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abnormality relates to the severity of epilepsy and, more criti-cally, to whether a seizure has occurred within 48 h. Anticon-vulsant drugs have a normalising effect. When these and otherfactors were considered I found that E.E.G. abnormalities

(spikes, sharp waves, and spike and wave) did relate to theclinical diagnosis. Of a hundred consecutive first referrals witha positive diagnosis of epilepsy two-thirds had definite E.E.G.features compared with less than a fifth when the request formsaid "? epilepsy"." bThe diagnosis of epilepsy should be based on seizures, not

E.E.G. abnormalities which may suggest the cause and type ofseizures. When there is a possibility of an underlying lesionthen neuroradiological investigations and/or computer-assistedtomography are essential. But these are not’to be generallyavailable. Nor are E.E.G. activation procedures or the intensiveE.E.G. investigations needed in drug-resistant patients wheresurgery is contemplated.Dr Hopkins and Mr Scambler rightly point out that many

patients are receiving medication which is failing to controltheir seizures and that dosage is probably inadequate becauseit is unrelated to body-weight. This has been learned frommeasurements of anticonvulsant blood-levels. Furthermore, asthe interaction between antiepileptic drugs has been realisedthere has been a change from the use of many agents simul-taneously to just one compound.7 Nevertheless it seems likelythat assays of drug level will be available to only a few generalpractitioners, and hospital referrals will still be needed. Dr

Hopkins and Mr Scambler state that no statistical techniquetakes into account the interval between seizures. This is not

entirely true since a paper" at a recent international sym-posium adopted just this approach, and we are now assessinga modification of the cumulative sum technique.9 The methodclearly displays a deviation from the patient’s average intervalbetween attacks, not obvious by other means, and it is particu-larly useful when a drug regimen has changed.Dr Hopkins and Mr Scambler make no positive suggestions

about improving the unsatisfactory situation they have found.They imply that patients with epilepsy can be treated bygeneral practitioners, but problems of both investigation andtreatment mean that most patients will require surveillance athospital clinics-indeed, a small proportion of those resistantto therapy may well benefit from referral to the type of multi-disciplinary centre suggested in the Reid report. 10E.E.G. Department,London Hospital,London E1 1BB D. F. SCOTT

SiR,—The survey by Dr Hopkins and Mr Scambler is im-portant and highlights the frequent shortcomings in the careof people with epilepsy. Inadequate diagnosis and unreasoninguse of electroencephalography are common, and patients oftensuffer more from their treatment than from seizures or are pre-scribed drugs which are inappropriate in other ways. Com-munication problems abound.

WelcC1!’e though this survey is, however, the conclusionsdrawn by Dr Hopkins and Mr Scambler and at least one com-mentator" are mistaken. The idea that "General practitionersshould diagnose and treat epileptics without referral" shouldnot follow from demonstrating that hospital referral is often

unsatisfactory. Unless a general practitioner has special inter-est or experience in seizure disorders (which is very unusual),it is unreasonable to expect him to cope with the wide rangeof seizure manifestations and their differential diagnosis or themanagement of the complex psychological and social complica-tions which people with epilepsy often experience. The fre-

6 Scott, D. Understanding E.E.G. London, 1976.7 Reynolds, E. H., Chadwick, D., Galbraith, A. W. Lancet, 1976, i, 923.8. Gutjahr, H., Künkel, H., Starch, R. in Epileptology Proc. 7th int. Symp. on

Epilepsy Stuttgart, 1976.9 Chaput de Saintonge, D. M., Vere, D. W. Lancet, 1974, i, 120.

10. People with Epilepsy. H. M. Stationery Office, 1970.11 Med News, 1977, 9, 3

quency of extreme complications, including death, is obscuredby studying only those patients who remain in the community.

People with epilepsy need special comprehensive provisionas envisaged in the Reid report.12 Epilepsy remains a neglectedarea of medical practice and what is still needed is an improve-ment in knowledge and skill in all sections of the medical pro-fession, including so-called "specialists".National Centre for Children with Epilepsy,Park Hospital,Headington, Oxford OX3 7LQ GREGORY STORES

VALPROATE AND CURLY HAIR

SIR,-In 1974 we reported" temporary hair loss or thinningof the hair in patients receiving sodium valproate, and thisside-effect has been confirmed. 14-16 We have lately encountereda side-effect which has not previously been reported namely,curliness or waviness of the hair. In three patients this fol-lowed temporary hair loss, but there was no obvious loss in theother two. The only factor common to all five patients is thatthey have received sodium valproate alone. There are threemales, aged 8, 10, and 16, and two females aged 14 and 16years. Three are blond and two brunette. All are receiving 1 gdaily.

It is possible that we have overlooked some other patients,but we think this must be a fairly rare side-effect since we haveseen it only 5 out of 250 patients.We thought the change might be welcomed by the patients,

but one girl prefered her hair to be long and straight, and oneboy was mortified by his curls and insisted on a short hair cut.We should be very interested to hear if others have found

this side-effect.

Children’s Hospital,Birmingham B16 SET

P. M. JEAVONSJ. E. CLARKG. F. A. HARDING

RECTAL VALPROATE IN INTRACTABLE STATUSEPILEPTICUS

SIR,-We have given sodium valproate rectally to two pa-tients with intractable tonic-seizure status epilepticus. Bothwere chronic epileptics whose medication had been omittedbefore their admission to hospital. They both required assistedrespiration and tracheostomy, and both had a paralytic ileusduring their illness.The first patient was an 18-year-old mental-hospital patient

with mental retardation. She had 18 tonic epileptic seizuresbefore admission. She was treated with parenteral diazepam,intravenous phenytoin, and later with intravenous sodium

amylobarbitone under electroencephalographic (E.E.G.) con-trol. She did not respond to these drugs, and attempts at with-drawal of sodium amylobarbitone on the ninth day led tofurther E.E.G. and clinical evidence of seizures. Sodium val-

proate was given by nasogastric tube, but a paralytic ileus de-veloped. 10 days later she was given enemas containing 400 mgof sodium valproate, and these were continued for 5 days untilseizures were controlled and the amylobarbitone was with-drawn. Plasma-valproate levels on rectal administrationreached 41 g/ml. She has made a remarkable recovery andhas been seizure free for the past 15 months.The second patient was a 23-year-old retarded male also

from a mental hospital. He was admitted to the intensive-careunit of the hospital and was treated with diazepam 20 mghourly, intravenous phenytoin 250 mg twice a day, and, later,clonazepam 1 mg intravenously 5-hourly, as well as sodium

12. People with Epilepsy. H.M. Stationery Office, 1970.13. Jeavons, P. M., Clark, J. E. Br. med. J. 1974, n, 175.14. Barnes, S. E., Bower, B. D. Devel. Med. Child Neurol. 1975, 17, 175.15. Haigh, D., Forsythe, W. I. ibid. p. 743.16. Hassan, M. N., Laljee, H. C. K., Parsonage, M. J. Acta neurol. scand. 1976,

54, 209.