- Email: [email protected]
CONTROLLED RESPIRATION IN STATUS ASTHMATICUS
247 as to their infectivity have to be made; and at home who either fail to attend for treatliving patients ment, fail to respond to it, or present special difficulties. A memorandum on leprosy in this country by Dr. R. G. Cochrane, until lately consultant adviser in leprosy to the Ministry of Health, is being distributed to hospital medical staff who are likely to be concerned, particularly neurologists and dermatologists. Dr. Cochrane points out that the importance of leprosy in this country lies not in numbers (340 patients remained on the central register and needed treatment and surveillance on Dec. 31, 1964) but in the need for expert care for patients with active disease and for help for those who are physically, psychologically, or socially handicapped.
decisions
CARE FOR THE OLD
FULLNESS of years is not the blessing it once was. Old people have lost their traditional right to be sources of wisdom and experience and, with it, their place at the head of households of three and four generations. Just as oldage is ceasing to be exceptional it is becoming a problem. A society which has to admit as much cannot clear its conscience by the most elaborate social provision-and there is nothing elaborate about the proposals put forward by the group of doctors and sociologists which, under the xgis of Socialist Commentary, has been studying the care
of the
elderly.i
In 1961 there were 53/4 million people in England and Wales over sixty-five years of age. In 1981 there will probably be 71/2 million-13% of the total population. And, as at present, about a quarter of these will have neither spouse nor children to care for or about them. How, in the face of these increasing numbers, care is to be forthcoming where necessary was the question tackled by the group. It considered only what was strictly practicable and left aside some basic but too considerable issuespensions and price stability, for instance, occupation and raison d’etre. Its report deals with the immediate steps that should be taken to forestall, wherever possible, physical, mental, and social deterioration in the elderly. To this end the group suggests that public-health nurses should be attached to general practices and should visit every patient over seventy years of age at least once a year. They would assess the medical and social situation and see that help was sought where it was needed. These nurses could well be part-time recruits from among married State-registered nurses. The group would also have the National Assistance Act amended so as to impose on local authorities the statutory duty of caring for infirm old people living in their own homes. Under the present permissive arrangement provision of home-meals, laundry, transport, and day and social centres is haphazard and varies from one area to another. To achieve some degree of uniformity, liaison between local and central Government should be better. New local-authority schemes should, for example, be centrally approved; assessment of need, and of schemes to meet it, should be more rigorous; and information about services, experiments, and pilot schemes should be published centrally. The group recognises that first responsibility for providing housing suitable for old people must rest with the local authorities, although housing associations can help. The National Corporation for the Care of Old People People: Next Steps in Social Policy. Socialist Commentary, January, 1966, suppl. Pp. 24. Is. 6d.
1. Our Old
estimates that 50,000 new one-bedroom dwellings are needed each year-i.e., a third of the current total of In addition, grouped new local-authority housing. a resident flatlets, supervised by warden, are needed for the more infirm; and there is still much to be done in the way of improving the out-dated housing in which many old people live. Finding accommodation for the elderly is made more difficult because, outside the county and London boroughs, the responsibility is divided between housing authorities (district and borough councils) and welfare authorities (county councils). The group suggests that the county councils in England and Wales should, like those in Scotland, be given authority to provide housing. As the community services improve, residential homes will have, increasingly, to cater for the very old and the very frail. Experiment of joint control by welfare authorities and hospital management committees would, therefore, seem apposite. What life in them is like will always depend ultimately on the staff. If these are to be of good calibre, conditions of work must be made attractive. Shortages should be met by employing part-time helpers, and the " young olds " (sixty-fives to seventy-fives) could appropriately help their seniors. The group complains that services to help old people have grown up piecemeal and are needlessly confusing. It suggests that a national committee, representing Government departments, local authorities, and voluntary organisations, should be set up to plan, experiment, lead public opinion, and disseminate information. Each local authority should also have its standing committee, representing health, welfare, and housing interests, to ensure that in its work for old people the left hand knows what the right is about. To all this it is hard to take exception. Less compelling is the group’s conclusion that its proposals will not be costly in practice. Staff, services, and resources are nowhere so abundant that Peter can be robbed to pay Paul and not feel himself the poorer for it. Perhaps the most that can be hoped is that local authorities may be moved by this report to adjust priorities in favour of the old.
