- Email: [email protected]
TREATMENT OF TETANUS
1017
Special
Rigidity generalised from the start. Vital capacity reduced. Minute volume at rest normal. Reflex spasms become more violent and frequent for several days but do not cause severe dyspnoea or cyanosis.
Articles
TREATMENT OF TETANUS * LESLIE COLE
HAROLD YOUNGMAN CAMBRIDGE, ENGLAND
THE modern
treatment
of
tetanus
began in
1953 when
on demonstrations to the Association of Physicians (Cambridge, 1966), the World Congress of Anesthesiologists (London, 1968), and the Royal College of Surgeons (Norwich, 1968). Lassen applied the principles, already used in the treatment of poliomyelitis with respiratory paralysis, to severe tetanus. After tracheostomy, by inducing paralysis with d-tubocurarine artificial ventilation was maintained until, on discontinuing the curarisation, severe spasms did not return. 3 out of the first 4 patients recovered completely and the 4th died of septicæmia after all signs of tetanus had passed (Lassen 1953, Lassen et al. 1954). Since then results in different centres have been variable (Ellis 1963, Mollaret and Pocidalo 1965, Adams et al. 1966, Spalding 1966). The reports suggest that causes of failure are (a) the technique is complicated, requiring experience, elaborate equipment and highly trained staff; (b) in some series severe cases are not recognised in the early stages and treated by tracheostomy and curarisation before complications arise. In 1967 the results of treatment in several centres were reviewed (Ablett 1967, Dundee and Gray 1967, Horton 1967, Macrae 1967, Pearce 1967). Detailed criteria of severity are not given. Much the best results were achieved at Leeds where, between 1958 and 1967, 54 severe cases were treated with curare and artificial ventilation and only 2 died (Ablett 1967). In most published series it is difficult to correlate the degree of severity with the treatment used. In this paper we submit detailed definitions of three grades of severity and a standard regimen of treatment for each grade. This is supported by a study of the fatal cases in the series, in all of which there were deviations from the standard
*
Based
regimen. Since 1954, 59 consecutive cases have been treated in the Cambridge area—50 at Addenbrooke’s Hospital, 7 at the West Suffolk Hospital, and 2 at Newmarket General Hospital. The majority of these patients were under our care or, by the courtesy of those in charge, under our observation. Criteria of Severitv Grade1: Mild Incubation period (injury to first symptom) over 14 days. Period of onset (first symptom to first spasm, if any) over 6
days. Trismus present but not severe. Difficulty in eating and drinking may occur-due
not
to
trismus,
dysphagia.
Localised stiffness near the injury may occur (a) alone, (b) preceding generalised rigidity by hours or days. This is local tetanus "; an important note on local tetanus in the head and neck region appears later. Generalised spasms if present are short, not violent, not interfering with breathing, and slow in getting worse. "
Grade 2 : Moderate Incubation period 10-14 days. Period of onset from over 3-6 days. Trismus marked. Dysphagia-i.e., swallowing with choking swallow—often present.
or
inability
to
Grade 3: Severe Incubation period under 10 days. Period of onset 3 days or less. Trismus and dysphagia severe, the latter causing aspiration of saliva, food, or regurgitated material early in the disease. This commonly occurs during the urgent inspiration at the end of
a
spasm.
Rigidity may limit breathing and cause continuous asphyxia. (The early signs of asphyxia are anxiety, sweating, tachycardia, and rise of blood-pressure; cyanosis is a late sign indicating severe asphyxia.) Generalised spasms rapidly become violent, frequent, and prolonged, causing temporary respiratory arrest and laryngeal spasm. The resulting addition of acute to chronic asphyxia is the commonest immediate cause of death. The prevention of asphyxia and prolongation of life by modern treatment has revealed that in severe tetanus a syndrome of overactivity of the sympathetic nervous system can arise, analogous to the obvious overactivity of the somatic motor system (Kerr 1967, Kerr et al. 1968). This is characterised by profuse sweating and salivation, extreme hyperpyrexia, tachycardia and hypertension, arrhythmia, and peripheral constriction with cyanosis, often ending in circulatory collapse and death.
Treatment
In the absence of any specific remedy for tetanus, treatconsists in removing the source of the toxin in the wound as far as possible, and in measures to prevent or treat asphyxial, pulmonary, and circulatory complications, including those due to sympathetic overactivity, continued until the toxin and any inaccessible organisms have been neutralised by the patient’s natural reaction. Thus success depends on the urgency and skill with which the following events are anticipated and prevented, or detected and controlled: ment
(1) Depression and arrest of respiration by rigidity and reflex spasms of the muscles of respiration. (2) Aspiration of foreign material into the lungs owing to inability to swallow, accumulation of saliva, the gastric regurgitation which occurs in asphyxia, and injudicious feeding by mouth.
(3) Consequent pulmonary collapse and secondary infection of the
lungs.
