views regarding thenature of epilepsy. Here we are presented with an ac-curate and comprehensive description of many famil-iar features of an epileptic seizure2:

12. [If at the time] of his fit [thepatient] loses consciousness and foamcomes from his mouth, it is miqtu [diur-nal epilepsy].

13. [If at the time] of his fit he loses con-sciousness and his arms and legs bendround to the same side as his neck, it ismiqtu.

14. If at the time of his fit. . . takes hold ofhim and foam comes from his mouth, an[unfulfilled] vow made by his father hasseized him. He [the child] will die.

15. If at the time of his fit after it has

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taken hold of him foam comes from hismouth,—handof Lil u.

16. If at the end of his fit when hislimbs become relaxed again his bowelsare sometimes seized and he has a motion,it is ‘hand of ghost’ [nocturnal epilepsy].

17–18. If at the end of his fit his limbsbecome paralysed, he is dazed [or dizzy],his abdomen is ‘wasted’ [sc. as of one inneed of food] and he returns everythingwhich is put into his mouth. . . - hand of aghost who has died in a mass killing. Hewill die.

19–22. If at the end of his fit his limbsbecome paralysed, [the demon] ‘pouringout’ upon him so much that he loses con-trol [of his functions]; if when he thus‘pours out’ upon him his eyes are redand his face expressionless; if his ser’anu-vessels pulsate at a quickened rate and hecries although the tips of his fingers andtoes remain cold; if when the exorcist asksthe sick person to repeat [a prayer] he re-peats what he says to him, but after [thedemon] has let him go he does not knowwhat he said, - hand of Lilu-la’bi.

23. If before his fit a half of his body is‘heavy’ for him and pricks him, and after-wards he has a fit with loss of conscious-ness and he loses control [of his func-tions], it is miqtu. At midday it will bemost serious for him.

24–25. If before his fit he suffers fromfrontal headaches and is emotionally up-set, and afterwards he. . . [..] his hands andfeet, [and] rolls from side to side [on theground] without deviation [of the eyes] orfoam[ing at the mouth], it is a fall due toemotional shock, or ‘hand of Ishtar’. Hewill recover.

26. If when he has his fit [the fallen per-son] is looking sideways or the whites ofhis eyes deviate to the side, and bloodflows from his mouth, for female [pa-tients] it is Lilu, and for male, Lilıtu.

Sakikku 12–26.

Our unknown Babylonian, however, unequivocallymaintains elsewhere: ‘if epilepsy falls once upon a per-son [or falls many times], [it is (as a result of) posses-sion] by a demon or a departed spirit.’

Our earliest literary sources for the history of Greekmedicine are the epic works of Homer and Hesiodwhich clearly reveal that the views of the Greeks of

the Heroic Age regarding disease and the operation ofremedies employed to effect a cure, were, like thoseof their ancient Egyptian and Mesopotamian counter-parts, permeated with belief in magic and the supernat-ural. As the Roman encyclopaedist Cornelius Celsuslater declared, ‘morbos. . . ad iram deorum immortal-ium relatos esse’.(On medicine, Proem, 4), diseaseswere attributed to the wrath of the gods—althoughhere the gods, for the most part, act directly and notthrough the intermediary of demons or evil spirits. Inthe first book of theIliad, for example, the plaguewhich attacks the Greek army besieging Troy is sentby Apollo in punishment for Agamemnon’s arroganttreatment of his priest Chryses, who had come to theGreek camp to try to ransom his captured daughter:

The arrows rattled on the shoulders ofthe angry god when he moved and hiscoming was like the night. Then he satdown apart from the ships and let fly ashaft. Terrible was the twang of the silverbow. He attacked the mules first and theswift dogs, but then he loosed his pierc-ing shafts upon the men themselves andshot them down and continually the pyresof the dead thickly burned. For nine daysthe missiles of the god ranged throughoutthe host. . .3

The same superstitious attitude towards epilepsy isalsoto be found in Classical Greece. Our best evidenceof this is afforded by the Hippocratic treatise,On theSacred Disease, whose author mounts a vigorous at-tack upon witch-doctors, faith-healers, charlatans andquacks who claim that epilepsy has a sacred charac-ter and who regard manifestations of mental diseasegenerally as due to supernatural causation4:

In my opinion those who first attributeda sacred character to this disease werethe sort of people we nowadays callwitch-doctors, faith-healers, charlatansand quacks. These people also pretend tobe very pious and to have superior knowl-edge. Shielding themselves by citing thedivine as an excuse for their own per-plexity in not knowing what beneficialtreatment to apply, they held this condi-tion to be sacred so that their ignorancemight not be manifest. By choosing suit-able terms they established a mode oftreatment that safeguarded their own po-sitions. They prescribed purifications andincantations. . .

Our author also attacks as charlatans those who di-agnose manifestations of mental disease as due to su-pernatural causation5:

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Men in need of a livelihood contrive andembroidermany fictions of all sorts withregard to this disease and many other mat-ters, putting the blame for each kind ofcomplaint upon a particular god. If the pa-tient acts like a goat, if he roars, or hasconvulsions on his right side, they say thatthe Mother of the Gods is responsible. Ifhe utters a higher-pitched and louder cry,they say he is like a horse and blame Po-seidon. If he should pass some faeces, asoften happens under stress of the attack,Enodia is the name applied. If the stoolsare more frequent and thin like those ofbird, it is Apollo Nomius. If he shouldfoam at the mouth and kick, Ares is toblame. In the case of those who are be-set during the night by attacks of fearand panic and madness and jump out ofbed and rush out of doors, they speakof attacks by Hecate and assaults by theHeroes.

