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The Apostle Paul had a chronic disease. Epilepsy is offered as the most likely hypothesis. Interpretation of parts of the Pauline epistles suggests the possibility of facial motor and sensitive disturbances coming after ecstatic seizures. Though unusual, there are, however, case histories of patients who experienced ecstatic auras.

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Motor attacks induced by voluntary movements are infrequent. Paroxysmal kinesigenic choreoathetosis (PKC) is rare and has only recently been individualized (Kertesz, 1967). We report the case of an 8 year-old boy who developed unilateral or bilateral attacks of abnormal, choreoathetotic movements during certain voluntary movements, especially when rising after a rest. The attacks were short (13 to 18 seconds) and frequent. Neurological examination was normal, as were the intelligence quotient, the inter-critical and critical EEG: CT and MRI. The patient's mother had suffered from the same disorder. The attacks disappeared during treatment with phenytoin but reappeared when it was stopped. This case is concordant with data from the literature, with male predominance, age from 6 to 15 years at the onset, shortness of the attacks (less than 1 minute in 80% of the cases) and normality of investigations in almost every patient. A familial factor has been found in 50% of the cases. The frequency of epilepsy in the family is above average. PKC can easily be distinguished from Mount and Reback' syndrome where the attacks are choreoathetotic but longer and unprovoked by movements and where there is also a familial factor. The relationship of PKC with epilepsy is asserted by some authors and denied by others, and in the literature the distinction between movement-induced tonic seizures and PKC is not always clear. Some authors have blamed a disturbance in the maturation of basal ganglia. To sum up, PKC is a very rare condition which is easy to diagnose, has a good prognosis and readily responds to antiepileptic drugs.

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A 7 year-old child with congenital oculomotor apraxia (Cogan's syndrome) presented with mainly voluntary horizontal saccadic movements. Fixation of a visual target could be obtained only by a sudden movement of the head preceded by eyelid blinking. Electro-oculography confirmed the predominant disturbance of saccadic movements (delay in onset, hypometria). CT scan showed agenesis of the corpus callosum and atrophy of the vermis together with enlargement of the 4th ventricle and pre-pontine cisternae. The role of these anomalies in the pathogenesis of this rare congenital syndrome of good prognosis is discussed.

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Eleven cases of primary reading epilepsy are reported. They confirm Bickford's description. These patients were otherwise normal. A family history of seizures was present in 6 cases. The first seizure occurred between 12 and 25 years. After a variable period of reading all patients developed a tightness and jerking in throat and jaw muscles. In 4 cases, occasionally, speaking could cause jaw or throat jerks. Whilst reading out loud or silently (exclusively in reading aloud in 1 patient) bilateral discharges were recorded in EEG, sometimes on the left hemisphere. The mechanisms are discussed. Seizures in primary reading epilepsy are facilitated by saccadic eye movements, impulse language muscles and mental concentration. The role of higher integrating systems of language is emphasized. Therapy is discussed.