(4) Circulatory failure due
to
asphyxia
or
sympathetic
overactivity. THE STANDARD REGIMEN
The
our present views, in these there were 59 cases and in 46 of the applied no deaths. In the remaining 13 cases there were departures from this regimen and 10 of the patients died; the causes of death are studied in detail later. On admission of a patient with tetanus the expected severity of the case was immediately assessed according to the criteria described above. The most important are the period of onset and the severity the spasms have already attained. The appropriate treatment for the grade of severity (see below) was instituted at once. A system by which the need for tracheostomy or curarisation is decided on by the severity of the fully developed attack leaves these measures too late. The patient was never left alone, and a careful watch was kept in the first few days for signs implying reassignment to a severer grade-for example, dysphagia in a case classed as grade 1, or the sudden violent spasm which sometimes occurs in a case previously deceptively mild. was
following scheme, representing
1018 Grade1 (Mild) Antitoxin (adult dose up to 100,000 units) was injected with precautions against reactions. (The value of this is regarded with increasing doubt [Cox et al. 1963, Vaishnava et al. 1966]). Surgical toilet of the wound, if any, was then carried out. Nursing included ensuring adequate nutrition and precautions against secondary infection. Sedation is the subject of a special paragraph below. When trismus without dysphagia is severe enough to prevent eating and drinking, we consider that a nasogastric feeding tube may safely be used without tracheostomy in younger patients. 9 of our patients under 70 were treated in this way, and 2 subsequently required tracheostomy; all recovered. The elderly, however, have sluggish protective reflexes and are prone to aspiration and pulmonary complications in any illness. Therefore, except in the very mildest cases, aged patients with tetanus should be assumed to be dysphagic and should be treated as grade 2 or 3 according to the severity of their other symptoms. Grade 2 (Moderate) In addition to the general treatment described above, tracheostomy with a cuffed tube (or temporary orotracheal intubation) was undertaken without delay under general anaesthesia. (This must be done before an ambulance journey.) A nasogastric tube is passed at the end of the operation. Ideally the tracheostomy completely prevents contamination of the chest by aspiration, but this may have occurred before the patient was seen. A humidifier to saturate the inspired air, regular changes of posture from one side to the other, physiotherapy to the chest, and suction of secretions from the bronchial tree are of first importance. Frequent examinations, including X-rays, were made to detect areas of pulmonary
collapse
or
congestion.
The respiratory minute volume and blood-pressure were monitored half-hourly in the early stages; these simple measurements give an early warning of deteriorating respiratory function and carbon-dioxide accumulation. The equilibrium method of estimating alveolar CO2, and, when it became available, direct measurement of blood-gases, provided a further check of respiratory sufficiency. Blood urea and electrolytes were measured daily, and adequate food and fluid intake was maintained by tube-feeding. Occasionally intravenous fluids were needed for a short time. A patient allocated to this grade may without warning suffer a spasm more severe than usual which depresses or arrests breathing. Against this emergency a catheter which would pass loosely into the trachea (as for suction) was kept attached to the oxygen supply by the bed. A brisk flow of oxygen through this into the trachea maintained some oxygenation of the blood by diffusion until the spasm passed off. Recurrence of such spasms was an indication for transfer of the case to grade 3.
Grade 3 (Severe) In addition to tracheostomy and the
general
above, the rigidity and superimposed spasms
by curarisation, and ventilation of artificially.
the
lungs
outlined abolished maintained
care
were was
The first dose of d-tubocurarine was given during an.Tsthesia for tracheostomy or temporary orotracheal intubation. Apparatus for manual ventilation of the lungs was available for ambulance journeys, and also at the bedside to provide for occasions of mechanical failure. The mechanical ventilator used was the East-Radcliffe, which applies a constant inspiratory pressure. The pressure was adjusted to produce slight over-ventilation, reducing the arterial Pco2 from the normal to about 36 mm. An advantage of this type of ventilator is that the simple bedside measurement of minute volume, as in the grade-2 cases, gives an easily understood warning of respiratory obstruction by secretions or pulmonary collapse, as well as of mechanical faults such as leaking connections. The usual dose of d-tubocurarine for an adult was 15-20 mg., either through an intravenous catheter or intramuscularly. Larger doses last longer but tend to cause abdominal
distension. At first the dose is repeated at the slightest sign of returning muscular activity; delay may allow a severe spasm to occur and doses may be needed every 20 minutes. The interval lengthens as the disease begins to wane. It is safe after a few days to allow the paralysis to become a little less complete before renewing the dose; at these times the patient is able to communicate by slight facial movements. Owing to the abolition of striated-muscle tone, bladder drainage and regular digital evacuation of the rectum are needed.