He then attacks the superstitious awe with whichepilepsy is regarded6:

I do not believe that the so-called ‘SacredDisease’is any more divine or sacred thanany other disease. It has its own specificnature and cause; but because it is com-pletely different from other diseases menthrough their inexperience and wonder atits peculiar symptoms have believed it tobe of divine origin. This theory of divineorigin is kept alive by the difficulty of un-derstanding the malady, but is really de-stroyed by the facile method of healingwhich they adopt, consisting as it does ofpurifications and incantations. But if it isto be considered divine on account of itsremarkable nature, there will be many sa-cred diseases, not one.

And claims that epilepsy has a similar nature andcause to that of other diseases7:

I believe that this disease is not more di-vine than any other disease; it has thesame nature as other diseases and a sim-ilar cause. It is also no less curable thanother diseases unless by long lapse oftime it is so ingrained that it is more pow-erful than the drugs that are applied. Likeother diseases it is hereditary. . . [3]. Thebrain is the cause of this condition as it isof other most serious diseases.

He holds that, like other diseases, epilepsy is sus-ceptible to treatment8:

This so-called ‘Sacred Disease’ is dueto the same causes as other diseases, tothe things that come to and go from thebody, to cold and sun and changing rest-less winds. These things are divine so thatthere is no need to put the disease in a spe-cial class and to consider it more divinethan the others; they are all divine and allhuman. Each has its own nature and char-acter; none is irremediable or unsuscepti-ble to treatment.

It is at first sight surprising to find in the above pas-sage that, although supernatural explanation is firmlyruled out, the notion of the divine is not entirely ex-cluded. According to our author the whole of natureis divine, but this belief does not allow any exceptionto his rule that natural effects are the result of natu-ral causes. Here, if I may anticipate, can be seen thecontinuing influence of Ionian natural philosophy. TheMilesians philosophers, as I shall proceed to show, inrejecting supernatural causation, did not reject the no-tion of divinity altogether, but regarded their own firstprinciples as divine. According to our medical author,diseases, too, share in this divinity in the sense that,as parts of the cosmos, they also possess their own in-dividual physeis(natures), which display in the regu-lar pattern of their origin, development and operationthe same intelligible laws inherent in the world aboutthem.

Another Hippocratic treatise, possibly by the sameauthor asSacred Disease, namely,Airs, Waters, Placesattempts to account for certain diseases, includingepilepsy, as due to the effect of particular climatic andtopographical factors. It is maintained that all thesediseases are endemic in cities ‘exposed to hot windsand sheltered from the north’9:

The women are unhealthy and prone tofluxes. Again, many of them are barrenthrough disease and not naturally so, andfrequently miscarry. The children are li-able to convulsions and attacks of asthmaand to what is thought to cause the diseaseof childhood and to be a sacred disease<i.e. epilepsy>. The men suffer fromdysentery, diarrhoea, ague, chronic feversin winter, pustules and haemorrhoids.

Here, then, towards the end of the fifth century BCis revealed a strikingly different and novel attitude to-wards the causation of disease. Medicine is now freedfrom magical and religious elements and based uponnatural causes. Even a disease like epilepsy with its

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at times dramatic and terrifying onset is no longer re-gardedas the result of supernatural causation. The im-portance of this revolutionary innovation for the his-tory of medicine can hardly be over-stressed. Here forthe first time is displayed an entirely different outlooktowards disease, whose causes and symptoms are nowaccounted for in purely natural terms. This revolution-ary attitude, however, did not spring forth fully devel-oped like Athena from the head of her father Zeus. Letus now endeavour to trace the factors which broughtabout thisvital step.

This emancipation of medicine from superstition,paving the way for its subsequent development as ascience, was the outcome of precisely the same atti-tude of mind which the Milesian Natural Philosophers,Thales, Anaximander and Anaximenes, were the firstto apply to the world about them in the sixth cen-tury BC. The latters’ attempts to explain the world interms of its physical constituents, without having re-course to supernatural agency brought about the tran-sition from mythological conjecture to rational ex-planation. Rain, for example, which was previouslyattributed to the activity of Zeus10 is now held tobe squeezed out from the clouds by compression11.Moreover, just as the natural philosophers had soughtto explain in purely natural terms such frighteningphenomena as earthquakes, thunder and lightning andeclipses(12a−g), which had previously been regarded asthe manifestations of supernatural powers(13a−c) so thesame outlook was applied by medical authors of Hip-pocratic treatises to explain in terms of natural cau-sation such frightening diseases as epilepsy (the ‘Sa-cred Disease’), apoplexy, delusions, and even impo-tence, which had all previously been attributed to di-vine action. Evidence of this relationship between phi-losophy and medicine may be seen in the fact thatthe medical literature of the fifth and early fourth cen-turies BC is written in the Ionic dialect. Although bothCos and Cnidus, whence the bulk of the treatises inthe HippocraticCorpusseem to have emanated, wereboth Dorian settlements, theCorpus itself is writtenthroughout in Ionic, which became at this time thestandard literary medium not only for philosophy butfor medicine and science generally. In ancient Greece,then, philosophers and medical men shared a com-mon intellectual background. They subscribed largelyto the same general assumptions, and, to a consider-able extent, adopted the same concepts, categories andmodes of reasoning.

