The poor understanding of epileptic disorders in the nineteenth century gave rise to what now would be considered a somewhat remarkable list of surgical and nonsurgical management schemes; these included remedies such as a variety of peculiar diets, bloodletting, magic, religious prayer, ligation of cerebral arteries, etc. In each epoch of time, the treatment of diseases or disorders was most often related to what was considered to be the causes of them at the time. Thus, witchcraft, herbs and plants of all kinds, fetishism, and amulets, often inscribed with sacred incantations, were all used at one time or another, particularly prior to the Renaissance.

At about the time of the Renaissance, epileptic seizures, also increasingly known as a falling sickness (see particularly Temkin 1971), began to be recognized as a physical ailment, rather than magical or occult abnormalities, evil spirits, demons, or irreligious disorders. Metals of various types became a popular treatment. There were many operations by a number of surgeons in the early half of the nineteenth century whose patients had epilepsy. Perhaps Dudley in 1828 might be considered as one whose primary operations could indeed be considered epilepsy operations (see Cutter 1930), but it was really towards the end of the century when epilepsy surgery took its place as a specialized surgery.

An example of a rather remarkable, but not necessarily isolated, report exhibiting the lack of understanding of the basic tenants of epilepsy was that of Alexander in 1883. He reported on his management of epilepsy in the 1870s and early 1880s through the ligature of the vertebral arteries. The report concerned 21 patients, the majority of whom had bilateral vertebral artery ligations. Three were doing quite well for nearly a year, nine others were free from fits sufficiently long “that it may be said a cure has resulted, or is likely to result,” and eight were “improved in so many respects, or are improving so steadily, that the operation would be justifiable were no better results ever obtained!” His conclusion was “I now think that ligature of the vertebral arteries ought to take its place as a recognized operation for the cure of epilepsy ….” It is difficult to know what type of person Alexander was and what might have been his knowledge of epilepsy as he stated, regarding a patient who had a retroflexed uterus, “It may be said, that had the retroflexed uterus been brought into place, the ligature of the vertebrals might have been unnecessary.” The detail of this paper is not to condemn Alexander, but rather to exhibit the ignorance of the understanding of the substrate of epileptic seizures in parts of the nineteenth century. This is particularly so, given that the publication was not only just 3 years prior to the publication by Horsley (vide infra) but that it was in the prestigious journal, Brain.

It was really towards the end of the nineteenth century when there became an increasingly widespread understandable awareness of epilepsy. It was also in this period when the first effective drug against epilepsy was discovered, e.g., bromine.

Sir Victor Horsley, at the age of 29, carried out a surgical operation with the specific objective of removing a cerebral cortical posttraumatic epileptic focus and thereby abolishing seizures on May 25, 1886. This is usually characterized as the first of such specific operative interventions, which is not completely accurate. However, it was really this particular operation that has led to Horsley being acknowledged as the father of epilepsy surgery. Certainly, it was a first from the point of view of the use of the developing neuroscientific evidence, which was burgeoning at the time. However, similar types of such operations are attributed to Duretus in the sixteenth century (noted by Penfield and Jasper 1954). Other early attempts in the USA included those of Dudley (1828) of the Transylvania University Medical School in Lexington, Kentucky (see also Patchell et al. 1987), Billings (1861), and Lloyd and Deaver (1888). Smith provided a survey of the cases in the USA up to 1852 (Smith 1852). In 1888, similar Horsley operations were carried out by Keen and by Nancrede (1896). By the end of 1886, Horsley had carried out nine operations similar to that of the one in May of the same year (1887). O’Leary and Goldring provide a very good nineteenth-century review of the initiation of surgical attempts at dealing with epileptic patients and the consequent advances during the latter part of the century (1976), and for those who enjoy history, Fox’s first chapter in his Dandy of Johns Hopkins, although brief, provides a very interesting history of the beginning of surgery in 10,000 BCE (1984).

