TREATMENT OF STATUS EPILEPTICUS

591 4 out of 33 (12-12%) alive for 4-5-7 years, and 9 out of 57 (15-8%) alive for 3-4 years.

including

PALLIATIVE TREATMENT

Morphine and cocaine given in increasing doses with alcohol will often afford reasonable relief and make existence tolerable. More severe neuralgic pains may yield to intervertebral injections of anaesthetics or may even require cordotomy, and I have also seen cases where division of the phrenic nerve has helped to relieve previously intractable painful dragging sensations. Sometimes the intense pain of bony secondary deposits may require osteotomy and the curetting out of the neoplastic tissue. Formerly the suffocative symptoms of mediastinal compression could be helped only by division of the upper sternum; this may still at times be useful, but such symptoms can usually be relieved by X-ray therapy. In such cases X-ray therapy should never be withheld, because it sometimes affords dramatic relief, and also because the growth may prove to be a radiosensitive lymphocytoma rather than a carcinoma. Pneumonectomy itself should notbe overlooked as a palliative operation, especially in cases of pseudohypertrophic pulmonary osteo-arthropathy and where pulmonary infection is causing distress. Once the problem of fistula and empyema after pneumonectomy is mastered, the scope of the operation in this field may well be widened. Variations in the natural course of cancer of the lung make it difficult to assess the results of treatment. I have known a case with a continuous history extending over about five years, but we know that most cases run I a very much shorter course, whatever the treatment. can recall two patients in whom, though the growth was probably still removable, gross metastases scattered throughout the pleura were considered to preclude further treatment ; subsequently these patients did heavy manual work for over a year before their strength declined and they ultimately died.-. Until we can get these cases- at a much earlier stage, they will continue to be a disheartening part of our work. Even so, despite all the risks and the work involved, pneumonectomy offers the best hope of long survival and should be considered whenever possible. I am greatly indebted to my colleagues, Mr. S. G. Griffin and Mr. W. C. Barnsley, assistant surgeons in the -Regional Chest Surgery Centre, and to Mr. W. Buckley, assistant thoracic surgeon to -Nottingham City Hospital, for all the trouble they have taken to obtain this information for me, besides the active part they have played in the management of the cases. Mr. Barnsley has done a vast amount of work in this connexion, and it is largely on this that I have drawn. REFERENCES

Björk, V. O. (1947) Acta chir. scand. 95, suppl. 125. Perry, K. M. A. (1947) Thorax, 2, 91.

"... in

wisdom

the custom-I might and purely scientific brethren, which now ordains that the young newcomer to medicine must establish himself on the basis of what he has already written. In plain language, he must write if he wants a job. This single fact is the causa causans of the chaos of medical literature today.... We have not the option of the bookstall, where to miss the worthwhile in a mass of futility does not necessarily matter. What has been written must be read, .for we cannot afford to be unaware of elements of progress however inconspicuous they may-be.... In England an alleged shortage of paper provided a faintly brighter prospect that has vanished with nearly every other post-war hope."-JULIAN TAYLOR, F.R.C.S., in the Hamilton Russell lecture, Aust. N.Z. J. Surg. August, 1949, p. 10. our

we

have

adopted

perhaps call it the curse-of our academic

TREATMENT OF STATUS EPILEPTICUS MARGARET TAYLOR C. W. M. WHITTY B.M. Oxfd B.M., B.Sc. Oxfd, M.R.C.P. From the Department of Neurology, Radcliffe Infirmary, Oxford STATUS epilepticus, the occurrence of several grand-mal convulsions without recovery of consciousness between

each, should be looked effective

on

as

grave emergency.

a

not taken is likely to die.

