Bringing Epilepsy Out of the Dark Ages: Diagnosis Before EEG

Until the development of EEG (electroencephalography) in the early 1900s, the diagnosis of epilepsy had been difficult to confirm and was often confused with other conditions. In the introduction to Owsei Temkin’s book, The Falling Sickness, he states that “in the struggle between the magic and scientific conception…epilepsy held one of the key positions.” This is because it caused both mental and physical symptoms. For example,

• When partial (focal) seizure involves a structure called the limbic system (the emotional center of the brain), an aura may consist of any emotion, from rage to spiritual ecstasy.
• Temporal lobe epilepsy commonly causes seizures consisting of odd behavior. It is sometimes associated with dream-like states.
• In his book Musicophilia, Oliver Sacks described temporal lobe seizures as, "an odd, superimposed state in which [people] experience strange moods, feelings, visions, or smells."

Did Vincent van Gogh have epilepsy?

Although the understanding of epilepsy had improved in the late 1800s, neurology as a science was still in its infancy. One excellent example of the difficulties in diagnosing seizures and epilepsy was the case of Vincent van Gogh, an artist who may have suffered from epilepsy.

• Around 1888, there were reports than Van Gogh was having auditory hallucinations (hearing voices or sounds) and was losing large chunks of time.
• His medical history included a "difficult birth" and a family history of seizures.
• All of these factors combined led his doctor to suspect he was suffering from seizures.

Van Gogh's physician was well-read and familiar with the work of his respected contemporary, the English neurologist Hughlings Jackson. Jackson regularly published his neurologic observations.

• In 1870, Jackson proposed that each part of the body (face, hand, arm, etc.) was represented by a specific part of the brain. This was based on his observations of jerking movements in partial seizures.
• Despite this growing understanding of the brain and epilepsy, an objective test for diagnosing epilepsy did not exist.
• All of these factors combined led his doctor to suspect he was suffering from epilepsy.

Since Van Gogh's doctor was relying on observation and family history, it would also be easy to think that Van Gogh had something other than epilepsy.

• For instance, Van Gogh could have had a mood disorder. Stories of a period of hyper-religious behavior, days to weeks of intense sadness, and periods of inspiration and painting are more suggestive of a primary psychiatric disorder such as bipolar disease. Although mood disorders are commonly associated with epilepsy, seizure-related behavioral change tends to be brief, typically lasting minutes to hours. This is in stark contrast to primary psychiatric symptoms, which last for much longer periods, anywhere from days to months.
• Van Gogh's situation was further blurred by the fact that he may have suffered from syphilis, a sexually transmitted infection that can cause brain lesions and seizures.

The Dark History of Centuries Long Ago

Psychiatric and infectious diseases were not the only things making it hard to diagnose epilepsy prior to the advent of the EEG. During the Middle Ages, many people believed that demonic possession caused epilepsy. As this belief faded, some people were thought to mimic or fake seizures for personal gain.

• In Renaissance Europe, people would feign seizures for a variety of reasons. One scheme involved two people: one to fake a seizure in a public place, thus gathering a crowd, while an accomplice would pick the pockets of distracted onlookers.
• Others would feign epilepsy as a means of begging.
• There are also reports of prisoners having “attacks” to evade punishment.

Unfortunately, this behavior only made it harder for people suffering from genuine seizures to be diagnosed and treated properly.

• Lacking objective tests and dealing with many myths and stigma, physicians at the time struggled to figure out who had epilepsy and what caused it. This resulted in a variety inaccurate and often cruel treatments and procedures.
• Sadly, for many centuries, physicians put their trust in causing pain or threats of operations to find out what was going on and expose frauds. One story tells of a young man pretending to be unconscious until the physicians in his room said out loud they intended to castrate him as treatment. The man became alert and begged them to stop.
• This was not always an empty threat. For over a century masturbation was considered a leading cause of epilepsy and castration was thought to cure it.

Diagnosing Epilepsy in Modern Times

• Although we now have technology that can objectively identify seizures, telling the difference between epileptic seizures from nonepileptic events can remain a challenge. Fortunately, the development of video-EEG has allowed epilepsy specialists to distinguish the two with a high degree of certainty. And this leads to better treatment for people with epilepsy and those with events from other causes.
• The spread of epilepsy centers and the team approach for caring for someone living with seizures has also improved diagnosis.
• Other modern advancements in diagnosis and care, include genetic testing, neuroimaging, patient-centered health care, and quality care principles, are also making a difference.