A variety of factors seems to have coalesced to initi-ate this intellectual revolution in the sixth century BC.Its place of origin, the Ionian Greek city of Miletus onthe west coast of Asia Minor, was possessed of enor-mous energy. A colony herself, she had founded on herown account no less than 90 new colonies. Throughthese offshoots she came into contact with older neigh-

bouring cultures. As a result of her trade in materialsand manufactured goods brought to the coast from in-ner Anatolia and by the export of her own manufac-tures she became extremely wealthy. Shipping, tradeand industry, then, brought Miletus great prosperityand a wide range of contacts with other lands and cul-tures. The standard of living of her citizens was tooobviously the product of human energy and initiativefor there to be any need to acknowledge an indebt-edness to the gods, such as we find in ancient agrar-ian economies. This secular spirit, which relegated thegods to the background, was doubtless fostered by thefact that the Milesians were not inhibited by any de-mands of a theocratic form of society. There was atMiletus no professional priesthood jealous to preservea dogmatic religious orthodoxy. There was no one truereligion expounded from a common sacred book byuniversally recognized spokesmen and supported byan organized religious authority. Unlike their Orientalneighbours, the Milesians were not constrained to ad-here to any inviolable dogmatic code and they sharedwith their counterparts in other Greek city-states acommon experience of regular participation in polit-ical debate and a characteristically irreverent attitudetowards traditional authority, coupled with the tolerantbelief that any citizen was entitled to voice his opinionon any subject. Moreover, the affluent environment ofcommercial Miletus provided both the leisure and thestimulus for disinterested intellectual enquiry.

No Greek medical literature prior to the Hippo-cratic Corpus has survived. Alcmaeon of Croton, aGreek colony in south Italy is the only pre-HippocraticGreek medical writer whose views have come downto us even in fragmentary form. That they survived atall may have been pure accident. His interests seemto have been primarily medical and physiological14,but, like so many of his Greek contemporaries, theywere wide. Some of the problems that engaged his cu-riosity subsequently aroused the interest of the nat-ural philosophers. Aristotle, therefore, took note ofhis opinions and he was later dutifully included byTheophrastus in hisPhysical opinions, the first His-tory of Philosophy. Although we possess only frag-mentary information regarding Alcmaeon’s medicalbeliefs, it is nevertheless sufficient to reveal that he dis-plays the same outlook which characterizes the Mile-sian Natural Philosophers before him and the Preso-cratic Philosophers after him. Just as Anaximanderhad viewed the cosmos in terms of a balance or evena legal contract between equal opposed forces15 so, inthehuman body, health is held by Alcmaeon to be dueto the equilibrium (isonomia) of the powers compos-ing it, while the supremacy (monarchia) of any oneof them causes diseases.16 Here is revealed a totallydifferent conception of disease from that encounteredpreviously in Greek epic. In Homer the more dramatic

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diseases, at any rate, are represented as being outsidenatureand subject to the whim of the gods. Alcmaeonrejects this conception of disease and holds it to bedue to disturbances of the body’s natural equilibriumand, in consequence, subject to the same rules that op-erate in the world at large. This medical theory be-came very influential and was adopted within the Hip-pocraticCorpus17. It was also linked, in combinationwith Empedocles’s Four Element Theory, with the hu-moral theory18. Its subsequent influence can be tracedthroughPhilistion of Locri19 in the fourth century toPlato20, and beyond.

Alcmaeon’s physiological interests are alsorecorded by Theophrastus and his researches into thenature of the sense organs21 also seem to have had animportantinfluence upon later philosophical thought.After him psycho-physiological investigations becamealmost standard topics of inquiry among later Preso-cratic philosophers. As a result of his researches Al-cmaeon came to the conclusion that all the senses wereconnected to the brain. Here we may see the first steptaken in the great debate as to whether the heart orthe brain was the seat of the intellect—a debate whichrumbled on down through the centuries and is echoed,for example, in Bassanio’s query in theMerchant ofVenice: ‘Tell me where is fancie bred, or in the heartor in the head?’

Interrelations between philosophy and medicinesubsequent to Alcmaeon became highly intricate. Wehave just seen how the initial influence of philoso-phy was instrumental in bringing about the develop-ment of rational medicine in ancient Greece. Now,as a result of a widening interest in medicine itselfin the fifth century, the impulse to turn from macro-cosm to microcosm was quickened considerably. Thephilosophers, themselves, began increasingly to ap-ply their views about the world at large to man him-self and base their medical and physiological theo-ries upon their unifying philosophical hypotheses. Themost influential philosophers in this respect are Empe-docles of Acragas and Diogenes of Apollonia. Bothof these philosophers had medical interests and mayeven have actually been doctors themselves. Empedo-cles is keenly interested in the human body and seeksin his didactic hexametre poem,On nature, to explainits composition, its organs and their functions uponthe basis of his highly influential four-element theory,which dominated philosophy and science for over twomillennia. We may note here that, although influencedby Alcmaeon’s researches in physiological psychol-ogy, Empedocles, firmly maintains that the heart (orrather the blood around the heart), not the brain, is theseat of the intellect.

Although a less important thinker than Empedocles,Diogenes, too, exercised a strong influence in the sub-sequent histories of both philosophy and medicine and

is a figure of seminal importance in any study of theearly history of epilepsy. Like Empedocles to whomhe is indebted for many of his biological theories,Diogenes may also have been a physician and mayeven have written a medical treatise. He revived in thefifth century the monistic hypothesis of Anaximenesthat air was the first principle, that all existent thingswere different modifications of air. Significantly henow sought to support his belief in air as his basic sub-stance on biological and physiological grounds, point-ing out that human beings and all other animals liveby breathing air; that air is their soul and intelligence,since when it is taken away, their intelligence failsand they die; that the semen is aeriform (revealed inits foamy appearance) and since it produces new life,its aerated nature is an important indication that airis the vital substance. Upon this monistic hypothesisthat all things are composed of air, Diogenes not onlyattempted to account for health and disease, but alsoto account for the different levels of intelligence en-countered within the animal world. He discriminatedin the first place between the animate and the inan-imate by claiming that living creatures differ in thatthey contain air that is warmer than that outside butmuch cooler than that near the sun. He then stressedthat this warm air was capable of many differentia-tions, both among different species of living creaturesand among the individuals which make up any givenspecies. Theophrastus has preserved several instancesof the manner in which Diogenes differentiated be-tween levels of intelligence possessed by various liv-ing creatures. Although all creatures derive their intel-ligence from this same air, variations may be causedby such factors as moisture or even physical structure.As thinking depends upon pure dry air and moisturehampers intellect, thought is consequently at a low ebbwhen one is either asleep, drunk or in a state of surfeit.Notwithstanding his biological debts to Empedocles,Diogenes follows Alcmaeon, rather than the latter, inregarding the brain as the central organ of sensationand thought.