measures are

promptly

If

to arrest the

fits, the patient The use of modern chemotherapy in the late

war

allowed the survival of many patients with severe brain wounds which would formerly have proved fatal. Hence there are more traumatic epileptics, and ipso facto cases of status epilepticus, in the community. The subject is inadequately dealt with in standard textbooks ; and the occurrence of several probably avoidable deaths from this cause has prompted us to make this brief review of 25 cases, mostly of the symptomatic group, and to mention one regime which in our experience has proved a safe and usually effective remedy. Status epilepticus can nearly always be cured if correct treatment is instituted early. Such treatment must not be allowed to obscure the medical or surgical measures required to deal with the underlying lesion in symptomatic epilepsy. However, even in these cases, arresting the fits is generally a life-saving measure and certainly an essential preliminary to further diagnosis and treatment, which may have to be delayed until special facilities are available. MATERIAL

Our material

was

gathered

from either the Radcliffe

Infirmary or the head-injury bureau at Wheatley Military Hospital, and the records of 36 patients were examined, of whom 12 had died.

Information

was

inadequate for detailed study in 11 cases ; of the remaining 25 patients (tables I and II), 17 were seen personally by one or other of us, details of the remaining 8 being obtained from case-records. In 2 patients two separate attacks of status epilepticus occurred ; 3 patients appeared to be idiopathic epileptics ; and .22 had some organic brain lesion as the presumed cause of the convulsions. Necropsy was performed in all the fatal cases ; in none of them was any definite cause found for their death apart from the fits’. In those with brain wounds there had been early and adequate neurosurgical treatment, and cases with an infective process showed evidence that this had been controlled by medical treatment. FINDINGS

If one compares the non-fatal cases (table I) with the fatal (table II), two points clearly emerge. In the fatal cases the interval between the onset of status epilepticus and the beginning of treatment was usually much longer than in the non-fatal cases, and the duration of status epilepticus was longer in the fatal cases than in the others. (The duration was taken to be the period in which convulsive movements continued without any recovery of responsiveness to questions or commands. In many cases it was subsequently found that a far longer period was occupied by a total amnesia. This was probably due partly to the drugs used in treatment, though in some cases it may have represented an extension of the epileptic process.) The type of treatment, on the other hand, seems to vary widely in both groups, and at first sight it might seem that the particular treatment used was of little importance. The detailed course of individual cases, however, suggests that this is a false impression. There is evidence that paraldehyde is the drug of choice, both

592 from the rapidity of its effect in checking convulsions and from itssuccess in abolishing fits in some cases where barbiturates had failed. These points are illustrated in the following brief case-records. Case 2.-A boy, aged 18, had a gunshot wound of the right frontal pole of the brain. After neurosurgical debridement this healed without incident. The patient returned to civilian life and to light employment. Some three years after his injury he suddenly had a series of grand-mal convulsions without recovery of consciousness between each. Within three-quarters of an hour of their onset he was taken to a local hospital, where he was given 5 ml. of paraldehyde intramuscularly. Within half an hour full convulsions ceased, and within three hours of the onset the patient could be roused to answer questions correctly, though he was still very drowsy. He was transferred two days later to another hospital, where he again went into status epilepticus. On this occasion he was given gr. 5 of sodium phenobarbitone intramuscularly within twenty minutes of the onset. However, his fits continued for a further hour, when they tailed off gradually. He was then given gr. 1 of phenobarbitone by mouth t.d.s. and has reported no further fits. Case 15.-A girl, aged 11 months, had been off her feeds and had had diarrhoea for some weeks. She seemed to have recovered from this and was feeding well again, when she suddenly developed status epilepticus. On admission to hospital two ,hours. later she was immediately given 5 ml. of paraldehyde intramuscularly and gr. 2 of phenobarbitone mouth. Within a quarter of an hour the convulsions ceased. However, occasional twitchings, -mainly of the mouth and face, started again some twelve hours later. These never proceeded to grand-mal convulsions and they cleared entirely in about two days. After the initial paraldehyde the patient was given gr. 1/4 of phenobarbitone four-hourly during her stay in hospital. -Some months later she had a further status epilepticus, in which she died.

by

The dose of 5 ml. ’of paraldehyde in this case was probably unnecessarily high and is not recommended

