Pediatric Annals

A Pediatrician's View

Milton I Levine, MD

Abstract

It seems almost unbelievable that one physician could have closely followed over 32,000 epileptic patients (most of them children), among whom there were 1,600 cases of myoclonic epilepsy of infancy and childhood and 708 cases of petit mal.

This record should at least entitle the physician, Dr. Samuel Livingston, not only to recognition as the world's authority on epilepsy but also to a notation in the "Guinness Book of Records" and an illustrated page in Ripley's "Believe It or Not."

Dr. Livingston established the Epilepsy Clinic at Johns Hopkins Hospital in 1936. At that time, and for a good many years that followed, there was a definite stigma attached to the condition. Most families kept its occurrence secret, for it usually was a bar to schooling and employment. Many states banned the marriages of epileptics, and some states even had sterilization statutes applicable to people with epilepsy.

Six years ago, in an issue of Pediatric Annals, Dr. Livingston described the early days of the Epilepsy Clinic. He noted that at that time, in 1936, only 10 per cent of the patients were controlled sufficiently to lead normal lives. Ten years later 17.4 per cent of the patients had been seizurefree five years or more. And after 37 years of close follow-up and treatment, approximately 60 per cent of the patients had complete seizure control, with 25 per cent more so well controlled they could live essentially normal lives.

Under Dr. Livingston's leadership and inspiration, there has been through the years a reeducation of physicians, an expansion of medical services available to the epileptic, and marked changes in the laws, attitudes of school and other educational officials, and acceptance of epileptics in most fields of employment.

Almost all of us in the practice of pediatrics have treated infants and children with seizure disorders. Many of the attacks, on the surface at least, appear to be clear-cut or definite in diagnosis, such as febrile convulsions, attacks of petit mal, or classic grand-mal attacks. But there are other situations that are more complex and require fuller diagnostic study. A child, age 12 years, who has had an uneventful past, develops attacks of thrashing about in bed at night. These resemble night terrors and are followed by a deep sleep from which he cannot be awakened. Are these epileptic seizures? Another child develops occasional attacks of abdominal pain, after which he falls asleep. A third child has a tendency to suffer from headaches always associated with abdominal pain. A fourth child is subject to febrile convulsions, sometimes lasting 30 to 45 minutes. Are all of these evidence of epileptic attacks?

Many other questions also confront us, among which are the importance and accuracy of electroencephalograms. Is a negative EEG of diagnostic importance in a child who has had a seizure? Also, once an EEG gives a positive finding, can one expect a successful symptomatic result to be followed by a normal reading? And, of course, what is the most effective treatment and how long should it be continued?

Dr. Livingston and his staff will cover the subject of the diagnosis, classification, and treatment of convulsive seizures and epilepsy in this issue of Pediatric Annals and the issue that follows.

The first article in this issue is devoted to a full discussion of febrile convulsions. Joining with Dr. Livingston in preparing this presentation are Dr. Lydia L. Pauli, Dr. Irving I. Kramer, and Mr. Irving Pruce. This authoritative paper is based on a careful and continuous study of 622 patients who have been followed from 1936 to the present time. The differentiation is made between…

It seems almost unbelievable that one physician could have closely followed over 32,000 epileptic patients (most of them children), among whom there were 1,600 cases of myoclonic epilepsy of infancy and childhood and 708 cases of petit mal.

This record should at least entitle the physician, Dr. Samuel Livingston, not only to recognition as the world's authority on epilepsy but also to a notation in the "Guinness Book of Records" and an illustrated page in Ripley's "Believe It or Not."

Dr. Livingston established the Epilepsy Clinic at Johns Hopkins Hospital in 1936. At that time, and for a good many years that followed, there was a definite stigma attached to the condition. Most families kept its occurrence secret, for it usually was a bar to schooling and employment. Many states banned the marriages of epileptics, and some states even had sterilization statutes applicable to people with epilepsy.

Six years ago, in an issue of Pediatric Annals, Dr. Livingston described the early days of the Epilepsy Clinic. He noted that at that time, in 1936, only 10 per cent of the patients were controlled sufficiently to lead normal lives. Ten years later 17.4 per cent of the patients had been seizurefree five years or more. And after 37 years of close follow-up and treatment, approximately 60 per cent of the patients had complete seizure control, with 25 per cent more so well controlled they could live essentially normal lives.

Under Dr. Livingston's leadership and inspiration, there has been through the years a reeducation of physicians, an expansion of medical services available to the epileptic, and marked changes in the laws, attitudes of school and other educational officials, and acceptance of epileptics in most fields of employment.