Local tetanus affecting the head and neck does not fit into the above classification. Though it may be relatively chronic and general symptoms absent or mild, dysphagia and laryngeal spasm may be present; and for these tracheostomy and tube feeding are indicated. Sedative and anticonvulsant drugs.-It is not surprising that most patients find tetanus and its treatment a frightening and painful ordeal (Cole and Youngman 1968). They should receive as much sedation as can safely be given. Drugs which can exaggerate the respiratory and circulatory embarrassment of tetanus must, however, be avoided. In our opinion this cuts out opiates, barbiturates, and tranquillisers, even with curarised patients. It also cuts out drugs causing partial paralysis such as mephenesin and triethylcholine. Both before (Cole 1945, Knott and Cole 1951) and throughout this series we have used paraldehyde freely, and in severe cases almost exclusively. Doses up to 12 ml. every 4 hours, by stomach tube (diluted 1 in 10) or by intramuscular injection, have been given throughout the illness without any undesirable side-effects. We think it is thanks to the use of this drug that in a series of 59 cases we have never seen the sympathetic overactivity of severe tetanus described by Kerr et al. (1968). These workers have demonstrated that this syndrome can be suppressed by halothane or by specific adrenergic blockers (Kerr et al. 1969). Paraldehyde appears to act in the same way and provides valuable sedation. be avoided in the initial stage of tetanus. It is the usual cause of the deceptive impression of mildness, terminated by the break-through of a violent spasm, already mentioned. Antibiotics and secondary infection.-Most patients were given large doses of penicillin from admission. Swabs from the upper respiratory tract and tracheostomy wound and specimens of sputum or tracheal aspirate were cultured daily and antibiotic treatment was altered according to the findings. In spite of this and strict hygienic precautions, secondary infection and cross-infection in the unit were common. We were tardy in adopting the efficient air-filters now available for attachment to the intakes of humidifiers and ventilators. They are now in use and reducing the incidence of infection. Brain damage due to a mechanical fault.-A patient, aged 13, suffered a severe anoxic episode due to a removable cuff slipping off his tracheostomy tube and blocking the trachea. Although he recovered from tetanus, some mental impairment remained.
Heavy sedation
must
Results
46 of the 59 patients were treated in accordance with the standard regimen described and all recovered. Of the 10 patients over 70, only 3 (with mild tetanus) received standard treatment, and they recovered. The other 7 (1 severe and 6 moderate) did not receive standard treatment but might have died however treated.
1019 Of the 13 patients treated with material departures from the standard regimen, 10 died. Data on both groups are summarised in tables i and 11. Some details of the fatal cases follow. Case 1
Male, aged 40. Incubation period (I.P.) 6 days, period of (P.o.) 36 hours. Very agitated, refused tracheostomy; very heavily sedated with chlorpromazine, amylobarbitone, and pethidine; slept; spasms ceased. After 8 hours sudden severe spasm with asphyxia and cardiac arrest. Resuscitated; trache-
onset
ostomy and curarisation. Normal progress 3 days, then sudden collapse and death. ? due to technical failure; no explanation of death at necropsy.
of delaying tracheostomy and curarisation in a case with such a short P.o. Deceptive effect of heavy sedation early in the disease.
Comment.-Danger
Case 2 7 years. l.P. 7 days, P.o. 12 hours. Admitted hospital with opisthotonos, severe spasms every 5 minutes. l.M. injection paraldehyde 5 ml.; spasms ceased temporarily. During transfer to Addenbrooke’s by ambulance had severe spasm, vomited, and died. Necropsy: bile-stained
Male, aged
local
debris in bronchial tree. This child had had a full course of triple vaccine as an infant and a booster dose of toxoid at age 6.
Comment.-Danger of delaying tracheostomy and curarisation in
a case
with such
a
short
P.o.
and
severe
Deceptive effect of early heavy sedation. Danger of ambulance journey without intubation and accompanying doctor. Full active immunisation did not spasms.
prevent
severe
tetanus.
arrival X-ray showed collapse right upper lobe. Tracheostomy. Spasms began, P.o. 4 days. Treated by partial paralysis with triethylcholine for 6 days. During this time he suffered numerous cyanotic and hypotensive episodes and chest infection developed. He was then transferred to orthodox treatment but died after 10 hours. Necropsy: on
bronchopneumonia.
Comment.-Again, the danger of delaying tracheostomy in a dysphagic patient. The reasons given by Bowman and Rand (1961) for expecting triethylcholine to lessen the spasms of tetanus while sparing the respiratory muscles, unlike any other muscle relaxant, appear to us fallacious. Cases 4-10 2 male and 5 female patients aged 70-83. These 7 aged patients, some of them very feeble with pre-existing chronic disease and injuries, were handled with varying degrees of reluctance to add to their suffering by vigorous treatment. 3 had tracheostomies late in the disease after they had developed aspiration pneumonia. 2 died shortly after admission, of pulmonary embolism or an asphyxial spasm, and 4 of bronchopneumonia. One, with severe tetanus, had a tracheostomy and then was treated by heavy sedation until the 8th day when a severe spasm caused cardiac arrest. The heart was re-started, but he remained unconscious and lived a vegetable life for a further 4 months. Comment.-With a feeble and senile patient it may well be right to decide that active treatment would be a profitless infliction and to let the disease take its course. Not all of these 7 old patients could be so regarded. In retrospect we think that, if the standard regimen had been some would have survived both the and the disease. Their records repeat again and again the lessons taught by those of the 3 younger patients whose records are recorded above in greater detail. In general it may be said that, where facilities and expert staff are available early in the disease, death from tetanus of an otherwise healthy patient is nearly always due to omission of precautions accepted as routine at the centres with long experience.
