The flowering of epileptology: Classification,
medical and surgical treatment
Early attempts at classification of the epilepsies defined seizures as large or small, grand mal or petit mal, a terminology which has persisted in some areas to this day. Though some of the historical descriptions of attacks suggest great powers of observation, a rational classification was only begun in the 20th century. There was then some question as to whether some of the minor attacks such as absences were indeed epileptic.
The advent of electroencephalography provided a basis for identifying the two major classes of focal or partial and generalized epilepsy. Classification of the epilepsies was entrusted to groups of outstanding epileptologists with particular interest and clinical experience. The first attempt led by Henry Gastaut, included Francis McNaughton, the first full Professor of Neurology at McGill. The International League assumed responsibility for the development of an International Classification of Epilepsies and of Epileptic Seizures. In the late 1980’s a group with Fritz Dreifuss, Jos Roger of the Marseille School and Peter Wolf, a disciple of Dieter Janz laid the foundations of the syndromic classification. This led to recognition of the benign partial epilepsies of childhood, a great boon and comfort to parents of affected children who can now be reassured about the benign prognosis.
At that time, the advent of new antiepileptic medications, such as Valproate, particularly effective in idiopathic generalized epilepsies led to improved management and prognosis. Attempts at specific responsiveness in other seizure patterns have been less successful.
Recognition of mesial temporal sclerosis and epilepsy by Murray Falconer and his group and William Feindel of Montreal laid the groundwork of the most common surgically treatable epilepsy. After early enthusiasm for surgical treatment, disillusionment followed in many countries and centers. When I asked Dr. Theodore Rasmussen what accounted for this, he replied, “The wrong surgeons operating on the wrong patients.” Despite the flowering of electroencephalography and the development of a rational classification, only few centers continued their efforts on behalf of people with epilepsy. In addition to the MNI and Murray Falconer at King’s Maudsley, Jean Bancaud and Talairach at Ste. Anne, Rossi in Rome and Zemskaya in Leningrad were amongst the few surgeons continuing to work in this field. In some countries, such as Germany and in Japan, surgical treatment of epilepsy was virtually proscribed. Prejudice continued to flourish widely.
In the late 80s and 90s the advent of modern imaging gave a new impetus to surgical treatment. The rise of modern epileptology, with specially qualified physicians, led to the realization that there were limits to what medical treatment could accomplish despite the introduction of new molecules. This was followed a virtual explosion of interest in surgical treatment, unfortunately driven in part also by the financial rewards which intensive monitoring promised. This time however this did not lead to an inappropriate selection of surgical candidates but to the development of well planned and organized units in a number of centers not only in North America but also in Brazil, France, Germany, England, Scandinavia, Australia and Japan among others. It was soon apparent that in certain forms of focal epilepsy excellent results could be obtained even with limited technical resources and provided that neurologists and neurosurgeons would abstain from undertaking surgery in patients with far more complicated problems where surgical results were not comparable.
This period of great flowering of medical and surgical treatment developed in parallel with advances in neuroscience, which promise eventually to lead to improved solutions to many epileptic problems.
Session IX -- Epilepsy Seminar
Montreal, Quebec, Canada