Philosophy, as we have seen, came to exercise apowerful influence upon the development of medicine.From this connection medicine derived certain im-portant benefits. It now became incorporated withinself-consistent and tightly integrated systems. Ratio-nal modes of explanation, based upon formal, deduc-tive reasoning and sustained by logical argument, werenow adopted to account for health and sickness. Manhimself was considered to be part and parcel of an or-dered world whose laws were discoverable, a productof his environment, made of the same substances andsubject to the same laws of cause and effect that op-erate within the cosmos at large. Furthermore, the dis-eases to which he is prone were themselves definedstrictly in accordance with the same natural processes

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and ran their course within a set period of time to-tally independent of any arbitrary, supernatural inter-ference. However, the disadvantageous effect of thisinfluence was almost equally great, for along with theabove benefits, medicine adopted, too, an undue ten-dency to deduce explanations from a preconceived po-sition, which resulted in a propensity to accommodateobserved facts to pre-established convictions. This hadan adverse effect upon the development of a moreempirical method more appropriate to the subsequentdevelopment of medicine, as the Hippocratic authorof Ancient medicineis at pains to point out in a bit-ter polemic inveighing against the intrusion of ‘new-fangled’ philosophical postulates into medicine. Norshould it be assumed that the advent of Ionian Ra-tionalism totally eradicated superstitious beliefs in thecausation of disease. Then, as indeed now, supersti-tion remained firmly entrenched—as the ‘cures’ (ia-mata) inscribed on the pillars at the temple of As-cepius at Epidaurus reveal. Interestingly one of theserecords the case of an epileptic from Argos. This man,we learn, during his sleep in the Abaton saw a vision:he dreamt that the god approached him and pressed hisring. . . upon his mouth, nostrils and ears and he recov-ered.

It is time now to return to our seminal textOn theSacred Disease. We have already seen that its author,influenced generally by the spirit of Ionian Rational-ism, had denied that epilepsy was due to supernaturalcausation and had put forward a theory to explain psy-chic affliction which was not only rational and natu-ral but based upon somatic factors. However, a moreimmediate and particular philosophical influence canbe descried since our author elaborates a comprehen-sive explanation of the disease upon the basis of twotheories, held, as we have just seen, by Diogenes—the belief that the brain is the seat of the intelligenceand that air is the source and principle of intelligencewithin the living organism. The first of these beliefs isclearly in evidence in Chapter 14 where we find theauthor maintaining:

Men ought to know that the source ofour pleasures, merriment, laughter andamusements as well as our grief, pains,anxiety and tears is none other than thebrain. It is by this organ especially thatwe think, see, hear and distinguish be-tween the ugly and the beautiful, the badand good, the pleasant and unpleasant.Somethings we differentiate by conven-tion, others by our perception of expe-diency. By this same organ, too, we be-come mad or delirious, and are assailedby fears and panics, sometimes by night,sometimes even in the daytime, by insom-nia, sleepwalking, thoughts that do not

come, ignorance of established usage andactions out of character. These things wesuffer all come from the brain whenever itis unhealthy. . .22

And the second of these beliefs—that air is thesource and principle of intelligence—is found inChapter 17:

For these reasons I consider the brain tobe the most potent organ in the body.So long as it is healthy, this is our inter-preter of the phenomena caused by air. Itis the air that supplies intelligence. Eyes,ears, tongue, hands and feet carry out theactions determined by the brain. For thewhole body participates in intelligence inproportion to its participation in air. Thebrain serves as messenger to comprehen-sion. For when a man draws in breath, theair first reaches the brain, and so is dis-persed into the rest of the body, havingleft in the brain its essence and whateverof intelligence it possesses23.

Accordingto our author, then, epilepsy is no moredivine than any other disease. It has the same natureas other diseases. It has the same cause that givesrise to other individual diseases. It is also curable noless than other diseases, unless by long lapse of timeit has become so ingrained that it is more powerfulthan the remedies that are applied. Its origin, like thatof other diseases lies in heredity, since in the pro-duction of semen diseased parts of the parents’ bod-ies give off diseased seed. The disease, however, af-flicts only the phlegmatics, never the cholerics. (Herethe author adopts the theory of the four humours.) Tomake the pathogenesis of the disease comprehensibleto his reader our author then presents a brief sketchof his anatomical and physiological beliefs. He holdsthat the human brain is double—divided in the middleby a delicate membrane. For this reason pain is not al-ways felt in the same part of the head, but sometimeson one side, sometimes on the other, and occasionallyall over. Many fine vessels lead up to it from all overthe body. Two thick vessels also connect it to the liverand the spleen. The vessel to the liver stretches down-wards on the right side, close by the kidney and themuscles of the loins, to the inner part of the thigh andreaches down to the foot. It is called the ‘hollow vein’.The other part of it stretches upwards through the rightside of the diaphragm and the right lung; branches splitoff to the heart and to the right arm while the remain-der passes up behind the clavicle on the right side ofthe neck and there lies subcutaneously so as to be vis-ible. It disappears close to the ear and then divides;the thickest, largest and most capacious part finishes in