Case 3
rigorously applied,
Male, aged 56. On admission to local hospital 2 days hisgeneral stiffness, dysphagia and stridor, no spasms, no injury found, chest X-ray clear. Ambulance to Addenbrooke’s;
treatment
tory of
Conclusions
Success with the modern treatment of tetanus depends forecasting the severity of an attack as soon as the disease is diagnosed and on immediately instituting the appropriate treatment to forestall respiratory and
on
TABLE II-RESULTS IN
Regimen and severity grade
notes on Notes on
59 CASES
treatment
Standard: Mild Moderate Severe Totals
Not standard:
Moderate
Severe
No. of
cases
deaths
24 6 16
0 0 0
-
Partial
paralysis (triethylcholine) Local tetanus with dysphagia; no tracheostomy Aged over 70; palliative treatment only Refused early treatment; oversedated Died in ambulance; not intubated Aged over 70; not curarised for 9 days and oversedated
Aged
over
treatment
Totals
No. of
70; palliative only
-
46
0
2
1
2
0
5
5
1
1
1
1
1
1
1
1
13
10
circulatory complications. Criteria for this forecasting divide the cases into three severity grades requiring (1) general nursing management ; (2) tracheostomy and tube feeding, and (3) curarisation and artificial ventilation. Paraldehyde in full doses is recommended as (a) an effective sedative without side-effects exaggerating the respiratory and circulatory embarrassment due to the disease, (b) a preventive of the dangerous sympathetic overactivity of severe tetanus. We wish to thank the many physicians and surgeons, past and present, of Addenbrooke’s, the West Suffolk, and Newmarket General Hospitals who have permitted us to see patients under their care or allowed us to treat them. We also thank particularly Sister P. M. Mountford, the sister-in-charge, and the staff of the intensivetherapy unit at Addenbrooke’s Hospital. Requests for reprints should be addressed to L. C., 15 Fitzwilliam
Street, Cambridge.
(references overleaf))
1020
Letters
to
the Editor
TEACHING OF PSYCHIATRY SIR,-While generally concurring with your leader of March 1 (p. 451), I would take issue with your advocacy of clerkship on an inpatient psychiatric unit as the method of training students how to relate to patients. While I agree that this is better than nothing, my experience is that this too can become an unrewarding attempt to seduce the non-psychologically minded from their disdain of such issues. The problem here is that it is all too easy for the students simply to obtain factual details of the " patient who occupies a bed " in a hospital, and to continue to use existing models. Too often the hospital setting promotes either somewhat dreary listing of symptoms, signs, and differential diagnoses, or sterile speculation about psychodynamics. During the past year an attempt has been made here to teach medical students under two rather different conditions; and, although I suspect they retain as much formal psychiatric knowledge as before, virtually all seem interested and excited by what they are doing. The first step was to move away, at least in part, from formal teaching on the wards, and to make use of the psychiatric home treatment service of the Boston State Hospital.l Two fourthyear students, assigned to the rotation for 4 weeks, visit people referred to this service in their homes, in the company of a nurse or social worker from the service, and a psychiatrist. One student evaluates the patient, while the other student may listen in or (after learning something of the problem) interview other members of the family. Depending on the skill of the student, guidance is necessary to make points about such factors as interviewing techniques, clarification of history, and the use of specialised questions to demonstrate psychiatric syndromes. The bulk of the definitive psychiatric evaluation is performed by the student, who is responsible for note-taking and for presentation at the weekly intake conference. On leaving the patient’s home, the team discuss the problem in the light of the total social picture. Wherever possible follow-up visits are made by the student. If, as is usual, a longer period of treatment is required, close liaison between the student and the permanent staff of the service ensures a smooth transition. At conferences, notes need seldom be consulted, for the details are made memorable by the impact of the visit. With hospital patients, a promising method has been to use similar techniques in interviewing patients in a general hospital ward. The aims here are to help the student to feel the emotional impact that any illness has on the patient and his family and to demonstrate many other aspects of physical and 1.
Becker,
A. Home Treatment.
Pittsburgh,
1968.
REFERENCES
mental illness, from the delineation of emotional factors as precipitants of physical illness to the normal ego’s defence against stress. In this setting the defences of the student who professes irritation with psychological concepts rapidly disappear. It is
hard for him to refute the evidence of what has been made apparent by his own interview or to be unimpressed by his own skill when a patient spontaneously tells him that the headache that was oppressing him all morning has gone, now that he has got some things off his mind. These methods seem easily transferable to the British scene. Commonwealth of Massachusetts PETER L. AGULNIK. Department of Mental Health, Boston State
Hospital.