’

as a routine. However, an initial dose of 2 or 3 ml. in infants over the age of 6 months, and 1 or 2 ml. for younger infants, is usually necessary to end the- fits. In the foregoing cases intramuscular paraldehyde ended the convulsions within an hour or so. When barbiturates were used the effect was more delayed. Thus in case 3 (table I) after the administration of gr. 3 of sodium phenobarbitone intravenously the fits continued for -some four hours, and in case 7 (table I), despite gr. 6 of sodium phenobarbitone intramuscularly, the fits continued for three hours, and ineach case barbiturates had to be repeated. In the following case paraldehyde appeared have a rapid effect when barbiturates had not modified’the status epilepticus :

to

’

Case 13.-A woman, aged 54, developed status epilepticus ten days after surgical removal of portions of both frontal lobes. She was in hospital at the time, and within half an hour of the start she was given gr. 3 of sodium phenobarbitone intramuscularly. This was repeated in half an hour, because the fits continued. However, three-quarters of an hour later she was still having grand-mal convulsions at intervals of about five minutes. Then, at about 6 P.M., she was given 10 ml. of paraldehyde intramuscularly. Within half an hour the fits ceased entirely and did not recur. The patient slept through that night and thereafter remained drowsy and confused, though able to respond to questions, for a further twelve hours. On phenobarbitone and hydantoin given regularly she has had no further fits. some

’

DISCUSSIONS AND CONCLUSIONS

Prompt in status

measures must be taken to end the

epilepticus.

TABLE I-RECOVERIES FROM STATUS EPILEPTICUS

The

longer

convulsions

the fits continue

593 TABLE II—DEATHS FROM STATUS EPILEPTICUS

’

unchecked the more probable is a fatal outcome. is emphasised by the following figures : Duration of - status epilepticus

Under 3 hr. 3-12 hr..... 12-24 hr. Over 24 hr..... Total

....

No. of deaths 0 4 1 6

..

..

..

..

11

be used in doses which abolish consciousness. Moreover, if fits continue for long, intravenous fluids may be necessary to combat either obvious dehydration or the accumulation of metabolites in tissue fluids and blood. An intramuscular injection in patients whose circulatory state suggests that it will not be absorbed is clearly valueless, and in these cases a drip should be set up

This

No. of recoveries 6 8 2 0

at

16

where fits have been finally controlled hours irreversible changes -seem to have place and death ensues after a further period of coma. This was so in 5 of the 11 cases given in table II. In our experience paraldehyde is a safe and effective drug in this condition. The principle of treatment is to establish as rapidly as possible an effective anticonvulsant blood-paraldehyde level and to maintain this until the fits stop, The regime we consider advisable for an average adult is as follows-: ,(1) As soon as possible ?-10 ml. of paraldehyde is injected

In,many

after taken

cases

some

..

’

,,’

"

into the gluteal muscle, and the site of injection is massaged. This treatment The paraldehyde need not be sterilised. usually stops the fits within half an hour. (2) If the fits continue, 5 ml: of paraldehyde intramuscularly is given every half-hour until they cease. The persistence of focal twitching without any tendency to spread does not require further sedation, and attempts to eliminate these entirely may lead to a dangerous level of narcosis. (3) If the patient’s general condition indicates it, an intravenous glucose-saline or plasma drip is given at the rate of one bottle in three hours. This will alsoprovide a convenient method of continuing the administration of paraldehyde, either by intermittent injections into the drip tubing, or in solution in the drip fluid in any required concentration, since it is soluble 1 in 8 in physiological saline solution.

-

once.

