Changing phenomenon

QOL is not a static phenomenon. It is in a constant state of flux, with changes being related both to objective circumstances (for example, deteriorating physical health) and subjective perceptions (for example, changing expectations).

CHAPTER 2 EPILEPSY

2.1 HISTORY

The sacred disease, an ancient name for epilepsy, is probably the oldest known disorder of the brain. As early as 2080 BC it was mentioned in the ancient Babylonian law of Hammurabi (Scott, 1973). The terminology 'the sacred disease' probably arose as a consequence of the belief that epilepsy was an illness inflicted by the gods. The thread of superstitious belief runs throughout the history of epilepsy. Not only has it been viewed as an infliction from the gods, but it has also been associated with possession by demons or evil spirits and as a punishment from Selene, the goddess of the moon (Temkin, 1948, p 6 ) .

The first reference to epilepsy as a disease with natural causes is to be found in a monograph entitled 'On the Sacred Disease' which is part of the Hippocratic collection of medical writings and dates from the year 400 BC. This treatise, written for the lay person, was aimed at dispelling the popular myths that surrounded epilepsy at that time. It proposes a theory of the aetiology of epilepsy which contains four main components. First, epilepsy is held to be a natural disease; second, like other diseases, it is hereditary; third, the seat of the cause of the disease lies in the brain; fourth, a humoral principle is proposed to explain the illness. The humoral theory, based on the four humors of blood, phlegm, black bile and yellow bile, was (with a few minor variations) generally accepted by subsequent physicians and philosophers. Galen, 500 ' years after Hippocrates systematised and expanded the humoral theory to include the four qualities of cold, warm, moist and dry. Galen believed (as did Hippocrates) that epilepsy originated in the brain and that it was due to an obstruction caused by the agglomeration of a thick humor in the middle or posterior ventricles of the brain. This blocked the passage of the psychic pneuma (which, through the spinal cord and nerves, accepted sensations and carries commands to the voluntary m u scles). Convulsions were the body's way of ridding itself of the blockage. He further

postulated that the humor could be either phlegmatic (cold and moist) or melancholic (cold and dry) (Temkin, 1948).

The Dark and Middle Ages saw a regression back towards a non-scientific approach to epilepsy. Little differentiation was made between epilepsy and other 'falling evils', for example, periodic ecstasies and raptures. Epilepsy became increasingly associated with possession, this idea being substantiated by Christian beliefs and writings about the miracles of Jesus (Hill, 1981). It was also during this period that the link between epilepsy and the moon was strengthened. The term 'lunatic' was used to describe people suffering from abnormal states that were regular and periodic attacks, including those suffering from epilepsy (Temkin, 1948, p 9 0 ) . The idea of epilepsy as a contagious disease can be traced back to the ancients, and during medieval times this view persisted. It was only in the 16th century, a time which saw increasing knowledge about contagious diseases, that the contagious aspect of epilepsy was refuted by physicians. The medical theories of the medieval ages saw little advance on those proposed by Galen. Temkin (1948) does however pay tribute to the physicians of this time for keeping alive the tradition of epilepsy as a natural disease.

The Renaissance period and onwards saw a broadening of clinical knowledge of epilepsy and a weakening of the superstitious beliefs, although there is some evidence to suggest their existence as late as the 20th century (Temkin, 1948, p 2 1 0 ) . One of the many theories to emerge at this time was the irritation theory of epilepsy. This theory, while partly based on the work of Galen, was first described by Fernelius [1485-1558] and sees cerebral irritation as the cause of epilepsy. This view was challenged by Willis [1621- 1675] and Boerhaave [1668-1738], who both viewed epilepsy from a more scientific and clinical viewpoint, seeing it simply as a physical consequence of pathological processes (Bunker, 194 8) . In the 19th century a divergence of views started to be seen in the psychiatric and neurological fields. Psychiatrists, generally dealing with the most resistant cases, saw epilepsy in global terms proposing a 'degeneracy

theory' where the disease was the result of a progressive hereditary degenerative strain. In contrast, neurologists were interested in a physiological understanding of the nervous system and the relationships between seizures and brain pathology (Hill, 1981).

In more recent times, Russell Reynolds (1861) was the first to acknowledge and define 'idiopathic epilepsy', while Hughlings Jackson (Jackson, 1870; Jackson, 1873; Jackson,

1890) in his writings on paroxysmal disorders produced the first scientifically accurate description of epilepsy: 'an occasional, sudden, excessive, rapid and local discharge of grey matter'. Gowers (Gowers, 1881; Gowers, 1907) and Lennox (Lennox, 1941; Lennox and Lennox, 1960) also deserve a mention for their contributions to the study of epilepsy. The 20th century has seen many advances in the our knowledge of epilepsy, including innovations in treatment and diagnoses. Undoubtedly one of the major contributors was the introduction of the EEG in 1929 by Hans Berger. Other major innovations include the introduction of phenobarbitone in 1912 and phenytoin in 1937 (Bunker, 1948).

2 . 2 DEFINITION AND CLASSIFICATION