CONTROLLED RESPIRATION IN STATUS ASTHMATICUS
STATUS asthmaticus can still be fatal, even though the corticosteroid drugs have significantly strengthened its treatment.1 Partial or complete resistance to bronchodilators may develop in some asthmatic patients, leading to medically irreversible status asthmaticus. The increased respiratory effort necessary to sustain adequate oxygenation cannot be maintained, and hypercapnia and hypoxia overwhelm the exhausted patient, whose death is probably due to failure of the respiratory and vasomotor centres. We have lately drawn attention to the possible dangers of giving sympathomimetic drugs in this condition.2 A radical but reasonable approach to the treatment of this condition is the introduction of controlled ventilation by intermittent positive pressure. Beam et al. reported its use in 3 moribund children treated successfully by muscle paralysis, endotracheal intubation, and controlled respiration, when vigorous medical therapy had apparently failed. In this issue (p. 227) Dr. Marchand and Dr. 1. 2. 3.
Carryer, H. M. J. Am. med. Ass. 1965, 194, 1122. Lancet, 1965, ii, 122. Beam, L. R., Marcy, J. H., Mansmann, H. C. J. Am. 194, 968.
med. Ass.
1965,
248
Hasselt review the treatment of 20 adults, 17 of whom were successfully maintained by a ventilator until antibiotics and bronchial lavage overcame the airway obstruction. Positive-pressure ventilation enables the patient to rest from respiratory effort, thus reducing metabolism and oxygen consumption. The pattern of respiration is more efficient, leading to improved oxygenation and carbondioxide elimination. Marchand and Hasselt’s patients were treated by tracheostomy, which allowed vigorous bronchial lavage and removal of tenacious mucous plugs. The difficulty in this form of treatment is to achieve adequate sedation or muscular paralysis to facilitate mechanical ventilation. Marchand and Hasselt used intravenous morphine in doses of 30-45 mg., and they found no evidence of sensitivity or other toxic reactions, even though morphine releases histamine.4 Tubocurarine chloride has a similar action 4; and, therefore, Beam et al. used gallamine to produce muscular paralysis in their patients, because it does not produce bronchospasm or release histamine, and it has an effective antidote in edrephonium chloride. In this situation, it is important to remember that certain antibiotics, such as neomycin5 have a curare-like effect, and hence may prolong muscular paralysis if given with gallamine or tubocurarine. Resistance to adrenaline in this condition may be linked with the severe respiratory acidosis 6and both Beam et al. and Marchand and Hasselt emphasise the importance of correcting acidosis with intravenous sodium bicarbonate. Mithoefer et al.report prompt relief of bronchospasm after correction of respiratory acidosis by bicarbonate infusion. Although this procedure is a last resort, and should not be tried before vigorous medical treatment, it should certainly not be delayed until coma or apnoea have developed, with their sequelae of hypoxia and irreversible tissue damage. Further experience of this treatment will give more closely defined indications for its use. Meanwhile, clinical judgment of the patient’s response to medical treatment, and information on arterial blood pH, oxygen, and carbon-dioxide levels, must suffice for the decision when to apply this technique. PETIT MAL
FEW clinical disorders are so clearly defined as petit-mal epilepsy, and yet few terms are so loosely used. The name is constantly being applied to different kinds of epileptic attack which have one feature only in common-they are not full-scale grand-mal convulsions. Yet the distinction between true petit mal and small attacks of other forms of epilepsy is vitally important, for the treatment is entirely different. Petit mal starts in childhood or adolescence and rarely continues into adult life. It is not a common form of epilepsy, but the children who are affected have many attacks, sometimes up to 100, each day. The attacks start suddenly with no prodromal or postictal features, and they consist of a short period of detachment from the surroundings, lasting from five to forty seconds. The child may stop in the middle of a sentence, stare into Pharmacological Basis of Therapeutics (edited by L. G. Goodman and A. Gilman). New York, 1965. 5. Ross, E. D. T., Settle, J. A. D., Telfer, A. B. M. Br. med. J. 1963, ii, 4. The
1109. 6. 7. 8.
