50 Years Ago in The Journal of Pediatrics:

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Holowach J, Thurston DL, O'Leary J. J Pediatr 1958;52:670-86

John Hughlings Jackson was an astute late 19^th century neurologist who took meticulous histories in his patients with epilepsy and focused often on minutiae overlooked by others. Eventually, he noticed a clinical pattern of the seizures that correlated to the anatomy of the cerebral cortex in postmortem examinations of his patients. His observations helped debunk the previous notion that seizures originate from the medulla oblongata; indeed, seizures arise from specific locations in the cerebral gray matter. Hence, motor and sensory partial seizures that start in the cortex and display “Jacksonian march” along the human homunculus carry his name to this day.

Over a half century later in 1958, thoughtful neurologists at St. Louis Children's Hospital reported in detail 114 cases of Jacksonian epilepsy in infants and children. Their observations mirrored an epidemiologic survey of patients with known and unknown diagnoses on the basis of history, pneumoencephalography, electroencephalography, and post-mortem study. They professed that although “Jacksonian seizures imply local organic pathology . . . a definite cause for convulsions could be determined in only . . . 34%.” Their findings hold true today, as Shinnar and Pellock in 2002 again demonstrated that only 36.6% of children with partial seizures can be found to have a localized etiology.¹ Interestingly, despite progress in imaging and pathologic study over the past 50 years, the chance of determining a cause for focal seizures has not changed significantly. Thankfully, advances in seizure treatment have progressed.

With the advent of new, “second” generation anticonvulsants, children with all seizure types have more, and sometimes superior, treatment options than they did in the 1950s. These newer “broad spectrum” medications may have similar or better efficacy in seizure control as the “older” generation anticonvulsants and also provide enhanced compliance, fewer side effects, less impact on cognition, and decreased overall morbidity and mortality rates in all ages. Among the newer agents, zonisamide, topiramate, levetiracetam, and lamotrigine are being used widely for monotherapy and adjuvant therapy of generalized epilepsy and partial seizures, in addition to oxcarbazepine. Pediatricians should familiarize themselves with these new agents. Nevertheless, the original anticonvulsants should not be disregarded when choosing a medication. Despite these developments over the years, the aspect of patient care that has remained unchanged is the importance of a thorough history and the nature of epilepsy, both well appreciated by Jackson and others over the last 50 to 100 years.

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1. Shinnar S, Pellock JM. Update on the epidemiology and prognosis of pediatric epilepsy. J Child Neurol. 2002;17:S4–S17
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