Pedro de Horta and The Medical-Moral Account on Epilepsy: The First Treatise of Epilepsy in Latin America

Dr Rocha has kindly written the following account of the first Latin American  treatise on epilepsy for Epigraph. This was completed in 1611 by Pedtro de Horta and provides a vivid insight into contemporary understanding of and attitudes about epilepsy.

Pedro de Horta was a Spanish physician who moved to Mexico at the middle of 18th century. He got the license to practice medicine by “Real Tribunal Protomedicato” of the New Spain. He was the physician-in chief of the “Hospital Real del Señor San Pedro” and of the “Convento de Señoras Religiosas Capuchinas” in Puebla. Pedro de Horta supported his theories on ideas of modern authors such as Hemann Boerhaave (1668-1738), a Dutch humanist and physician of European fame, considered the founder of the clinical teaching and of the modern academic hospital. Before Pedro de Horta, the description of epilepsy appeared in important medical Spanish books from the 17th century, such as “Liber Deaffectionibus Puerorum”, a treaty on pediatry written by Francisco Perez-Cascales in 1611, including a chapter dedicated to describe the epilepsy in children. The “Praelectiones Vallisoletanae”, considered the first Spanish treaty about the epilepsy, was written in 1631 by Antonio Ponce de Santa Cruz.

In September 7 of 1754, in Puebla (meaning in nahuatl the place where the water becomes red) town (located at 150 km East to Mexico City), the nun Alexandra Beatriz de los Dolores, prioress of the convent of the religious order of “San Jerónimo”, sent a letter to her confessor Gaspar Antonio Mendez de Zisneros in order to inform him the situation of 15 nuns afflicted by severe convulsions during 1 to 12 years. In such report, the prioress described the signals and symptoms that the nuns underwent during the seizures. The incidence of such illness was higher from 1750 to 1754, a situation that suddenly disappear after the nuns pried for a miracle to Guadalupe Virgin. At the request of prioress Alexandra Beatriz de los Dolores in order to understand the causes of seizures, the first treaty of epilepsy in New Spain was written by Pedro de Horta entitled “Informe Médico Moral de la Penosissima y Rigurosa Enfermedad de la Epilepsia“ (The Medical-Moral Account of the Most Troublesome and Rigorous Illness of Epilepsy), and it was printed in 1763 at the shop of Domingo Fernandez de Arrojo in Madrid.

In his Medical-Moral Account, de Horta divided the abnormal movements improperly known as “telele” or “tembeleque”, as follows: a) epilepsy, as “forced, involuntary preternatural, violent, convulsive shaking of the nervous (system)-membranous-muscular parts of the whole body, with loss of consciousness”; b) convulsive movements as “spasmodic wandering movements continuously changing their location in the body, not associated with loss of consciousness, which are originated in the nervous membranes around the joints and secondarily propagated to meninges of the brain and spinal cord”; c) seldom spasmodic movements, as “muscular contractions specially of limbs, not associated with loss of consciousness that are induced by irritation of meninges of spinal cord and nerves”. Epilepsy was also classified as hereditary or nonhereditary, accidental, idiopathic and sympathetic.

The causes of epilepsy were divided into immediate and remote. The immediate causes of epilepsy were disturbances of the body functions. They were classified as follows: a) hereditary nature; b) congenital disposition, c) damage of the brain and its membranes by factors such as tumors, cartilaginous changes of the venous sinuses, infections, etc., d) association of hereditary or congenital weakness with conditions that increased influx of liquids toward the brain; e) violent affects of nervous type such as severe pain; f) retention of biological fluids (urine, menstrual blood, lochia, semen); g) vapors and miasmas ascending to the brain; h) diseases such as malaria; i) presence of fever or infections; j) other situations such as mood alterations and lack of sleep.

The remote causes were situations that make the body susceptible to epilepsy, but themselves are insufficient to produce it, such as abuse of unnatural things, the character, the natural disposition, the origin of the person, deprivation of sleep, and other conditions that could produce acute or chronic diseased that finally result in epilepsy. In this case, de Horta indicated that convulsions could also result from the toxic effects induced by herbs, animals or minerals applied for magic purposes. The duration of the epilepsy induced by remote causes, the most difficult to treat, can be short or long continuous or periodical, frequent or seldom. The periodicity of the convulsions was associated with events such as the Moon stations, weather situation, mood changes, exhaustive meditation or ingestion of alcoholic substances.

The causes of epilepsy were also classified as natural, “sobrenatual” and “transnatural”, the later two associated with demoniac sources. Pedro de Horta extensively emphasized the role of the physician to investigate and treat the natural causes of epilepsy before to think about “sobrenatural” and “transnatural” causes. He described the signs and symptoms associated with the aura, the ictal and postictal periods. However, he rejected that the ability to talk or understand an unknown language by the patient during the postictal period could be associated with epilepsy of natural causes.

About the therapy of the epilepsy, de Horta used the term “antiepileptic” and he suggested treatments that should be applied during the attack (stimulation of the body, especially the feet, focused to recover the conscience of the person and reduced the attack) and during the postictal and interictal intervals. Depending on the cause of epilepsy, he recommended sedatives, distillation of fragrant flowers, bloodlettings, purgatives, emetic agents, anodynes, narcotics, antihysterical agents, caustic substances, diuretics, opiates, diuretics, etc. He put attention into prevent subsequent convulsions trying to restore the normal functions.

