Hippocratic Approach to Epilepsy; Natural Theory and Practice

The birth of the Hippocratic medicine marked a transition from ritual and folk healing to a profession of secular theory and practice. Epilepsy, with its common occurrence, dramatic presentation, and hidden cause attracted the attention of many healers in the ancient world and was the primary subject of full Hippocratic medical treatise written in fourth century BC. This work known as ‘Sacred Disease’ was the first emphatic argument for a naturalistic understanding and treatment of epilepsy and made advances that would not be surpassed for two thousand years.

Galen one of the most well known and prolific physicians who practiced in Rome in the second century A. D. modeled himself after the Hippocratic ideal physician. This ideal can be conceptualized as a physician healed the sick through skilled practice by applying diligent trial and error and logic, and also was a learned natural philosopher who could defend his actions by knowledge of nature and an understanding of the human body.

The advances of Greco-Roman medicine in understanding and treating epileptic disorders found in the ‘Sacred Disease’ can provide an example how an idealized Hippocratic physician should approach medicine with skilled practice arising from carefully deduced and deafened natural theory. Hippocrates of Kos (cir. 460 BC-380 BC) was an ancient Greek physician is often called “the father of medicine”, and is know for writings an collection of writings of his name the Corpus Hippocraticum.

The corpus was attributed to Hippocrates in antiquity, and its teaching followed principles of professionalism, natural theory, and rigorous practice of applying general diagnoses and passive treatment which was aimed to aid nature in restoring the sick to health. Hippocrates argued that diseases were caused by natural process within the body and not as a result of supernatural action or Gods and his natural philosophy and treatment approaches were emulated and idealized for centuries later.

The principle of naturalistic causes of disease and relying on natural philosophy was forcibly forwarded in the treatise ‘Sacred Disease’ which described the Hippocratic approach to epilepsy. The title, ‘Sacred Disease’ , is counter to the authors premise that epilepsy was in no way a sacred disease, but was simply a disorder of natural origin like other diseases. The writing opens with the assertion: I do not believe that the ‘Sacred Disease’ is any more divine or sacred then any other disease but, on the contrary has specific characteristics and a definite cause.

Nevertheless, because it is completely different from other disease, it has been regarded as a divine visitation by those who, being only human, view it with ignorance and astonishment. 1 This strict application of science or natural philosophy toward the understanding of disease is present throughout the Hippocratic writings and is clearly stated in other treatise ‘Tradition in Medicine’ Medicine has long possessed the qualities necessary to make a science. These are a starting point and a known method according to which many valuable discoveries have been made over a long period of time.

By such method, too, the rest of the science will be discovered if anyone who is clever enough is versed in the observations of the past and makes these the starting point of his researches. If anyone should reject these and, casting them aside, endeavor to proceed by a new method and then assert that that he has made a discovery, he has been and is being deceived. 2 Basing the origin of disease on a understanding of the observable world as opposed to gods or spiritual possession made use of unyielding aspect of a natural philosophy and the idealized Hippocratic physician.

This is because Galen’s view of an ideal physician would be a practitioner that would apply scientific understanding to all processes and not set aside when dealing with hidden or poorly understood processes. Stating that epilepsy has a definite and natural cause is not the end of the argument for Hippocratic author of the ‘Sacred Disease’, he also addresses the counter argument that it is supernatural. The author explains the flaws the supernatural explanations and ritualistic cures for epilepsy in the ancient Greek world.

The author does by using important faculty of sound logic and a desire to inform the common man inherent in the idealized Hippocratic physician. The Greek supernatural understanding of epilepsy assumed that different deities aspects were responsible forms and symptom’s. 3 The author disputes this with logic based argument that the gods would not pollute themselves with possession of the human body. 6 The author of the Treatise also makes the makes logical assertion about the purification rituals and it practitioners:

If the disease can be cured by purification and similar treatments then what is to prevent its being brought on by like devises? The man who can get rid of a disease by his magic could equally well bring it on; again there is nothing divine about this but a human element is involved. 4 By countering the supernatural assumptions regarding the causes of epilepsy that were prevalent during the author’s time the he provided an example of how to defend a naturalistic theory that could be a logical alternative to supernatural explanations.

With limited technology and taboos regarding posthumous forensic techniques on humans the Hippocratic author had an sophisticated understanding of the natural causes of epilepsy. The author of the ‘Sacred Disease’ made two very important derived assertions that epilepsy is heritable, that epilepsy is brain disorder, and the symptoms are influenced by the environment. The author uses these observations to describe the naturalistic explanations of the disease which is another quality of the idealized Hippocratic physicians because he must defend his actions and understanding based on observations of the natural world.

The Hippocratic author explanations his theory of heredity as, “The seed comes from all parts of the body; it is healthy when it comes from healthy parts, diseased when it comes from and diseased parts. ”5 The author when on to make a final deductive argument for heritability and against the supernatural origin of epilepsy by writing: Another important proof that this disease is no more divine then any other lies in the fact that the phlegmatic are constitutionally liable for it while bilious escape.