FAILURE OF CERVICAL CYTOLOGY? SIR,-The increasing use of diagnostic cytology in England in the past ten years has not lowered the death-rate from cancer of the cervix. The accompanying figure shows cohort deathrates at certain ages for total cancer of uterus since 1911 and cancer of cervix since 1950. The death-rates at successive age-groups of each cohort are plotted on the same ordinate. The lines join the same age-specific death-rates in successive cohorts. The diagram confirms the approximate validity of the rule: " The death-rate from cancer at one age-group always bears a constant ratio to that of any other age-group in every cohort ".11
Cancer of uterus, England and Wales. Annual death-rates from total uterine cancer and cancer of cervix in certain age-groups in generation-cohorts of women.
The death-rate from total uterine cancer (and presumably of of the cervix, which forms the bulk of uterine cancers under the age of 50), fell at all ages until 1945-50. Then the trend of death-rates at the younger ages was reversed to reach a secondary peak for 30-34 years in 1957 with a rapid fall to the pre-existing-trend level.The women affected by this rise were born between about 1915 and 1925. They should, by the rule, continue at subsequent ages to have a death-rate higher than women born earlier or later. These women are now aged 40-50, at which age the death-rate has risen appreciably since 1956. The fall in cervical-cancer death-rate at the younger ages is Corbett, J. L., Prys-Roberts, C., Crampton-Smith, A., Spalding, claimed to be due to the cytology service. Will its supporters " J. M. K. (1968) Lancet, ii, 236. explain " the rise at age 40-50 years-at which the value of (1969) ibid. i, 542. Knott, F. A., Cole, L. (1951) in British Encyclopædia of Medical Practice; cytology should now be maximal ? vol. £11, p. 40. London. 2nd ed. Division of Laboratories, Lassen, H. C. A. (1953) Lancet, i, 37. Department of Health, Bjørneboe, M., Ibsen, B., Neukirch, F. (1954) ibid. ii, 1040. Charlottetown, Macrae, J. (1967) in Symposium on Tetanus in Great Britain; p. 11. Leeds. T. W. LEES. Prince Edward Island, Canada. Ann. N.Y. Acad. Sci. 121, 898. Mollaret, P., Pocidalo, J. J. (1965) Pearce, D. J. (1967) in Symposium on Tetanus in Great Britain; p. 31. 1. Lees, T. W. Trends in Cancer: The Wave Theory of Cancer Leeds. Mortality. Unpublished; Lancet, 1965, i, 1116. Spalding, J. M. K. (1966) Proc. R. Soc. Med., 59, 29. 2. Registrar-General, England and Wales; Annual Reports and Statistical Vaishnava, H., Goyal, R. K., Neogy, C. N., Mathur, G. P. (1966) Lancet, Reviews, 1911-1966. H.M. Stationery Office, 1912-1968. 1371. ii,
(1967) in Proceedings of a Symposium on Tetanus in Great Ablett, J. J. Britain (edited by M. Ellis); p. 1. Leeds. Adams, E. B., Holloway, R., Thambiran, A. K., Desai, S. D. (1966) Lancet, ii, 1176. Bowman, W. C., Rand, M. J. (1961) ibid. i, 480. Cole, L. (1945) Br. med. J. i, 219. Youngman, H. R. (1968) Lancet, ii, 567. Cox, A. C., Knowelden, J., Sharrard, W. J. W. (1963) Br. med. J. ii, 1360. Dundee, J. W., Gray, R. C. (1967) in Symposium on Tetanus in Great Britain; p. 17. Leeds. Ellis, M. (1963). Br. med. J. i, 1123. Horton, J. A. G. (1967) in Symposium on Tetanus in Great Britain; p. 25. Leeds. Kerr, J. H. (1967) ibid. p. 49. L.
—
—
—
—
—
—
—
—
cancer
Special
Rigidity generalised from the start. Vital capacity reduced. Minute volume at rest normal. Reflex spasms become more violent and frequent for several days but do not cause severe dyspnoea or cyanosis.
