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CHILDHOOD SEIZURES
1416 CHILDHOOD SEIZURES
SIR,-It is possible that the way in which Mr Harrison and Taylor (May 1, p. 948) present their follow-up data on childhood seizures has overemphasised the seriousness of one seizure (or group of seizures) occurring only in the first two years of life. In the analysis of the various aspects of their follow-up information, all their patients are grouped together, irrespective of the time of onset, total number, and duration Dr
of seizures. This method of presentation may be obscuring some important difference between subgroups of these children. For instance, in a follow-up study of epilepsy in the approximately 5000 children in the National Survey of Health and Development; it seemed clear that children who have one seizure (or one group of
seizures) in the first two years of life are rarely the same children who have continuing or even occasional epi-
lepsy later on. This implies that if the data of Harrison and Taylor were presented to show the fate of these two groups separately, the prognosis of children with continuing or latero, iset epilepsy might be very much worse than that of children who have only infantile seizures. Occupational achievement and income are analysed by Harrison and Taylor in respect of remitted or continuing epilepsy, but the time of remission is not stated. Further subdivision into (a) seizures before the age of 2 years only, (b) seizures remitted since age of 2 years, and (c) continuing epilepsy, might well show an important gradient of poor prognosis. It is necessary to avoid causing undue concern to parents of infants who have an isolated seizure, and by a simple rearrangement of their data, Harrison and Taylor could throw further light on this important point. Professorial Unit,
Mapperley Hospital Nottingham NG3 6AA
*** This letter has been shown follows.-ED. L.
J. E. COOPER to
Mr Harrison, whose
of childhood seizure disorders for any age of onset. We do feel that the sociological perspective of epilepsy has been ignored or, perhaps more accurately, confused with the medical perspective, in particular by what we would regard as the arbitrary removal of certain groups in the study of prognosis of seizure disorders. This we hold to be responsible for the discrepancy between the doctors’ perception of the significance of some types of seizures and that of the patients or parents. We may be at fault for insufficiently stressing the sociological bias of our paper which we trust is now apparent. As a result we hope that there will be a greater appreciation of why some parents with a child who has a seizure at any age may be extremely frightened. Development Research Unit, Department of Psychiatry, University of Oxford, Park Hospital for Children, Headington, Oxford OX3 7LQ Human
R. M. HARRISON
RECURRENT HERPES SIMPLEX
SIR,—Dr Boyd (March 20, p. 650) is puzzled by the restricted distribution of the vesicular rash of herpes simplex. May I suggest that the circumoral distribution of herpes-simplex lesions could be explained by the fact that this region is the part of the trigeminal dermatome which receives both an abundant blood-supply and a liberal sensory innervation. Since replication of the herpes type-I virus is sometimes favoured by an increase in temperature this simple anatomical fact may explain why the eruption favours the circumoral region. Medical School, University of Tasmania, Hobart, Tasmania, Australia
RUPERT G. SHERWOOD
reply SMOKING AND THE FETUS
SIR,—Iwelcome Professor Cooper’s letter suggesting that the
SIR,—Dr Davies and his colleagues (Feb. 21, p. 385),
one
with Rush,’ have suggested that a large part of the effect of maternal smoking during pregnancy on birth-weight is mediated through low maternal weight gain, with only a very small additional direct effect on the fetus. On the other
presentation of our data overemphasises the seriousness of seizure (or group of seizures) occurring in the first two years of life. It gives an opportunity to underline the purpose of presenting the data in the way we did. We do have sufficient information to rearrange the data in the way Professor Cooper suggests and intend to do so in a future publication. This rearrangement does indicate better and worse prognosis for certain groups and may produce a more favourable prognosis for the group Professor Cooper suggests. It should be emphasised, however, that because of relative mortality-rates, the rearrangement of data to indicate the significance of age of onset for prognosis is not as simple as sug-
together
MEANS
±
S.D. OF MATERNAL AND INFANT VARIABLES ACCORDING TO
MATERNAL SMOKING HABITS
gested. Such a discussion, however, misses the point of the paper. It was exactly our concern with the anxieties and fears of parents which brought us to arrange the data in the manner we did. The paper was biased towards viewing epilepsy from a sociological perspective rather than a predominantly medical one. That is, we were concerned to present epilepsy or the sequelæ of childhood seizures as they might be seen by the layman. Our data show that, at that time, of all children who have ever had a fit or seizure, one in ten died, one in ten went to an institution, and one in five now has chronic epilepsy. It is precisely these children who are the noticeable residue and represent to the general public the outcome of childhood seizures.
Surely if doctors are to reassure parents who have a child who has a seizure they must have some appreciation of the sort of fear and anxieties parents could bring into the consultingroom. In this context the lay community’s experience of what happens to all children with seizures is of utmost importance. We have no wish to paint an unnecessarily gloomy picture 1.
Cooper, J. E. Br. med. J. 1975, i, 1020.
Dr Mau (May 1, p. 972) reports the findings of a Gerstudy in which there is no association between smoking habit and maternal weight gain. The results of a French study, carried out since 1971 in the maternity hospital at Haguenau (Alsace), accord with the German study. Maternal weight gain was calculated by subtracting the usual weight before pregnancy from the weight before delivery. The well-known relation between smoking and birth-
hand,
man
1.
Rush, D. D. J. Obstet. Gynœc. Br. Commonw. 1974, 81, 746.