If its origin were divine, all types were be affected without this particular distinction. 6 The Hippocratic author of the ‘The Sacred Disease’ made the revolutionary determination that epilepsy was a result of a brain disorder, and began his detailed theory on the origin of epilepsy by, “… , the brain is the seat of this disease, as it is of many other very violent diseases. I shall explain clearly the manner in which it comes about and the reasons for it. ”7

The author then includes what was know at the time regarding brain anatomy and physiology including a discussion of the neural membrane surrounding the brain, the fluid filled cavities, and blood supply, during which he made another innovative assertion that headaches are somehow related to the blood supply to the neural membranes. 7 The author also linked the natural origin of epilepsy to disruptions of the flow of of essential air through the blood vessels be the execration of excess phlegm by the brain. 8 For the author the root cause occurs before childbirth:

Its [epilepsy] inception is even while the child is still within its mothers womb, for the brain is rid of undesirable matter and brought to full development, like the other parts, before birth… if this “cleansing” doesn’t not take place but the material is retained in the brain, a phlegmatic constitution is bound to result. This explanation of epilepsy was based on the Hippocratic understanding of Humorism in that the human body was filled with the four fluids of yellow bile, black bile, phlegm, and blood that are in balance when a person is healthy and diseases resulted from an excess or deficit of one of these four humors.

The author explains how an excesses of phlegm causes the various symptoms of epilepsy: Should these routes for the passage of phlegm from the brain be blocked, the discharges enters the blood-vessels which I have described. This causes loss of voice, chocking, foaming at the mouth, clenching of the teeth, and convulsions movements of the hands; the eyes are fixed, the patient becomes unconscious and, in some cases passes stool. 9 The author defends and grounds his theory not only with the prevailing understanding of humoral medicine of ancient Greece but also in sound observations and logical deductions.

The most complex example of this is the authors examination of epileptic goats and the relation to humans. The author describes his finds as: This observation results specially from the study of animals, particularly goats which are liable to this disease… If you cut open the head you will find the brain is wet, full of fluid and foul-smelling, convincing proof that disease and not deity is harming the body. It is just the same with man, for when the malady becomes chronic it is incurable.

The brain is dissolved by phlegm and liquifies; the melted substance thus formed turns to water… 247 The author suggests how epilepsy is related to the weather and winds and may effect the severity or unset of epileptic due to changes of temperature and moisture. He also explains that winds from the South that often carried storm systems and moisture into Greece and the norther Mediterranean areas brought on the attacks and wrote,”Attacks are most likely when the wind is southerly”.

He defends his position on the weather and winds contributing to the illness by writing: … the human body is made to feel changes in the wind and undergo changes at that time, it follows that southerly winds relax the brain and make it flabby relaxing the blood vessels at the same time. 250 The author reenforces his argument later with: As the brain is the first organ in the body to perceive the consciousness derived from the air, if the seasons cause any violent change in the air, the brain undergoes its greatest variation. 51 The author of the ‘Sacred Disease’ provides an example of how an ideal Hippocratic physician should approach the theory in medicine through natural philosophy, because each of his assertion are backed by real observation and logical deduction. The assertions that epilepsy is a disease or the brain, is heritability, and effected by the environmental conditions of the patient are revolutions in thought compared to the supernatural assumptions that came before and after Hippocratic medicine.

The author of the sacred disease understood the complexity and huge limitations in treating a disorder of the brain such as epilepsy in his time when he states “… diseases of the brain are the most acute, most serious and most fatal, and the hardest problem in diagnosis for the unskilled practitioner. ” 251The author recommends no specific drugs or offers any quick cure for epilepsy. The author does offer general recommendations that are in tuned how an idealized Hippocratic physician should always attempt to do no harm in there treatment with the statement:

In this disease as in all others, it should be your aim not to make the disease worse, but to wear it down by applying the remedies most hostile to the disease and those things to which it is unaccustomed. 250 The Hippocratic author also urges the treating physician to use his accumulated skill in recognizing the particular patient and their illness and design a regime of diet and life style to limit the advance of the disease or even cure it given enough skill of the practitioner.

In this way the author provides an example of an idealized Hippocratic physician greatly skilled in his practiced by years of experience and careful observation of his patient can bring his patient back to health. The Hippocratic author of the ‘Sacred Disease’ provided a case example of what an idealized Hippocratic physician should approach the theory and practice of the difficult disease of epilepsy. The author may be credited as being the first person to express that epilepsy was a disease caused naturally within the body and not as a result of superstition or Gods.

The Hippocratic author recognized that epilepsy was a brain disorder, that it was heritable, and sensitive to the patients environment. For the treatment of epilepsy the author used the Hippocratic cannon of first doing no harm and using skilled practice with passive treatments aimed to restore balance and health. These revolutionary ideas were distilled into a full naturalistic theory and treatment of epilepsy defended by many years of observation and deduction and are exemplary of Galen’s idealized Hippocratic physician. G. E. R. Lloyd (ed. ), Hippocratic Writings (London: Penguin Books, 1983). ISBN 0140444513

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