DEVELOPMENTAL MEDICINE A N D CH ILD
NEUROLOGY. 1975, 17
seems likely that these events are due simply to ordinary acute hypovolemic shock from the amount of blood needed to fill the suddenly dilated vascular bed in the skull. When one considers that a quick blood-loss of 15 per cent of the blood volume in an infant may be fatal, and that many of these infants are ill and dehydrated, it is surprising that more do not die. There does not seem to be any need to invoke a mysterious ‘brain-stem shock’ as the cause of death. Blood-volume loss of the order observed would be sufficient to explain the shock and occasional death. Thus, using suction is unnecessarily risky and may well help to perpetuate the subdural haematoma. The description of the treatment as ‘aspiration’ suggests that a syringe should be used, as in aspirating a pleural effusion. Perhaps the term ‘needle drainage’ should be substituted, as it would better describe the treatment and discourage suction. GRA HAM MARTIN J . C . WALLACE JAN Ross Departments of Neurosurgery and Nuclear Medicine, Wellington Hospital, Private Bag, Wellington, New Zealand. REFERENCES 1. Rosenberg, 0. (1913) ‘Die Pachymeningitis haemorrhagica interna im Kindesalter.’ Bertiner Klinische Wochenschrift. 50,2272. 2. Putnam, T. J., Cushing, H. (1925) ‘Chronic subdural hematoma, its pathology, its relation to pachymeningitis hemorrhagica and its surgical treatment.’ Archives of Surgery, 11, 329. 3. Horrax, G., Poppen, J. L. (1937) ‘The frequency, recognition and treatment of chronic subdural haematomas.’ New England Journal of Medicine, 216, 381. 4. Ingraham, F. D., Heyl, H. L. (1939) ‘Subdural hematoma in infancy and childhood.’ Journal of the American Medical Association, 112, 198. 5 . Matson, D. D. (1969) Neurosurgery of Infancy and Childhood. Springfield, Ill.: Charles C Thomas. 6. Rabe, E. F., Flynn, R. E., Dodge, P. R. (1968) ‘Subdural collections of fluid in infants and children.’ Neurology, 18, 559. 7. Yashon, D., Jane, J. A., White, R. J., Sugar, 0.(1968) ‘Traumatic subdural haematoma of infancy: long-term follow up of 92 patients.’ Archives of Neurology, 18, 370. 8. McLaurin, R. L., Isaacs, E., Lewis, H. P. (1971) ‘Results of non-operative treatment of 15 cases of infantile subdural haematoma.’ Journal qf Neurosurgery, 34, 753. 9. Martin, G. T., Wallace, J. C., Ross, I. (1975) To be published. 10. Guthkelch, A. N. (1953) ‘Subdural effusions in infancy.’ British Medical Journal, 1, 233.
TEACHING MEDICAL STUDENTS ABOUT EPILEPSY To increase the general public understanding of epilepsy, the International Epilepsy Bureau makes instructional tours around the world. But how far is comparable progress being made in the education of medical students? After all, epilepsy is a powerful example of the inter-relation of physiological, behavioural and socio-cultural issues. Because of lack of competence and confidence, epilepsy creates feelings of unease in many general practitioners, school doctors and paediatricians. Hospital notes contain entries such as ‘known epileptic’ from which large implications about behaviour are thought to follow automatically and reference is still being made, even in psychiatric circles, to ‘the epileptic personality’. The experience of the Special Centres for Epilepsy has suggested that virtually every section of the medical fraternity needs help and advice concerning seizure disorders. That this applies no less to recently graduated doctors implies a deficiency in current medical education. Epilepsy has many sides. It is, of course, inaccurate to refer to ‘epilepsy’ as if it were a disease entity in its own right. I t is a symptom of diverse aetiology often associated with a 518
constellation of neurological, psychological or social factors. This group of disorders transcends any one specialty. In particular it links the disciplines of neurology and psychiatry which, sadly, have gone their separate ways. This very transcendence of boundaries creates problems of medical education which, in traditional courses, is compartmented. In the Oxford Medical School about one in eight students spend their two months’ psychiatric attachment at the Park Hospital for Children where they see a wide range of general child psychiatry, and also become well versed in the seizure disorders of childhood and the effect they can have on behaviour. Seminar discussions for all students are organised around the following propositions : 1. Seizures are common in the general population and are of considerable numerical importance in mentally handicapped groups. 2. ‘Epilepsy’ is a symptom and not an adequate diagnosis; seizures may be due to local or general disorder. 3 . Seizures are not either grand nial or petit ma1 attacks. There is a wide diversity of types of attack, including some of subtle clinical manifestation which nevertheless may seriously affect behaviour. Detailed description is not just an academic exercise but can be of considerable therapeutic and prognostic importance. 4. Epilepsy is not only a matter of having fits, and management is not merely a matter of prescribing drugs. Emphasis is placed on the educational, psychiatric and social complications that many people with epilepsy suffer in their lives, often for preventable reasons such as harmful drug-effects or adverse social pressures. The impact of epilepsy on the family, on education, and on employment and marriage prospects-as well as its other social implications-exemplifies principles of real-life social medicine. A basically developmental approach stresses the way in which the efl‘ect of seizures on a person’s life is largely determined by the stage of development at which they occur. Students at the Park Hospital formulate the seizure disorder in terms of aetiology, clinical and EEG type (including precipitating and inhibiting factors), as well as associated problems of a physical, educational, social or psychiatric nature. With this formulation they then plan comprehensive management in the light of the uniqueness of each individual case. Behavioural aspects of epilepsy are not neglected in all medical schools, but a higher general level in the teaching of the subject presupposes a wider interest than exists at present. The only way out of this impasse seems to be for those relatively few committed people to secure the opportunity to present the subject to medical students in a challenging and effective way as a subject worthy of serious consideration. I t is hoped that more widespread enthusiasm will eventually be engendered. GREGORY STORES
University Department of Psychiatry and the Park Hospital for Children. Oxford.
INVOLUNTARY MOVEMENTS IRREGULARjerky movements of the limbs can sometimes be difficult to classify. Are they myoclonic or are they choreiform? The context in which they occur can be the deciding factor in how they are labelled. Associated symptoms and signs may indicate a particular disease or syndrome. For example, if the movements are associated with progressive mental and physical deterioration in a young child, investigations may confirm a diagnosis of 519