Blumenthal, J. S., Blumenthal, M. N., Brown, E. B., Campbell, G. S., Prasad, A. Dis. Chest. 1961, 29, 516. Wood, W. B., Manley, E. S., Woodbury, R. A. J. Pharmac. exp. Therap. 1963, 139, 238. Mithoefer, J. C., Runser, R. H., Karetsky, M. S. New Engl. J. Med. 1965, 272, 1200.
space, and then pick up the thread of what was being said. Motor features, if any, are confined to a little nodding of the head, blinking of the eyelids, and perhaps a few mumbled words. Often only close relatives know that anything is amiss. The attacks are easily precipitated by hyperventilation and are accompanied by bilateral symmetrical spike-and-wave discharge in the electroencephalogram (E.E.G.), usually at a rate of 3 "per second. Some-" times attacks are so frequent that a petit-mal status results. Such a child may be inattentive, confused, and disoriented for hours on end, and yet he may carry on apparently normal functions during this time, having no memory of the period afterwards. He may fall inexplicably behind at school, and no-one realises that he is only partly conscious for most of the day. The prognosis for children with petit mal has been a matter of controversy. Lees and Liversedge1 believed that attacks persisted into adult life, but that most affected adults learnt to live with them and to disregard them. Currier et al. stated that in 56% of their series attacks continued beyond the age of 21. Most clinicians hold an opposite view 3 however, and Gastaut 4 maintained that petit mal was " a real curiosity " in an adult. Livingston et awl. have now studied the frequency of petit mal in 15,102 epileptic patients seen at the Johns Hopkins Hospital between 1936 and 1964. Only 354 patients (2-3%) fulfilled the true criteria for petit mal; 117 of these were satisfactorily followed up for over five years (five to twenty-eight years). None started attacks after the age of 15. 92 became and remained free of attacks and typical E.E.G. abnormality during the period of observation (five years), and in 89 of these the attacks stopped before the age of 20. Of the 25 still having attacks, 22 were under the age of 21. 95 % were normal or of high intelligence at the onset of the attacks. Only 6 children were mentally retarded, but 17 had had other forms of fit before the onset of petit mal. At the end of the study 89% were mentally retarded, which means that 7 more children now had evidence of brain damage, and it is highly significant that 6 of these 7 had had frequent attacks of petit-mal " status ". Clearly mental retardation is very rare, and this contrasts with views expressed by some paediatricians 67who have probably been using the term to cover too wide a spectrum of small epileptic attacks. Grand-mal attacks eventually developed in 54 of the 100 patients who started with pure petit mal. Whereas in the 41 who were given treatment for petit mal alone (trimethadione and ethosuximide being the commonest drugs) as many as 80% developed grand mal, major fits appeared in only 35% of the 59 who were also given treatment
against major epilepsy.
This report seems to confirm that true petit mal is uncommon, that it is usually compatible with normal intelligence, and that its outcome as regards both the attacks themselves and the mental state is benign. It also shows, however, that repeated petit-mal status may have a serious effect on the child’s mentality and that the later development of major seizures is very common, though they can be reduced by giving phenobarbitone or one of the other drugs effective against grand mal. 1. Lees, F., Liversedge, L. A. Lancet, 1962, ii, 797. 2. Currier, R. D., Koci, K. A., Saidman, L. J. Neurology, 1963, 13, 959 3. Lennox, W. G. Epilepsy and Related Disorders. Springfield, Ill., 1954. 4. Gastaut, H. The Epilepsies: Electro-clinical Correlations. Springfield, Ill., 1954. 5. Livingston, S., Torres, I., Pauli, L. L., Rider, R. V. J. Am. med. Ass. 1965, 194, 227. 6. Holowach, J., Thurston, D. L., O’Leary, J. L. Pediatrics, Springfield, 1962, 60, 893. 7. Keith, H. M. Convulsive Disorders in Children. Boston, 1963.