In the undertaking of his initial operation, Horsley was both influenced and encouraged to operate on this patient of Hughlings Jackson by Jackson himself. The latter, in turn, had been influenced by the studies of the localization of function within the motor cortex, occurring about the same time, by Hitzig (1900).

It is rather interesting that after epilepsy became recognized as a bona fide disease entity, rather than a psychiatric disability, its acknowledged appearance in many historically important figures began to emerge more often, e.g., Socrates, Greek philosopher (469–399 BCE); Julius Caesar (100–44 BCE); Saint Paul, the Apostle (5–15 CE); Joan of Arc, French saint (1412–1431); Napoléon Bonaparte (1769–1821); Lord Byron, English poet (1788–1824); Fyodor Mikhailovich Dostoyevsky (1823–1881); Alfred Nobel (1833–1896); and Vincent van Gogh (1853–1890).

In the early twentieth century, a stream of prominent German neurosurgeons who operated under local anesthesia provided a significant boost to the quality, experiential background, and frequency of the epilepsy operations (Krause 1909, 1924; Krause and Schum 1931; Foerster 1925, 1926, 1929a, b, 1934, 1936a, b; Foerster and Penfield 1930; Foerster and Altenburger 1935). The success of this led to further operations typical of those that Horsley had conducted on the nine patients by the end of 1886.

In the early part of the twentieth century in North America, when epilepsy surgery was in its infancy, there was a general view among neurologists, especially in the USA, that surgery was of little value in the management of epilepsy. Dr. Wilder Penfield, after studying neurophysiology with Sherrington in Oxford and cerebral morphology with Pío del Río Hortega in Madrid, trained with Foerster in Breslau and then went on to Montreal in 1928 where he developed the Montreal School of Epilepsy Surgery that was so prominent in the training of epileptic surgeons who eventually chaired most of the epilepsy centers throughout the world in the middle of the twentieth century. The review of the influence of the Montreal school has been well documented by others (O’Leary and Goldring 1976; Feindel 1986; Meador et al. 1989; Feindel et al. 2009; Olivier 2010). Parallel to Penfield in Montreal were similar initiatives in the USA by Sachs (1935) and particularly Bailey and Gibbs (Bailey et al. 1935; Bailey and Gibbs 1951). Interestingly, Cushing conducted two operations on patients, under local anesthesia, in 1908 (1909). Documentation of the very significantly important Chicago school has undergone a similar review by Hermann and Stone (1989).

The Chicago (Bailey and Gibbs 1935; Bailey et al. 1951) and Montreal (Penfield and Steelman 1947) schools devoted to epilepsy surgery began in the second quarter of the twentieth century and gained momentum over the middle part of the century, especially the school in Montreal, championed by Drs. Herbert Jasper and Theodore Rasmussen, in addition to Dr. Penfield. Over this era, trainees, the majority of whom had had all or at least some of their formal training at the Montreal Neurological Institute, led epilepsy units worldwide. A plethora of publications over the last half of the century outlined the contributions of the surgical management of intractable epilepsy, which gave impetus to the appreciation of the contributions of neurosurgery in the management of intractable epilepsy (Penfield 1939, 1947, 1950, 1954a, b; Penfield and Evans 1935; Penfield and Steelman 1947; Penfield and Flanigin 1950; Penfield and Welch 1949, 1951; Penfield and Baldwin 1952; Penfield and Paine 1953, 1955; Penfield and Jasper 1954; Rasmussen 1963, 1975a, b, 1977, 1983a, b, c; Rasmussen and Jasper 1958; Rasmussen and Branch 1962).

This heralded the onset of the modern era of epileptology, electroencephalography, and epilepsy surgery in North America. Penfield, using the techniques of cortical stimulation in conscious patients that he learned from the German school, undertook comprehensive stimulation of the cortex, arriving at his now famous homunculus—the cortical localization of human motor and sensory function in the pre- and postcentral gyri.