For children the dosage in the regime described above is smaller ; but it is still higher than is generally realised, and even in infants aged only a few months 2 or 3 ml. of paraldehyde. intramuscularly must be given to be effective. The value in certain cases of an adequately maintained blood-paraldehyde level, which can best be achieved by continuous intravenous drip, is well illustrated in the following case, which in our experience was unusually severe :

Case 26.-A man, aged 27 (not included in table I) was admitted to hospital in status epilepticus with fits every TABLE

III-—CASE

OF STATUS EPILEPTICUS TREATED INTRAVENOUS PARALDEHYDE SOLUTION

WITH

’

-

’

’

In practice most cases will be controlled by the intramuscular injections and a drip will not be required. However, if fits recur as the effect of the paraldehyde wears off, an intravenous drip gives a means of adjusting accurately blood-paraldehyde level so that fits are controlled but coma is not too deep. This is important, since drugs which control status, to be effective, must

In the next 24 hr. the drip was stopped and paraldehyde 2 drachms 4-hourly by mouth was given. This was changed gradually to phenobarbitone gr. 1 q.d.s.

594 five minutes. He had had s.erial epilepsy for four days previously, and had had an unknown amount of sodium cyclonal intravenously followed by paraldehyde intramuscularly, with only a slight reduction in the number of his fits. Since he appeared dehydrated, a glucose-saline drip was set up at a rate of about 540 ml. (1 bottle) in three hours, through which paraldehyde was given. The subsequent course of fits and medication are shown in table ill. It will be seen that intermittent dosage had little effect, but the maintenance of an effective blood-paraldehyde level stopped the fits within six hours. The very large doses which may be safely used when occasion demands is also well shown. This patient had 202 ml. of paraldehyde intramuscularly in three days.

Additional clinical evidence of the value of paraldehyde is provided by the experimental work of de Elio et al.1 who find that intravenous paraldehyde promptly abolishes both the convulsions and the abnormal cortical electrical activity of experimentally induced epilepsy in animals, and the fits induced sometimes during cerebral operations in man. The rapidity with which paraldehyde acts is strikingly shown in their work, and they remark that once the epilepsy has ceased it usually does not recur even though the pharmacological effect of the paraldehyde has worn off. Other remedies are undoubtedly effective in status epilepticus, but the rapid action and relative safety of paraldehyde make it the drug of election. If it is not available, an attempt should be made immediately to stop the fits by other means, because it is essential that the fits be interrupted as rapidly, as possible. If phenobarbitone is used it should be given in doses ofgr. 6-12, smaller doses being of little value, and preferably in the " soluble " form by intramuscular or intravenous route. Thiopentone in anaesthetic doses may be used, or chloroform anaesthesia if no other remedy is at hand. But the effect of these methods is often short-lived, and it may be necessary to establish heavy sedation by other means and to maintain this for twenty-four hours or longer afterwards if the fits tend to recur. The respite given by the immediate measures is probably best used in establishing paraldehyde sedation. Though cases of status epilepticus at times seem to subside practically without treatment, it is safest to regard every case as potentially fatal and to act accordingly. Once status epilepticus has been controlled, the patient must be put on regular anticonvulsant therapy, of which the barbiturates and hydantoins remain the most convenient and widely used. The patient should clearly understand that the regular use of these medicines for an indefinite period is essential to avoid a recurrence of the convulsions. The commonest setting for status epilepticus is as an episode or the terminal event in idiopathic grand-mal epilepsy. However, it can also occur as the first manifestation of a traumatic epilepsy or of a symptomatic epilepsy from cerebral neoplasm, as Clark and Prout2 have noted. When status epilepticus occurs during the course of an established epilepsy it is often preceded by an increased frequency of individual attacks, which may become so numerous as to constitute serial epilepsy. This gives timely warning of a possible status epilepticus ; hence anticonvulsant therapy can be appropriately increased. In 9 of the 25 cases reviewed here there was such a preliminary increase of fits. The omission of the patient’s usual anticonvulsants in either symptomatic

idiopathic epilepsy is a common precipitating factor of status epilepticus. This should be explained to those liable to be careless about their medication. or

SUMMARY

The treatment

epilepticus

are

and

course

of

25

cases

of

status

reviewed.