decisions
CARE FOR THE OLD
FULLNESS of years is not the blessing it once was. Old people have lost their traditional right to be sources of wisdom and experience and, with it, their place at the head of households of three and four generations. Just as oldage is ceasing to be exceptional it is becoming a problem. A society which has to admit as much cannot clear its conscience by the most elaborate social provision-and there is nothing elaborate about the proposals put forward by the group of doctors and sociologists which, under the xgis of Socialist Commentary, has been studying the care
of the
elderly.i
In 1961 there were 53/4 million people in England and Wales over sixty-five years of age. In 1981 there will probably be 71/2 million-13% of the total population. And, as at present, about a quarter of these will have neither spouse nor children to care for or about them. How, in the face of these increasing numbers, care is to be forthcoming where necessary was the question tackled by the group. It considered only what was strictly practicable and left aside some basic but too considerable issuespensions and price stability, for instance, occupation and raison d’etre. Its report deals with the immediate steps that should be taken to forestall, wherever possible, physical, mental, and social deterioration in the elderly. To this end the group suggests that public-health nurses should be attached to general practices and should visit every patient over seventy years of age at least once a year. They would assess the medical and social situation and see that help was sought where it was needed. These nurses could well be part-time recruits from among married State-registered nurses. The group would also have the National Assistance Act amended so as to impose on local authorities the statutory duty of caring for infirm old people living in their own homes. Under the present permissive arrangement provision of home-meals, laundry, transport, and day and social centres is haphazard and varies from one area to another. To achieve some degree of uniformity, liaison between local and central Government should be better. New local-authority schemes should, for example, be centrally approved; assessment of need, and of schemes to meet it, should be more rigorous; and information about services, experiments, and pilot schemes should be published centrally. The group recognises that first responsibility for providing housing suitable for old people must rest with the local authorities, although housing associations can help. The National Corporation for the Care of Old People People: Next Steps in Social Policy. Socialist Commentary, January, 1966, suppl. Pp. 24. Is. 6d.
1. Our Old
estimates that 50,000 new one-bedroom dwellings are needed each year-i.e., a third of the current total of In addition, grouped new local-authority housing. a resident flatlets, supervised by warden, are needed for the more infirm; and there is still much to be done in the way of improving the out-dated housing in which many old people live. Finding accommodation for the elderly is made more difficult because, outside the county and London boroughs, the responsibility is divided between housing authorities (district and borough councils) and welfare authorities (county councils). The group suggests that the county councils in England and Wales should, like those in Scotland, be given authority to provide housing. As the community services improve, residential homes will have, increasingly, to cater for the very old and the very frail. Experiment of joint control by welfare authorities and hospital management committees would, therefore, seem apposite. What life in them is like will always depend ultimately on the staff. If these are to be of good calibre, conditions of work must be made attractive. Shortages should be met by employing part-time helpers, and the " young olds " (sixty-fives to seventy-fives) could appropriately help their seniors. The group complains that services to help old people have grown up piecemeal and are needlessly confusing. It suggests that a national committee, representing Government departments, local authorities, and voluntary organisations, should be set up to plan, experiment, lead public opinion, and disseminate information. Each local authority should also have its standing committee, representing health, welfare, and housing interests, to ensure that in its work for old people the left hand knows what the right is about. To all this it is hard to take exception. Less compelling is the group’s conclusion that its proposals will not be costly in practice. Staff, services, and resources are nowhere so abundant that Peter can be robbed to pay Paul and not feel himself the poorer for it. Perhaps the most that can be hoped is that local authorities may be moved by this report to adjust priorities in favour of the old.