SIR,-It is possible that the way in which Mr Harrison and Taylor (May 1, p. 948) present their follow-up data on childhood seizures has overemphasised the seriousness of one seizure (or group of seizures) occurring only in the first two years of life. In the analysis of the various aspects of their follow-up information, all their patients are grouped together, irrespective of the time of onset, total number, and duration Dr
of seizures. This method of presentation may be obscuring some important difference between subgroups of these children. For instance, in a follow-up study of epilepsy in the approximately 5000 children in the National Survey of Health and Development; it seemed clear that children who have one seizure (or one group of
seizures) in the first two years of life are rarely the same children who have continuing or even occasional epi-
lepsy later on. This implies that if the data of Harrison and Taylor were presented to show the fate of these two groups separately, the prognosis of children with continuing or latero, iset epilepsy might be very much worse than that of children who have only infantile seizures. Occupational achievement and income are analysed by Harrison and Taylor in respect of remitted or continuing epilepsy, but the time of remission is not stated. Further subdivision into (a) seizures before the age of 2 years only, (b) seizures remitted since age of 2 years, and (c) continuing epilepsy, might well show an important gradient of poor prognosis. It is necessary to avoid causing undue concern to parents of infants who have an isolated seizure, and by a simple rearrangement of their data, Harrison and Taylor could throw further light on this important point. Professorial Unit,
Mapperley Hospital Nottingham NG3 6AA
*** This letter has been shown follows.-ED. L.
J. E. COOPER to
Mr Harrison, whose
of childhood seizure disorders for any age of onset. We do feel that the sociological perspective of epilepsy has been ignored or, perhaps more accurately, confused with the medical perspective, in particular by what we would regard as the arbitrary removal of certain groups in the study of prognosis of seizure disorders. This we hold to be responsible for the discrepancy between the doctors’ perception of the significance of some types of seizures and that of the patients or parents. We may be at fault for insufficiently stressing the sociological bias of our paper which we trust is now apparent. As a result we hope that there will be a greater appreciation of why some parents with a child who has a seizure at any age may be extremely frightened. Development Research Unit, Department of Psychiatry, University of Oxford, Park Hospital for Children, Headington, Oxford OX3 7LQ Human
R. M. HARRISON
RECURRENT HERPES SIMPLEX
SIR,—Dr Boyd (March 20, p. 650) is puzzled by the restricted distribution of the vesicular rash of herpes simplex. May I suggest that the circumoral distribution of herpes-simplex lesions could be explained by the fact that this region is the part of the trigeminal dermatome which receives both an abundant blood-supply and a liberal sensory innervation. Since replication of the herpes type-I virus is sometimes favoured by an increase in temperature this simple anatomical fact may explain why the eruption favours the circumoral region. Medical School, University of Tasmania, Hobart, Tasmania, Australia
RUPERT G. SHERWOOD
reply SMOKING AND THE FETUS
SIR,—Iwelcome Professor Cooper’s letter suggesting that the
SIR,—Dr Davies and his colleagues (Feb. 21, p. 385),
one
with Rush,’ have suggested that a large part of the effect of maternal smoking during pregnancy on birth-weight is mediated through low maternal weight gain, with only a very small additional direct effect on the fetus. On the other
presentation of our data overemphasises the seriousness of seizure (or group of seizures) occurring in the first two years of life. It gives an opportunity to underline the purpose of presenting the data in the way we did. We do have sufficient information to rearrange the data in the way Professor Cooper suggests and intend to do so in a future publication. This rearrangement does indicate better and worse prognosis for certain groups and may produce a more favourable prognosis for the group Professor Cooper suggests. It should be emphasised, however, that because of relative mortality-rates, the rearrangement of data to indicate the significance of age of onset for prognosis is not as simple as sug-
together
MEANS
±
S.D. OF MATERNAL AND INFANT VARIABLES ACCORDING TO
MATERNAL SMOKING HABITS
gested. Such a discussion, however, misses the point of the paper. It was exactly our concern with the anxieties and fears of parents which brought us to arrange the data in the manner we did. The paper was biased towards viewing epilepsy from a sociological perspective rather than a predominantly medical one. That is, we were concerned to present epilepsy or the sequelæ of childhood seizures as they might be seen by the layman. Our data show that, at that time, of all children who have ever had a fit or seizure, one in ten died, one in ten went to an institution, and one in five now has chronic epilepsy. It is precisely these children who are the noticeable residue and represent to the general public the outcome of childhood seizures.
Surely if doctors are to reassure parents who have a child who has a seizure they must have some appreciation of the sort of fear and anxieties parents could bring into the consultingroom. In this context the lay community’s experience of what happens to all children with seizures is of utmost importance. We have no wish to paint an unnecessarily gloomy picture 1.
Cooper, J. E. Br. med. J. 1975, i, 1020.
Dr Mau (May 1, p. 972) reports the findings of a Gerstudy in which there is no association between smoking habit and maternal weight gain. The results of a French study, carried out since 1971 in the maternity hospital at Haguenau (Alsace), accord with the German study. Maternal weight gain was calculated by subtracting the usual weight before pregnancy from the weight before delivery. The well-known relation between smoking and birth-
hand,
man
1.
Rush, D. D. J. Obstet. Gynœc. Br. Commonw. 1974, 81, 746.