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the brain, while the smaller branches go separately totheright ear, the right eye and to the nostril. From thespleen, too, a vessel extends downwards and upwardsto the left. It is similar to the one from the liver, butthinner and weaker. (We may note here that this no-tion of two vessels, one connecting the liver with theright arm, the other the spleen with the left is also, sig-nificantly, attributed by Aristotle to Diogenes of Apol-lonia.) Our author goes on to explain that it is by thesevessels that we take in the greater part of our breathwhich they then spread over the body through the mi-nor vessels. If the breath is held up anywhere, that partof the body where it is stopped becomes paralysed. Hegoes on to describe a variety of other conditions thatmay arise when the air is obstructed by discharges, es-pecially by phlegm, and then applies this general the-ory to epilepsy: should the routes for the passage ofphlegm be blocked, the discharge enters the vessels de-scribed; this causes loss of voice, choking, foaming atthe mouth, grinding of the teeth and convulsive move-ments of the hands; the eyes roll, the patient becomesunconscious, and, in some cases, he passes excrement.

Although our author gives here a reasonably accu-rate description of an epileptic attack and his asser-tion that the young are more prone to the disease thanthose who are older is valid, most of his pathological,anatomical and physiological theories are highly spec-ulative and over schematic. (These deficiencies shouldnot surprise us at a time when deeply seated reli-gious beliefs in Ancient Greece had given rise to whatamounted to a taboo interdicting the dissection of thehuman corpse.) Again, although in the opening chapterof Sacred Diseaseour author criticizes his opponentsfor ‘pretending to have superior knowledge about whatcauses and what cures disease’, he is himself suscepti-ble to this same charge, since the particular treatmentrecommended by him, dietetic control of temperatureand humidity, in fact afforded no greater possibilityof cure. While his establishment of a naturalistic ba-sis for the understanding of madness and his rejectionof any reference to the divine or demonic marks a re-lease from one sort of mystification, he achieves thisat the cost of the substitution of another. His manifestconfidence that salutary effects are to be derived fromthe antibilious or antiphlegmatic diet he recommendsis itself clearly a matter of faith. Our author is patentlyover-confident in his assessment of the procedures headvocates. Although they are, in principle, capable ofbeing subjected to further tests with a view to theirverification, in practice, they remain speculative anduntested.

While it is true, then, that many of his theories andexplanations are quite fanciful, we must be careful notto throw out the baby with the bathwater. For amidall this foam and froth there is a large and lusty baby,indeed. These explanations of the causes of madness,

epilepsy and other mental disturbances, by purely nat-ural causes stand in marked contrast to the belief inthe supernatural causation of these afflictions found incontemporary works of Greek tragedy as well as thediagnoses of those charlatans, who, as we saw earlierare attacked by the author ofSacred Disease. His at-tempt to explain a frightening disease long investedwith superstition without recourse to supernatural ex-planation but rather by natural causes; his attempt toput forward a corporeal cause for a mental affliction,is avital step forward.

To illustrate the progress of this baby and show howit was fostered by later philosophers and physicians,permit me in conclusion briefly to review its progressthroughout the subsequent history of Greco-Romanmedicine. At times our evidence exists in only frag-mentary form. Yet, nevertheless, it is sufficient, I be-lieve, to show that even when thinkers differed in theirparticular views of the causation of epilepsy and dif-fered, too, in their belief as to the location of the seat ofthe intellect, they were unanimous in their convictionthat this disease, so often shrouded in superstition, wasdue to purely natural causes. Plato agrees with the au-thor of Sacred Diseasethat epilepsy is an affliction ofthe brain and caused by phlegm (with, in this case, anadmixture of black bile). It may be noted here that, al-though he retains the use of the term ‘Sacred Disease’,he justifies it upon a non-supernatural basis, claimingthat epilepsy is justifiably called the ‘Sacred Disease’because it is an affliction of the sacred substance i.e.of the brain marrow24.

Unlike Plato, both Diocles of Carystus, the secondHippocrates, and Praxagoras of Cos, the last really im-portant Hippocratic doctor, hold that the heart, not thebrain is the seat of the intellect. Their explanation ofthe cause of epilepsy, however, is not dissimilar. Bothof them hold that it is caused by the blocking of thepsychicpneuma25.

In the third century BC Greek rational medicine wastransplanted into Egypt and at Ptolemaic Alexandriait achieved its greatest success. Expatriate Greek doc-tors, attracted there by better opportunities for researchunder the Ptolemies, displayed on the one hand, thesame rational attitudes towards medicine that we havepreviously encountered at Cos, Athens and elsewherein Classical Greece; but being uprooted from theirnative environments and thus no longer constrainedby traditional customs and attitudes still in force inMainland Greece, they also reflected in their pioneer-ing approach to medicine the new freedoms they en-countered in this new and cosmopolitan city. Levelsof sophistication in the knowledge of human anatomywere attained at Alexandria that remained unsurpasseduntil the Renaissance. The immediate cause of thesegreat scientific advances is not difficult to discern. Forhere certain medical researchers first began systemati-

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Epilepsy in ancient Greek medicine—the vital step 19

cally to dissect the human body which had previouslybeenprotected from violation by powerful taboos. AtAlexandria, however, an authoritarian state had comeinto being, whose founders, the first Ptolemies, soughtto enhance their regime’s prestige by fostering notonly the arts but also the sciences. To further anatomi-cal research, it is alleged, they even supplied criminalsfor dissection from out of the royal gaols.