CONTROLLED RESPIRATION IN STATUS ASTHMATICUS
STATUS asthmaticus can still be fatal, even though the corticosteroid drugs have significantly strengthened its treatment.1 Partial or complete resistance to bronchodilators may develop in some asthmatic patients, leading to medically irreversible status asthmaticus. The increased respiratory effort necessary to sustain adequate oxygenation cannot be maintained, and hypercapnia and hypoxia overwhelm the exhausted patient, whose death is probably due to failure of the respiratory and vasomotor centres. We have lately drawn attention to the possible dangers of giving sympathomimetic drugs in this condition.2 A radical but reasonable approach to the treatment of this condition is the introduction of controlled ventilation by intermittent positive pressure. Beam et al. reported its use in 3 moribund children treated successfully by muscle paralysis, endotracheal intubation, and controlled respiration, when vigorous medical therapy had apparently failed. In this issue (p. 227) Dr. Marchand and Dr. 1. 2. 3.
Carryer, H. M. J. Am. med. Ass. 1965, 194, 1122. Lancet, 1965, ii, 122. Beam, L. R., Marcy, J. H., Mansmann, H. C. J. Am. 194, 968.
med. Ass.
1965,
248
Hasselt review the treatment of 20 adults, 17 of whom were successfully maintained by a ventilator until antibiotics and bronchial lavage overcame the airway obstruction. Positive-pressure ventilation enables the patient to rest from respiratory effort, thus reducing metabolism and oxygen consumption. The pattern of respiration is more efficient, leading to improved oxygenation and carbondioxide elimination. Marchand and Hasselt’s patients were treated by tracheostomy, which allowed vigorous bronchial lavage and removal of tenacious mucous plugs. The difficulty in this form of treatment is to achieve adequate sedation or muscular paralysis to facilitate mechanical ventilation. Marchand and Hasselt used intravenous morphine in doses of 30-45 mg., and they found no evidence of sensitivity or other toxic reactions, even though morphine releases histamine.4 Tubocurarine chloride has a similar action 4; and, therefore, Beam et al. used gallamine to produce muscular paralysis in their patients, because it does not produce bronchospasm or release histamine, and it has an effective antidote in edrephonium chloride. In this situation, it is important to remember that certain antibiotics, such as neomycin5 have a curare-like effect, and hence may prolong muscular paralysis if given with gallamine or tubocurarine. Resistance to adrenaline in this condition may be linked with the severe respiratory acidosis 6and both Beam et al. and Marchand and Hasselt emphasise the importance of correcting acidosis with intravenous sodium bicarbonate. Mithoefer et al.report prompt relief of bronchospasm after correction of respiratory acidosis by bicarbonate infusion. Although this procedure is a last resort, and should not be tried before vigorous medical treatment, it should certainly not be delayed until coma or apnoea have developed, with their sequelae of hypoxia and irreversible tissue damage. Further experience of this treatment will give more closely defined indications for its use. Meanwhile, clinical judgment of the patient’s response to medical treatment, and information on arterial blood pH, oxygen, and carbon-dioxide levels, must suffice for the decision when to apply this technique. PETIT MAL
FEW clinical disorders are so clearly defined as petit-mal epilepsy, and yet few terms are so loosely used. The name is constantly being applied to different kinds of epileptic attack which have one feature only in common-they are not full-scale grand-mal convulsions. Yet the distinction between true petit mal and small attacks of other forms of epilepsy is vitally important, for the treatment is entirely different. Petit mal starts in childhood or adolescence and rarely continues into adult life. It is not a common form of epilepsy, but the children who are affected have many attacks, sometimes up to 100, each day. The attacks start suddenly with no prodromal or postictal features, and they consist of a short period of detachment from the surroundings, lasting from five to forty seconds. The child may stop in the middle of a sentence, stare into Pharmacological Basis of Therapeutics (edited by L. G. Goodman and A. Gilman). New York, 1965. 5. Ross, E. D. T., Settle, J. A. D., Telfer, A. B. M. Br. med. J. 1963, ii, 4. The
1109. 6. 7. 8.