Articles
TREATMENT OF TETANUS * LESLIE COLE
HAROLD YOUNGMAN CAMBRIDGE, ENGLAND
THE modern
treatment
of
tetanus
began in
1953 when
on demonstrations to the Association of Physicians (Cambridge, 1966), the World Congress of Anesthesiologists (London, 1968), and the Royal College of Surgeons (Norwich, 1968). Lassen applied the principles, already used in the treatment of poliomyelitis with respiratory paralysis, to severe tetanus. After tracheostomy, by inducing paralysis with d-tubocurarine artificial ventilation was maintained until, on discontinuing the curarisation, severe spasms did not return. 3 out of the first 4 patients recovered completely and the 4th died of septicæmia after all signs of tetanus had passed (Lassen 1953, Lassen et al. 1954). Since then results in different centres have been variable (Ellis 1963, Mollaret and Pocidalo 1965, Adams et al. 1966, Spalding 1966). The reports suggest that causes of failure are (a) the technique is complicated, requiring experience, elaborate equipment and highly trained staff; (b) in some series severe cases are not recognised in the early stages and treated by tracheostomy and curarisation before complications arise. In 1967 the results of treatment in several centres were reviewed (Ablett 1967, Dundee and Gray 1967, Horton 1967, Macrae 1967, Pearce 1967). Detailed criteria of severity are not given. Much the best results were achieved at Leeds where, between 1958 and 1967, 54 severe cases were treated with curare and artificial ventilation and only 2 died (Ablett 1967). In most published series it is difficult to correlate the degree of severity with the treatment used. In this paper we submit detailed definitions of three grades of severity and a standard regimen of treatment for each grade. This is supported by a study of the fatal cases in the series, in all of which there were deviations from the standard
*
Based
regimen. Since 1954, 59 consecutive cases have been treated in the Cambridge area—50 at Addenbrooke’s Hospital, 7 at the West Suffolk Hospital, and 2 at Newmarket General Hospital. The majority of these patients were under our care or, by the courtesy of those in charge, under our observation. Criteria of Severitv Grade1: Mild Incubation period (injury to first symptom) over 14 days. Period of onset (first symptom to first spasm, if any) over 6
days. Trismus present but not severe. Difficulty in eating and drinking may occur-due
not
to
trismus,
dysphagia.
Localised stiffness near the injury may occur (a) alone, (b) preceding generalised rigidity by hours or days. This is local tetanus "; an important note on local tetanus in the head and neck region appears later. Generalised spasms if present are short, not violent, not interfering with breathing, and slow in getting worse. "
Grade 2 : Moderate Incubation period 10-14 days. Period of onset from over 3-6 days. Trismus marked. Dysphagia-i.e., swallowing with choking swallow—often present.
or
inability
to
Grade 3: Severe Incubation period under 10 days. Period of onset 3 days or less. Trismus and dysphagia severe, the latter causing aspiration of saliva, food, or regurgitated material early in the disease. This commonly occurs during the urgent inspiration at the end of
a
spasm.
Rigidity may limit breathing and cause continuous asphyxia. (The early signs of asphyxia are anxiety, sweating, tachycardia, and rise of blood-pressure; cyanosis is a late sign indicating severe asphyxia.) Generalised spasms rapidly become violent, frequent, and prolonged, causing temporary respiratory arrest and laryngeal spasm. The resulting addition of acute to chronic asphyxia is the commonest immediate cause of death. The prevention of asphyxia and prolongation of life by modern treatment has revealed that in severe tetanus a syndrome of overactivity of the sympathetic nervous system can arise, analogous to the obvious overactivity of the somatic motor system (Kerr 1967, Kerr et al. 1968). This is characterised by profuse sweating and salivation, extreme hyperpyrexia, tachycardia and hypertension, arrhythmia, and peripheral constriction with cyanosis, often ending in circulatory collapse and death.
Treatment
In the absence of any specific remedy for tetanus, treatconsists in removing the source of the toxin in the wound as far as possible, and in measures to prevent or treat asphyxial, pulmonary, and circulatory complications, including those due to sympathetic overactivity, continued until the toxin and any inaccessible organisms have been neutralised by the patient’s natural reaction. Thus success depends on the urgency and skill with which the following events are anticipated and prevented, or detected and controlled: ment
(1) Depression and arrest of respiration by rigidity and reflex spasms of the muscles of respiration. (2) Aspiration of foreign material into the lungs owing to inability to swallow, accumulation of saliva, the gastric regurgitation which occurs in asphyxia, and injudicious feeding by mouth.
(3) Consequent pulmonary collapse and secondary infection of the
lungs.