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PIP: Young epileptic women frequently question their physicians concerning appropriate contraception for them, the effects of pregnancy on epilepsy, and the effects of the disease on the fetus. In 1/2 of cases the frequency of epileptic crises is unaffected by pregnancy, in 1/4 it is augmented and in 1/4 it is decreased. An increase in crises may be caused by psychological factors or by changing the treatment to avoid injuring the fetus. Recent studies show that the plasma level of the medications tends to decline during pregnancy and to increase postpartum. During the past decade several cases of pregnancy in young women taking oral contraceptives (OCs) and antiepileptic drugs have been observed. The inactivation of OCs, which occurs with all antiepileptics except sodium valproate and the benzodiazepines, appears to be due to a mechanism of enzymatic induction. Most cases of pregnancy were in women using sequential pills with 50 mcg or less of ethinyl estradiol. (EE) Sodium valproate can be prescribed for women with primary epilepsy, but in cases of incompletely controlled epilepsy or those requiring various drugs, it is better not to modify a successful regimen. Another method of contraception such as the IUD can be prescribed, or possibly a higher dose formulation of OC can be selected. The vascular risk of a stronger dose of contraceptive steroids should be weighed, but it may be that the process of enzymatic induction maintains a level of EE comparable to that of the minipill. If combined OCs are used, the appearance of metrorrhagia should be noted and the temperature shift should be recorded for the 1st months of treatment to guard against possible failure to inhibit ovulation. The teratogenic risk of antiepileptic medications has not been entirely evaluated, but diphenylhydantoines have been shown experimentally to cause malformations in monkeys. Statistics indicate a doubled risk of malformation in the children of epileptic mothers treated during pregnancy. All antiepileptic drugs were found to be involved. In a personal series of 170 babies of treated epileptic mothers, there were 4 malformations and 1 fatal neonatal hemorrhage. It would be reasonable to assume that malformations result from the interaction of genetic factors related to the severity of the disease, maternal age at pregnancy, and medication used. The role of the anticonvulsants may possibly be explained by their effect on nucleic acid metabolism or by deficiencies of folic acid and vitamin K, which in turn may play a role in neonatal hemorrhage. In case of pregnancy, the patient should be reassured about the small risk of malformation. The smallest possible doses and, if possible, single drugs should be used. Injections of vitamin K for the mother before delivery and for the infant may prevent coagulation problems. The infant may have withdrawal symptoms for which replacement medication may be prescribed for a few weeks. Breastfeeding does not appear to be contraindicated.^ieng

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From the analysis of 115 cases of primary generalized epilepsies treated for a mean duration of 43 months with sodium valproate as sole therapy, it appears that: the mean effective daily dosage is 21 mg/kg; the efficacy of valproate proved excellent in 82.6% of cases (seizures fully controlled: 74%, seizures occurring exceptionally: 9%); a loss of activity was never observed; in these circumstances of prolonged administration of the drug, no signs of major intolerance were seen; side-effects occurred in 29% of cases, including 20% long-term effects (weight gain, essential tremor); 64 series of laboratory tests including 15 parameters made it possible to evaluate the hematological, hepatic and pancreatic tolerance of valproate: the majority of the tests were normal. The authors believe that during long-term therapy with valproate, monitoring does not need to include the routine performance of liver function tests, but that it would be more advisable, should a suggestive clinical sign be noted, to investigate the platelet count, coagulation (partial activated thromboplastin time) and protein synthesis (fibrinogen).

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Three percent of epileptic patients have their first seizure after the age of 60. More than at other ages, the real nature of such fits is very difficult to assert. Most of the reversible attacks occurring at this age are not of grave nature, syncopes are much more frequent. Some semeiological aspects are discussed. Focal seizures are more frequent after the age of 60. Absence status may be the first epileptic symptom in some rare cases (almost all of them being women). 100 patients whose ages ranged from 60 to 83 years, were examined after their first seizure and aetiological problems were examined. The following topics are discussed:--The possible onset of a primary epilepsy, extremely rare at that age;--The incidence of neoplasms, not exceeding 10% for patients whose late onset epilepsy is still an isolated symptom, and who have not been selected from specialized neurological or neurosurgical hospital departments;--The role of vascular epilepsy; in a very few cases, but of great practical interest, the epilepsy may announce a cerebrovascular accident which will occur later. It is, however, difficult to specify the vascular origin of a certain number of temporary unexplained late onset epilepsies. Some other aetiological factors are taken into account: antecedents of trauma, alcoholism, and dementia. The authors agree that in 50% of the cases the aetiology is not obvious. In this group of unknown aetiology it seemed interesting to isolate the following electroclinical form;--Epilepsy grand mal, with apparently generalized seizures; no special pathological antecedents; the neuropsychological and neurological examinations are normal, showing no intellectual disorders; the EEG generally shows slight modifications: quick rhythms, some sharp waves; a global cerebral atrophy is seen by the scanner. Such patients have been called victims of 'secondary late-onset generalized epilepsy'. They form 16% of a series of 156 epileptic patients who were over 65 years old, and 21% of our own 100 patients.

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