Blumenthal, J. S., Blumenthal, M. N., Brown, E. B., Campbell, G. S., Prasad, A. Dis. Chest. 1961, 29, 516. Wood, W. B., Manley, E. S., Woodbury, R. A. J. Pharmac. exp. Therap. 1963, 139, 238. Mithoefer, J. C., Runser, R. H., Karetsky, M. S. New Engl. J. Med. 1965, 272, 1200.
space, and then pick up the thread of what was being said. Motor features, if any, are confined to a little nodding of the head, blinking of the eyelids, and perhaps a few mumbled words. Often only close relatives know that anything is amiss. The attacks are easily precipitated by hyperventilation and are accompanied by bilateral symmetrical spike-and-wave discharge in the electroencephalogram (E.E.G.), usually at a rate of 3 "per second. Some-" times attacks are so frequent that a petit-mal status results. Such a child may be inattentive, confused, and disoriented for hours on end, and yet he may carry on apparently normal functions during this time, having no memory of the period afterwards. He may fall inexplicably behind at school, and no-one realises that he is only partly conscious for most of the day. The prognosis for children with petit mal has been a matter of controversy. Lees and Liversedge1 believed that attacks persisted into adult life, but that most affected adults learnt to live with them and to disregard them. Currier et al. stated that in 56% of their series attacks continued beyond the age of 21. Most clinicians hold an opposite view 3 however, and Gastaut 4 maintained that petit mal was " a real curiosity " in an adult. Livingston et awl. have now studied the frequency of petit mal in 15,102 epileptic patients seen at the Johns Hopkins Hospital between 1936 and 1964. Only 354 patients (2-3%) fulfilled the true criteria for petit mal; 117 of these were satisfactorily followed up for over five years (five to twenty-eight years). None started attacks after the age of 15. 92 became and remained free of attacks and typical E.E.G. abnormality during the period of observation (five years), and in 89 of these the attacks stopped before the age of 20. Of the 25 still having attacks, 22 were under the age of 21. 95 % were normal or of high intelligence at the onset of the attacks. Only 6 children were mentally retarded, but 17 had had other forms of fit before the onset of petit mal. At the end of the study 89% were mentally retarded, which means that 7 more children now had evidence of brain damage, and it is highly significant that 6 of these 7 had had frequent attacks of petit-mal " status ". Clearly mental retardation is very rare, and this contrasts with views expressed by some paediatricians 67who have probably been using the term to cover too wide a spectrum of small epileptic attacks. Grand-mal attacks eventually developed in 54 of the 100 patients who started with pure petit mal. Whereas in the 41 who were given treatment for petit mal alone (trimethadione and ethosuximide being the commonest drugs) as many as 80% developed grand mal, major fits appeared in only 35% of the 59 who were also given treatment
against major epilepsy.
This report seems to confirm that true petit mal is uncommon, that it is usually compatible with normal intelligence, and that its outcome as regards both the attacks themselves and the mental state is benign. It also shows, however, that repeated petit-mal status may have a serious effect on the child’s mentality and that the later development of major seizures is very common, though they can be reduced by giving phenobarbitone or one of the other drugs effective against grand mal. 1. Lees, F., Liversedge, L. A. Lancet, 1962, ii, 797. 2. Currier, R. D., Koci, K. A., Saidman, L. J. Neurology, 1963, 13, 959 3. Lennox, W. G. Epilepsy and Related Disorders. Springfield, Ill., 1954. 4. Gastaut, H. The Epilepsies: Electro-clinical Correlations. Springfield, Ill., 1954. 5. Livingston, S., Torres, I., Pauli, L. L., Rider, R. V. J. Am. med. Ass. 1965, 194, 227. 6. Holowach, J., Thurston, D. L., O’Leary, J. L. Pediatrics, Springfield, 1962, 60, 893. 7. Keith, H. M. Convulsive Disorders in Children. Boston, 1963.