Among the doctors attracted to work at Alexan-dria two were outstanding, Herophilus of Chalcedonand Erasistratus of Ceos. Herophilus, the elder of thetwo, moved to Alexandria after initial training underPraxagoras. His greatest contributions to medical re-search were largely in anatomy and he conducted im-portant investigations, based at times on human dissec-tion, into the brain, the nervous and vascular systems.His most impressive contribution to anatomy, how-ever, is his discovery of the nervous systems. Havingdiscovered the nerves and demonstrated that they orig-inated from the brain, settling once and for all—onemight have been tempted incorrectly to assume—thelong-standing debate regarding the seat of the intellect,he then distinguished between the sensory and motornerves and traced the optic nerves from brain to eye.

Like Herophilus, Erasistratus made important con-tributions to the development of anatomy. AlthoughHerophilus was the actual discoverer of both sensoryand motor nerves, Erasistratus carried the inquiry intothe brain and nervous system considerably further. Hisdiscoveries here put the work of his predecessor in theshade. His description of the structure of the brain,as can be seen from a verbatim account preservedby Galen26 reveals greater accuracy than that attainedby Herophilus. Like Herophilus, Erasistratus distin-guished thecerebrum (enkephalos)from thecerebel-lum (which he calledepenkranisnotparenkephalis, asthe former had done). He also described in some de-tail the cerebral ventricles or cavities within the brain.It seems likely that he agreed with Herophilus that thefourth ventricle of thecerebellumwas the seat of in-tellectual activity since his observations that thecere-bellumof the human brain has more convolutions thanthat of other animals had led him to the conclusionthat the number of convolutions varied according tothe degree of intellectual development. He was also inagreement with Herophilus that the brain was the start-ing point of all the nerves and, like him, differentiatedbetween the sensory and motor nerves.

Unfortunately little has survived concerning theAlexandrians’ views on epilepsy, it is not even knownwhether Herophilus put forward any theories onepilepsy at all. Some information preserved in Galen,however, reveals that Erasistratus did discuss epilepsy.Here we learn that, like other diseases generally, it wascaused byplethora—the flooding of the veins by a su-perfluity of blood engendered by an excessive intake

of nourishment. Unfortunately, in this case the organaffected is not specified and it is, thus, impossible todetermine whether his views on epilepsy were in anyway connected with his researches into the nervoussystem.

As time is pressing, we must now jump four cen-turies or so and turn finally to the ‘Prince of physi-cians’. Galen was committed to the integration of phi-losophy and medicine and believed that to be a gooddoctor one had to be a philosopher; that medicinepresupposed all parts of philosophy. The good doc-tor had to master the natural sciences in order to un-derstand human physiology, anatomy and pathology.He had to know logic in order to give proper defi-nitions, to make the right conceptual distinctions, toanalyse proofs and to avoid fallacies. He needed train-ing in ethics so that he could exercise sound moraljudgement. In philosophy Galen was influenced pri-marily by Plato, Aristotle and the Stoics; in medicineby the writings of Hippocrates (or what he conceivedto be such) and by the anatomical and physiologicalresearches of Herophilus and Erasistratus.

Integrating these influences, Galen put forward aconception of nervous disorders that was based at onceon anatomical knowledge and upon traditional spec-ulation. Galen believed that the soul was domiciledwithin the brain where reason originated and the mem-ory of sensual perceptions was stored. Sensibility andthe voluntary motions of the body were functions ofthis rational soul, and to carry out these functions, thesoul employed the psychic pneuma, located in the ven-tricles of the brain, as its instrument, which receivedsensations and transmitted the soul’s commands to themuscles via the spinal cord and the nerves. Here onemay discern the influence of the anatomical researchesof the Alexandrians. All epileptic attacks, Galen held,were due to affections of the brain. The brain couldbe affected itself primarily and directly, or indirectlyfrom another part of the organism. In the first case,Galen considered that epilepsy was the outcome of an‘idiopathic’ (‘protopathic’) disease of the brain. In thesecond case, he held that the involvement of the brainwas ‘sympathetic’ i.e. the brain, though healthy in it-self, had become involved in a disease-process whichhad started external to it.

In the former instance of epilepsy as an idio-pathic disease of the brain, Galen held that the causeof seizure was an accumulation of a thick humour,which might consist either of phlegm or of blackbile, in the cerebral ventricles, blocking the psychicpneuma. Generalized convulsions ensued, producedby the shaking of the origin of the nerves. These con-vulsions were a biological reaction to the impediment,as the brain sought to rid itself of the irritation. Thisaffliction began in early childhood and most epilepticsbelonged to this group.

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20 J. Longrigg

In a limited number of cases, the original lesion waslocatedelsewhere in the body, and the epileptic at-tacks were the result of a ‘sympathetic’ affliction ofthe brain. Galen distinguished two possible causes ofsuch sympathetic involvement. The first of these he at-tributed to an impairment or to a general weakenessof thecardia (i.e. the stomach here) which he held tobe extremely sensitive because of its abundant supplyof nerves. According to the second possibility the pri-mary lesion lay sometimes in the extremities, some-times elsewhere in the body. In the case of such anattack, patients noticed an upward motion of theaura(a Greek term meaning ‘breeze’—this term was ap-parently introduced into medicine by a thirteen yearold epileptic patient of Galen). This subjective symp-tom led to Galen believe that some qualitative changehad come about or a ‘pneumatic substance’ had spreadover the body until it finally reached the brain, just asthe poison from the bite of a scorpion or spider gradu-ally affects the entire organism.

Galen’s tightly integrated and comprehensive sys-tem, offering a complete medical philosophy, came torepresent the very embodiment of Greek and Romanmedical knowledge and dominated medicine through-out the Middle Ages and beyond until the very be-ginning of the modern era. In the particular case ofepilepsy what is of crucial importance is his rationalattitude towards the disease. This attitude, as I havesought to show, was a direct legacy of the vital steptaken by his Hippocratic predecessor several centuriesearlier. Galen follows directly in the latter’s footstepsand so, in this respect, do we ourselves.