(4) Circulatory failure due
to
asphyxia
or
sympathetic
overactivity. THE STANDARD REGIMEN
The
our present views, in these there were 59 cases and in 46 of the applied no deaths. In the remaining 13 cases there were departures from this regimen and 10 of the patients died; the causes of death are studied in detail later. On admission of a patient with tetanus the expected severity of the case was immediately assessed according to the criteria described above. The most important are the period of onset and the severity the spasms have already attained. The appropriate treatment for the grade of severity (see below) was instituted at once. A system by which the need for tracheostomy or curarisation is decided on by the severity of the fully developed attack leaves these measures too late. The patient was never left alone, and a careful watch was kept in the first few days for signs implying reassignment to a severer grade-for example, dysphagia in a case classed as grade 1, or the sudden violent spasm which sometimes occurs in a case previously deceptively mild. was
following scheme, representing
1018 Grade1 (Mild) Antitoxin (adult dose up to 100,000 units) was injected with precautions against reactions. (The value of this is regarded with increasing doubt [Cox et al. 1963, Vaishnava et al. 1966]). Surgical toilet of the wound, if any, was then carried out. Nursing included ensuring adequate nutrition and precautions against secondary infection. Sedation is the subject of a special paragraph below. When trismus without dysphagia is severe enough to prevent eating and drinking, we consider that a nasogastric feeding tube may safely be used without tracheostomy in younger patients. 9 of our patients under 70 were treated in this way, and 2 subsequently required tracheostomy; all recovered. The elderly, however, have sluggish protective reflexes and are prone to aspiration and pulmonary complications in any illness. Therefore, except in the very mildest cases, aged patients with tetanus should be assumed to be dysphagic and should be treated as grade 2 or 3 according to the severity of their other symptoms. Grade 2 (Moderate) In addition to the general treatment described above, tracheostomy with a cuffed tube (or temporary orotracheal intubation) was undertaken without delay under general anaesthesia. (This must be done before an ambulance journey.) A nasogastric tube is passed at the end of the operation. Ideally the tracheostomy completely prevents contamination of the chest by aspiration, but this may have occurred before the patient was seen. A humidifier to saturate the inspired air, regular changes of posture from one side to the other, physiotherapy to the chest, and suction of secretions from the bronchial tree are of first importance. Frequent examinations, including X-rays, were made to detect areas of pulmonary
collapse
or
congestion.
The respiratory minute volume and blood-pressure were monitored half-hourly in the early stages; these simple measurements give an early warning of deteriorating respiratory function and carbon-dioxide accumulation. The equilibrium method of estimating alveolar CO2, and, when it became available, direct measurement of blood-gases, provided a further check of respiratory sufficiency. Blood urea and electrolytes were measured daily, and adequate food and fluid intake was maintained by tube-feeding. Occasionally intravenous fluids were needed for a short time. A patient allocated to this grade may without warning suffer a spasm more severe than usual which depresses or arrests breathing. Against this emergency a catheter which would pass loosely into the trachea (as for suction) was kept attached to the oxygen supply by the bed. A brisk flow of oxygen through this into the trachea maintained some oxygenation of the blood by diffusion until the spasm passed off. Recurrence of such spasms was an indication for transfer of the case to grade 3.
Grade 3 (Severe) In addition to tracheostomy and the
general
above, the rigidity and superimposed spasms
by curarisation, and ventilation of artificially.
the
lungs
outlined abolished maintained
care
were was
The first dose of d-tubocurarine was given during an.Tsthesia for tracheostomy or temporary orotracheal intubation. Apparatus for manual ventilation of the lungs was available for ambulance journeys, and also at the bedside to provide for occasions of mechanical failure. The mechanical ventilator used was the East-Radcliffe, which applies a constant inspiratory pressure. The pressure was adjusted to produce slight over-ventilation, reducing the arterial Pco2 from the normal to about 36 mm. An advantage of this type of ventilator is that the simple bedside measurement of minute volume, as in the grade-2 cases, gives an easily understood warning of respiratory obstruction by secretions or pulmonary collapse, as well as of mechanical faults such as leaking connections. The usual dose of d-tubocurarine for an adult was 15-20 mg., either through an intravenous catheter or intramuscularly. Larger doses last longer but tend to cause abdominal
distension. At first the dose is repeated at the slightest sign of returning muscular activity; delay may allow a severe spasm to occur and doses may be needed every 20 minutes. The interval lengthens as the disease begins to wane. It is safe after a few days to allow the paralysis to become a little less complete before renewing the dose; at these times the patient is able to communicate by slight facial movements. Owing to the abolition of striated-muscle tone, bladder drainage and regular digital evacuation of the rectum are needed.
Local tetanus affecting the head and neck does not fit into the above classification. Though it may be relatively chronic and general symptoms absent or mild, dysphagia and laryngeal spasm may be present; and for these tracheostomy and tube feeding are indicated. Sedative and anticonvulsant drugs.-It is not surprising that most patients find tetanus and its treatment a frightening and painful ordeal (Cole and Youngman 1968). They should receive as much sedation as can safely be given. Drugs which can exaggerate the respiratory and circulatory embarrassment of tetanus must, however, be avoided. In our opinion this cuts out opiates, barbiturates, and tranquillisers, even with curarised patients. It also cuts out drugs causing partial paralysis such as mephenesin and triethylcholine. Both before (Cole 1945, Knott and Cole 1951) and throughout this series we have used paraldehyde freely, and in severe cases almost exclusively. Doses up to 12 ml. every 4 hours, by stomach tube (diluted 1 in 10) or by intramuscular injection, have been given throughout the illness without any undesirable side-effects. We think it is thanks to the use of this drug that in a series of 59 cases we have never seen the sympathetic overactivity of severe tetanus described by Kerr et al. (1968). These workers have demonstrated that this syndrome can be suppressed by halothane or by specific adrenergic blockers (Kerr et al. 1969). Paraldehyde appears to act in the same way and provides valuable sedation. be avoided in the initial stage of tetanus. It is the usual cause of the deceptive impression of mildness, terminated by the break-through of a violent spasm, already mentioned. Antibiotics and secondary infection.-Most patients were given large doses of penicillin from admission. Swabs from the upper respiratory tract and tracheostomy wound and specimens of sputum or tracheal aspirate were cultured daily and antibiotic treatment was altered according to the findings. In spite of this and strict hygienic precautions, secondary infection and cross-infection in the unit were common. We were tardy in adopting the efficient air-filters now available for attachment to the intakes of humidifiers and ventilators. They are now in use and reducing the incidence of infection. Brain damage due to a mechanical fault.-A patient, aged 13, suffered a severe anoxic episode due to a removable cuff slipping off his tracheostomy tube and blocking the trachea. Although he recovered from tetanus, some mental impairment remained.