Almost all of us in the practice of pediatrics have treated infants and children with seizure disorders. Many of the attacks, on the surface at least, appear to be clear-cut or definite in diagnosis, such as febrile convulsions, attacks of petit mal, or classic grand-mal attacks. But there are other situations that are more complex and require fuller diagnostic study. A child, age 12 years, who has had an uneventful past, develops attacks of thrashing about in bed at night. These resemble night terrors and are followed by a deep sleep from which he cannot be awakened. Are these epileptic seizures? Another child develops occasional attacks of abdominal pain, after which he falls asleep. A third child has a tendency to suffer from headaches always associated with abdominal pain. A fourth child is subject to febrile convulsions, sometimes lasting 30 to 45 minutes. Are all of these evidence of epileptic attacks?

Many other questions also confront us, among which are the importance and accuracy of electroencephalograms. Is a negative EEG of diagnostic importance in a child who has had a seizure? Also, once an EEG gives a positive finding, can one expect a successful symptomatic result to be followed by a normal reading? And, of course, what is the most effective treatment and how long should it be continued?

Dr. Livingston and his staff will cover the subject of the diagnosis, classification, and treatment of convulsive seizures and epilepsy in this issue of Pediatric Annals and the issue that follows.

The first article in this issue is devoted to a full discussion of febrile convulsions. Joining with Dr. Livingston in preparing this presentation are Dr. Lydia L. Pauli, Dr. Irving I. Kramer, and Mr. Irving Pruce. This authoritative paper is based on a careful and continuous study of 622 patients who have been followed from 1936 to the present time. The differentiation is made between "simple febrile convulsion" and "epileptic seizures precipitated by fever," designations first made by Dr. Livingston in 1954. This article answers most of the questions that arise concerning febrile convulsions. Among these are the questions of a need for a spinal tap, the need for phenobarbital routinely at the first elevation of temperature in children who have suffered one attack, the validity of continuous daily treatment with phenobarbital for several years to prevent attacks, and the question of whether or not repeated febrile convulsions adversely affect the mental ability of the children suffering from them.

The next article is a most informative discussion on the diagnosis of epilepsy by Dr. Livingston and Dr. Pauli. First, the taking of the patients' medical histories is discussed, with descriptions of the various types of aura. Then follows a description of the typical grand-mal seizure. The precipitating factors are then discussed in detail - some of which, I believe, will be unfamiliar to most pediatricians. Among the precipitating factors mentioned are musicogenic epilepsy (seizures provoked by certain types of music), and reading epilepsy (seizures precipitated by reading). The use and value of electroencephalograms is next considered. How dependable are the findings, and can these be used in determining the prognosis? Other diagnostic procedures are also discussed, including especially the computerized axial tomography (CAT) scan. An area of discussion that is of special interest to pediatricians is that devoted to the differentiation of epilepsy from emotional or psychiatric disorders. Here Dr. Livingston covers syncopal attacks, nightmares and night terrors, abdominal pain and headaches, migraine, narcolepsy, breath holding, and emotional upsets. This is an article that should be carefully read by all pediatricians, for it clearly covers most of the situations that confront the practitioner in his attempt to diagnose the nature of a seizure disorder.

The final contribution in this first of two issues on epilepsy is the "Classification and Clinical Features of Epilepsy Seizures," by Dr. Livingston, Dr. Pauli, Mr. Pruce, and Ms. Maria Zobniw. This article is of particular value, for there have been so many classifications and so many nomenclatures that the practicing physician is often confused. In this paper, Dr. Livingston and his associates have presented a simple and clinically meaningful classification based on their own direct clinical observations and electroencephalographic studies of their approximately 32,000 patients evaluated in their clinic. They have listed them in five categories: grand-mal epilepsy, petit-mal epilepsy, psychomotor (temporal-lobe) epilepsy, myoclonic epilepsy, and autonomic epilepsy (which includes abdomepilepsy). All of these various are described with discusion of their clinical manifestation, electroencephalograms, and prognosis. The purpose of this article on classification, then, is to serve not only as a guide to diagnosis but, more important, as a guide to to treatment and prognosis.

With the articles in this issue and the following issue of Pediatric Annals, the practicing pediatrician will have the most authoritative and up-to-date text on epilepsy during childhood and adolescence that is now available. I am sure that most readers will file them for ready reference.

10.3928/0090-4481-19790301-03

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