FOOTNOTES

1. Temkin, O.TheFalling Sickness: A History of Epilepsy fromthe Greeks to the Beginnings of Modern Neurology. 2nd Edi-tion, Baltimore, Johns Hopkins, 1971.

2. Wilson, Kinnier J. V. and Reynolds, E. H. Translation and anal-ysisof a cuneiform text forming part of a Babylonian treatiseon epilepsy.Medical History1990;34: 185–198.

3. Homer,Iliad, I, 46–53.4. [Hippocrates],Sacred Disease, Chapter 1 (VI. 354, 12–20L.).5. [Hippocrates],Sacred Disease, Chapter 4 (VI. 360, 9ff.L.).6. [Hippocrates],Sacred Disease, Chapter 1 (VI. 352, 1–9L.).7. [Hippocrates],Sacred Disease, Chapter 2–3 (VI. 364, 9–15,

366, 5–6L.).8. [Hippocrates],Sacred Disease, Chapter 18 (VI. 394, 9–15L.).9. [Hippocrates],Airs, Waters, Places, Chapter 3 (II. 18, 2–6L.).

10. Zeus rains upon us, and from the sky comes down enor-mouswinter. Alcaeus, 4.Aristophaneslater exploits the comic potential of this tradi-tional belief in theCloudswhen the old peasant, Strepsiades,describes his earlier belief that the rain was caused by Zeusurinating through his ‘chamber-pot sieve’ (Clouds, 373)

11. Here, according to our doxographer, Anaximenes implicitlyrejectsthe traditional belief that Zeus sends the rain and de-duces instead from his first principle (aer) the natural explana-tion that it is ‘squeezed out’ from the clouds.

Anaximenes said that clouds are formed when the air isthickened further; when it is compressed further still, rainis squeezed out; hail occurs when the descending watercondenses, and snow, whenever some portion of the air isincluded within the moisture.

Aetius,Onthe opinions of the philosophersIII. 4.1 (D.K.13A17).

This mode of explanation is parodied atClouds 367–369:Strep.:What do you mean ‘there is no Zeus?’ Who sends therain? First of all tell me this.Soc.:The Clouds do, of course, I’ll prove it to you by strongevidence.

12a <Thales>saidthat the Earth is held up by water and rideslike a ship and when it is said to ‘quake’ it is then rockingbecause of the movement of the water.

Seneca,Natural questions, III. 14 (D.K. 11A15).

Here Thales dispenses with two Olympian gods—Atlas, whosupports the earth, and Poseidon, the ‘earthshaker’

12b Anaximenes said that when the earth becomes soaked orparched it breaks and is shaken by the high ground that isbroken off and falls. It is for this reason, too, that earth-quakes occur both in times of drought and during heavyrains; for in droughts, as has been said, the earth becomesdried up and breaks, and when it becomes excessively wetby the rains it falls apart.

Aristotle,Meteorologica, B7. 365b6 (D.K.13A21).

In the above passage Anaximenes attributes earthquakes tonatural causes—not to Poseidon, the ‘earth-shaker god’. Asimilar theory is attributed by Ammianus to Anaximander(XVII, 7, 12 (D.K. 12A28).

12c Thunder and lightning are no longer attributed to the agencyof Zeus.With regard to thunder, lightning, thunderbolts, water-spouts and whirlwinds: Anaximander says that all theseare caused by wind. When it is enclosed in thick cloud andforces its way out by reason of its fine texture and lightness,then the tearing makes the noise and the rent in contrast tothe blackness of the cloud produces the flash. Anaximenesis of the same opinion.

Aetius,Onthe opinions of the philosophers, III, 1 (D.K.12A23) & III. 3,2 (D.K.13A17= Dox.367–368).

12d Zeus is no longer regarded as the cause of eclipses. Here andin the following contexts below a natural cause is put forward.According to Anaximander, the sun is a circle twenty-eight�twenty-seven?�times the size of the earth and resem-bles a chariot wheel. The felloe is hollow and filled with fire.At a certain point it allows the fire to shine out through anorifice, as though through the nozzle of a pair of bellows.

Aetius,Onthe opinions of the philosophersII, 20, 1 (D.K.12A21).

12e The cause of a solar eclipse.According to Anaximander, the sun is eclipsed when theorifice of the blow-hole of fire is closed.

Aetius,Onthe opinions of the philosophersII, 24, 2 (D.K.12A21).

12f A similar explanation is put forward to account for a lunareclipse.According to Anaximander, the moon is a circle nineteen�eighteen?� times the size of the earth, resembling achariot wheel with its felloe hollow and full of fire like thatof the sun. It lies oblique also like the sun and has one blow-hole like the nozzle of a pair of bellows. . .

Aetius,Onthe opinions of the philosophersII, 25, 1 (D.K.12A22).

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Epilepsy in ancient Greek medicine—the vital step 21

12g It, too, is caused by the blockage of its ‘blow-hole’.According to Anaximander, the moon is eclipsed when theorifice in the wheel becomes blocked.

Aetius,Onthe opinions of the philosophersII, 29, 1 (D.K.12A22).

13a Zeus and Poseidon respectively cause thunder and earth-quakes.The Father of Gods and Men thundered terribly from onhigh and from below Poseidon caused the boundless earthto quake and shook the lofty mountain peaks.

Homer,Iliad, 20. 56–58.13b Zeus is the cause of thunder and lightning.

. . . even Okeanos fears the lightning of great Zeus and histerrible thunder when it crashes from heaven.

Homer,Iliad, 21. 198–199.13c Zeus is also the cause of eclipses.

Zeus, the Father of the Olympians, made night at noonwhen he concealed the light of the shining sun.. . .