Although de Horta established that epilepsy and convulsions are difficult to be treated, especially in persons with high susceptibility to suffer them, their cure is not impossible. He described different prognosis of epilepsy, depending on the cause. At this point, he established that the epilepsy is incurable when is associated with hereditary predisposition or brain damage induced by tumors or venous malformations. In contrast, the epilepsy could be medically treated when appears before or after the puberty. Interestingly, he indicated that infants are more susceptible to present convulsions. de Horta established that the prognosis is poor if the epilepsy induces blindness, reduced memory or stubbornness, and decreased cerebral functions could be induced if the patient with epilepsy becomes old.

In the last part of his book, de Horta extensively described the treatment by exorcisms of the epilepsy induced by “transnatural” causes. He indicated that this type of epilepsy is normally resistant to medications. In addition, he indicated that the antiepileptic drugs, such as narcotics and opiates, may induce secondary undesired effects in patients with this type of epilepsy, and eventually they die as consequence of the convulsions. 

De Horta described the personality of epileptic patients in which the mood alterations facilitate the seizures. He also distinguished between the true epileptic seizures from nonepileptic seizures (pseudoseizures), the latter attributed to demonic forces. Indeed, de Horta suggested that the persons dedicated to spiritual exercises, such as nuns, are more susceptible to present epileptic attacks induced by the devil and that the application of exorcisms is the best strategy for their treatment. At this point, he emphasized the necessity to discover and treat the possible natural causes of epilepsy by the physician, before to call the confessor for treating the moral causes.

He established that the “pseudoseizures” are associated with mental disorders (melancholy, hysteria, maniac alterations) or with some type of personalities (compulsive or shy). Although he put emphasis on the evaluation these disorders in order to avoid erroneous diagnosis, he indicated that some mental alterations (hysteria, maniac disorder, melancholy) could be associated with epilepsy.

It is clear that the nuns of the religious order of the Hieronymites underwent “epilepsy” as consequence of collective hysteria because they were suddenly cured one day after they pried to the Virgen de Guadalupe. Calva-Rodirguez (2004) indicated that this was a common situation in places where the people stayed uncommunicated and during long periods of starvation, such as Mexican convents during the 18th century. However, this incident resulted in the first manuscript about epilepsy written in the New World. In this book it is possible to find out very interesting descriptions, that reveal the scientific attitude of the author to explain the epilepsy according with the following aspects: a) the role of the physician to treat and prevent further seizures; b) a clear classification of the seizures; c) the identification of natural causes of epilepsy; d) the treatment of seizures using traditional medicine and drugs such as narcotics and opiates; e) the prognosis of epilepsy; f) the association of epilepsy with mental disorders; and g) the identification of pseudoseizures. Definitely, the treatments suggested by de Horta are in contrast with the rough actions suggested by priest at that time in other countries, such as processes and burning the people suffering convulsions.

The deficiency of Galenic concepts throughout the Medical-Moral Account supports the use of new medical concepts by Pedro de Horta. Although the medicine in the New Spain during the XVIII century was influenced by superstitions and magic ideas, there was a group of physicians that introduce new ideas about physiology, anatomy, surgery and pathology as well as the use of instruments such as the microscope and thermometer. Important schools for physicians were founded, such as the “Escuela Real de Cirugía” in 1768. Interestingly, the medical literature was extensive at that time. This situation, in agreement with the advance of the science in different fields in New Spain (astronomy, mineralogy, metallurgy, zoology, botany) could explain the advanced concepts used by de Horta to explain the epilepsy.

Although it is clear the influence of the Mexican traditional medicine for the treatment of epilepsy, de Horta also claimed for non natural or “moral” causes of epilepsy with the purpose to explain the pharmacoresistant epilepsy and pseudoseizures that should be treated by the confessors applying exorcisms. It is possible that this last situation helped the favorable reception of the book by the catholic authorities.

At present, a copy of Pedro de Horta´s book is located in the “Palafoxiana” library located at downtown of Puebla, a beautiful building that contains several ancient books written by scientists from the old Mexico.

References
Calva-Rodríguez, C. Reseña Histórica del Informe Médico Moral de la Penosísima y Rigurosa Enfermedad de la Epilepsia “1754”. Puebla: Secretaría de Salud, 2004.

García-Albea, E. El Informe Médico-Moral de la penosissima y rigurosa enfermedad de la epilepsia (1763), del hispano Pedro de Horta, el primer tratado americano sobre la epilepsia. Rev. Neurol. 26: 1061-1063, 1998.

Soria, E.D., Fine E.J. The Medical-Moral Account on Epilepsy by Pedro de Horta: a Historical Review. Epilepsia 36: 736-739, 1995.

Autor: Luisa Rocha M.D., Ph.D. Depto. Farmacobiología. Sede Sur del Centro de Investigación y Estudios Avanzados. México, D.F. lrocha@cinvestav.mx