Elío, F. J., Jalón, P. G., Obrador, S. J. Neurol. Neurosurg. Psychiat. 1949, 12, 19. 2. Clark, W., Prout, E. S. Amer. J. Insanity, 1905, 61, 81. 1. de

This condition constitutes a grave medical emergency and may be fatal unless the fits are rapidly controlled. A regime of treatment considered to be safe and effective, based on the use of intramuscular or intravenous paraldehyde, is described. Our thanks are due to Dr. Victoria Smallpeice, physician in charge of the children’s department, Radcliffe Infirmary, under whose care four of the patients were admitted, and to Dr. W. Ritchie Russell, who provided facilities for reviewing the head-injury cases and helped us with valuable criticism.

TORSION AND OTHER AFFECTIONS OF THE APPENDICES EPIPLOICÆ

Sir CECIL WAKELEY K.B.E.;

C.B., D.Sc., P.R.C.S.,

F.R.S.E.

SENIOR SURGEON AND DIRECTOR OF SURGICAL

COLLEGE

HOSPITAL ;

STUDIES, KING’S

SURGEON TO THE ROYAL MASONIC

HOSPITAL AND BELGRAVE HOSPITAL FOR CHILDREN CONSULTANT SURGEON TO THE ROYAL NAVY

;

PETER CHILDS M.A., D.M., M.Ch. Oxfd, F.R.C.S. FIRST SURGICAL

ASSISTANT, KING’S COLLEGE HOSPITAL

MORBID conditions of the appendices epiploicae, which symptoms and signs of acute or subacute abdominal disease, and necessitate urgent surgery, are uncommon. 64 such cases have been reported (Hunt 1919, Klingenstein 1924, Fiske 1936, Pines et al. 1941, Marinis and Cheek 1949). This number does not include those running a chronic course, those in which appendices epiploic8& situate within hernial sacs arediseased, those associated with other acute disease, or those in which diseased appendices epiploicae are found incidentally at operation or at autopsy. To these previous reports and reviews we wish to add 8 further cases from the personal case-records of one of us (C. W.). cause

’

CASE-HISTORIES

aged 36, was admitted to hospital January, 1915, as a case of acute appendicitis. He gave a history of right-sided abdominal pain which had started quite suddenly 24 hours before admission. Temperature, 100°F ; pulse-rate, 92 ; respirations, 30. Examination showed considerable guarding over the right iliac fossa, and a small lump could be palpated. Operation was performed an hour after admission, through a muscle-splitting incision over the right iliac fossa. There was some bloodstained free fluid inside the abdomen. On lifting the caecum out of the abdominal cavity a large gangrenous appendix epiploica was seen on the outer side of the caecum. The appendix vermiformis was normal and overhung the pelvic brim. The gangrenous fatty lump was excised and its attachment to the caecum invaginated with a purse-string suture. The vermiform appendix was also removed. The patient made an uneventful Case 1.—A married man,

in

recovery.

Case 2.-A married woman, aged 39, was admitted in June, 1921, complaining of acute abdominal pain and vomiting. The pain had commenced after she had passed a constipated motion. On admission she was acutely ill. T., 99; P., 120; R., 32. There was considerable guarding of the lower quadrants of the abdomen. Per vaginam there was some tenderness in the posterior fornix, and per rectum some tenderness in the upper part of the anterior rectal wall. The diagnosis of torsion of the left ovary was made. A laparotomy was performed through a midline incision and a gangrenous appendix epiploica was found on the lower part of the sigmoid colon ; it was excised. Recovery was uneventful.

Case 3.-A boy, aged 19, was admitted in 1929 complaining of acute abdominal pain, of 48 hours’ duration, limited to the right iliac fossa. Appendicectomy had been performed 3 years before admission. T., 99°8 ; P., 96 ; R., 28. There was definite tenderness and guarding over the right iliac fossa. As the appendix vermiformis had been removed previously it was decided to watch the patient for 12 hours. There was a leucocytosis of 18,000 by the following day and the temperature had risen to 101°. Operation was decided upon. The old operation. scar was excised and the abdomen opened over the