Archilochus, 74. 3.14. Diogenes LaertiusVIII, 83 (D.K.24A1)15. The Milesian philosopher, Anaximander, conceives the

universe to be a balance maintained between opposing forces.Anaximander said that the first principle <arche>and element of existing things was the apeiron<indefinite/infinite>. He was the first to introducethis name for the arche. He says that it is neither water norany other of the so-called elements, but some other apeironnature, from which come into being all the heavens andthe worlds in them. Things also pass away into thosethings out of which they come into existence ‘accordingto necessity; for they pay penalty and retribution to oneanother for their injustice according to the assessment ofTime’, as he puts it using somewhat poetical terms.

Simplicius,Commentaryon Aristotle’s physics, 24. 13(D.K.12B1 vgl. 12A9).

16. This cosmic theory is adopted by Alcmaeon as the basis of histheoryof health.Alcmaeon holds that what preserves health is the equal-ity <isonomia> of the powers—moist and dry, cold andhot, bitter and sweet and the rest—and the supremacy<monarchia> of any one of them causes disease; for thesupremacy of either is destructive. The cause of disease isan excess of heat or cold; the occasion of it surfeit or defi-ciency of nourishment; the location of it blood, marrow orthe brain. Disease may come about from external causes,from the quality of water, local environment or toil or tor-ture. Health, on the other hand, is a harmonious blendingof the qualities.

Aetius,Onthe opinions of the philosophers, V, 30, 1(D.K.24B4).

17. See, for example, [Hippocrates],AncientMedicine, 14 (1.602,9–14L= CMG1.1, pp. 45–46 Heiberg)

18. See, for example, [Hippocrates],Nature of Man, 4 (VI. 38,19–40, 9L.= CMG I, 13, pp. 172–4 Jou.).

19. Anonymus Londinensis,20.25–37 (Jones, 1947, p. 80)20. Timaeus,82A21. Alcmaeon’s researches into the nature of the sense organs (pre-

seved here by Theophrastus), together with other physiologicalenquiries, exercised a strong influence upon later philosophi-cal thought and contributed to the trend manifested by certainof the Presocratic philosophers in the second half of the fifthcentury to turn from macrocosm to microcosm.[25.] Among those who explain sensation by what is unlike,Alcmaeon begins by defining the difference between manand the lower animals. Man, he says, differs from othercreatures because he alone has understanding, whereasthey have sensation, but not understanding; thought and

sensation are different, not, as Empedocles holds, the same.He next speaks of each sense separately. Hearing, he says,takes place through the ears because they contain emptyspace, which resounds. Sound is produced by the cavityand the air echoes it. Smelling is effected by means of thenostrils when air is drawn up into the brain. Tastes are dis-tinguished by the tongue. Since it is warm and soft it dis-solves substances by its heat and, owing to its porous anddelicate structure, it receives and transmits the flavour.[26.] Eyes see through the water surrounding them. Thatthe eye contains fire is evident, for the fire flashes forthwhen it is struck. Vision is due to the gleaming elementand the transparent when it gives back a reflection; thepurer this element is, the better the eye sees. All the sensesare connected in some way to the brain. Consequently theyare incapacitated if it is moved or shifts its position. For itobstructs the passages through which the sensations takeplace. Concerning touch he tells us neither the manner northe means whereby it is effected. This, then, is the extent ofhis explanation.

Theophrastus,Onthe senses, 25 & 26 (D.K.24A5).22. [Hippocrates],Sacred Disease, Chapter 14 (VI. 386, 15–388,

4L.)23. [Hippocrates],Sacred Disease, Chapter 16 (VI. 390, 10–20L.)24. When<white phlegm> is mixed with black bile and is dif-

fused over the most divine circuits in the head and throwsthem into confusion, the visitation, if it comes during sleep,is comparatively mild, but when it attacks those who areawake it is harder to throw off. As an affliction of the sa-cred substance<i.e. the brain marrow> it is most justlytermed the ‘Sacred Disease’.

Timaeus,85 a–b.25. Praxagoras says that epilepsy occurs in the region round

the thick artery <aorta> when phlegmatic humours ag-gregate within it. These, being formed into bubbles, blockthe passage of the psychic pneuma from the heart and thusthe pneuma makes the body shake and convulse. Againwhen the bubbles have been settled, the condition ceases.Diocles also believes that there is an obstruction in the sameregion and concurs in other respects with Praxagoras.

Anonymus Parisinus3= Ancedotamedica3 (p. 541 Fuchs=DioklesFrg. 51 Wellmann= Praxagoras70 Steckerl).

26. His account is as follows: ‘I examined also the structure ofthe brain. It was divided into two parts, like that of otheranimals, and has ventricles lying there, elongated in shape.These two ventricles were connected by a passage wherethe two parts are joined. From here the passage led into theso-called epencranis<i.e. the cerebellum>, where therewas another small ventricle. Each of the parts was dividedoff by itself—as was also the cerebrum, which was similarto the jejunum and had many folds. The epencranis wasto a still greater extent than the cerebrum furnished withmany varied convolutions. So the observer learns fromthese that, just as in the case of the other animals, the deer,the hare, or any other that far excels the others in running,is well provided with muscles and sinews useful for thisfunction, so in man, too, since he is far superior to otheranimals in intellect, this organ is large and very convoluted.All the nerves grow out of the brain, and, speaking gener-ally, the brain seems to be the source of bodily activity. Forthe sensory channels from the nostrils opened onto it as didthose from the ears. And from the brain nerves led to thetongue and the eyes.

Galen,Onthe doctrines of Hippocrates and Plato, 7.3(V.602K.= CMG V 4, 1, 2 p. 440 De Lacy= Frg. 289

Garofalo).The above description seems to have been based upon humanas well as upon animal brains.