Heavy sedation
must
Results
46 of the 59 patients were treated in accordance with the standard regimen described and all recovered. Of the 10 patients over 70, only 3 (with mild tetanus) received standard treatment, and they recovered. The other 7 (1 severe and 6 moderate) did not receive standard treatment but might have died however treated.
1019 Of the 13 patients treated with material departures from the standard regimen, 10 died. Data on both groups are summarised in tables i and 11. Some details of the fatal cases follow. Case 1
Male, aged 40. Incubation period (I.P.) 6 days, period of (P.o.) 36 hours. Very agitated, refused tracheostomy; very heavily sedated with chlorpromazine, amylobarbitone, and pethidine; slept; spasms ceased. After 8 hours sudden severe spasm with asphyxia and cardiac arrest. Resuscitated; trache-
onset
ostomy and curarisation. Normal progress 3 days, then sudden collapse and death. ? due to technical failure; no explanation of death at necropsy.
of delaying tracheostomy and curarisation in a case with such a short P.o. Deceptive effect of heavy sedation early in the disease.
Comment.-Danger
Case 2 7 years. l.P. 7 days, P.o. 12 hours. Admitted hospital with opisthotonos, severe spasms every 5 minutes. l.M. injection paraldehyde 5 ml.; spasms ceased temporarily. During transfer to Addenbrooke’s by ambulance had severe spasm, vomited, and died. Necropsy: bile-stained
Male, aged
local
debris in bronchial tree. This child had had a full course of triple vaccine as an infant and a booster dose of toxoid at age 6.
Comment.-Danger of delaying tracheostomy and curarisation in
a case
with such
a
short
P.o.
and
severe
Deceptive effect of early heavy sedation. Danger of ambulance journey without intubation and accompanying doctor. Full active immunisation did not spasms.
prevent
severe
tetanus.
arrival X-ray showed collapse right upper lobe. Tracheostomy. Spasms began, P.o. 4 days. Treated by partial paralysis with triethylcholine for 6 days. During this time he suffered numerous cyanotic and hypotensive episodes and chest infection developed. He was then transferred to orthodox treatment but died after 10 hours. Necropsy: on
bronchopneumonia.
Comment.-Again, the danger of delaying tracheostomy in a dysphagic patient. The reasons given by Bowman and Rand (1961) for expecting triethylcholine to lessen the spasms of tetanus while sparing the respiratory muscles, unlike any other muscle relaxant, appear to us fallacious. Cases 4-10 2 male and 5 female patients aged 70-83. These 7 aged patients, some of them very feeble with pre-existing chronic disease and injuries, were handled with varying degrees of reluctance to add to their suffering by vigorous treatment. 3 had tracheostomies late in the disease after they had developed aspiration pneumonia. 2 died shortly after admission, of pulmonary embolism or an asphyxial spasm, and 4 of bronchopneumonia. One, with severe tetanus, had a tracheostomy and then was treated by heavy sedation until the 8th day when a severe spasm caused cardiac arrest. The heart was re-started, but he remained unconscious and lived a vegetable life for a further 4 months. Comment.-With a feeble and senile patient it may well be right to decide that active treatment would be a profitless infliction and to let the disease take its course. Not all of these 7 old patients could be so regarded. In retrospect we think that, if the standard regimen had been some would have survived both the and the disease. Their records repeat again and again the lessons taught by those of the 3 younger patients whose records are recorded above in greater detail. In general it may be said that, where facilities and expert staff are available early in the disease, death from tetanus of an otherwise healthy patient is nearly always due to omission of precautions accepted as routine at the centres with long experience.
Case 3
rigorously applied,
Male, aged 56. On admission to local hospital 2 days hisgeneral stiffness, dysphagia and stridor, no spasms, no injury found, chest X-ray clear. Ambulance to Addenbrooke’s;
treatment
tory of
Conclusions
Success with the modern treatment of tetanus depends forecasting the severity of an attack as soon as the disease is diagnosed and on immediately instituting the appropriate treatment to forestall respiratory and
on
TABLE II-RESULTS IN
Regimen and severity grade
notes on Notes on
59 CASES
treatment
Standard: Mild Moderate Severe Totals
Not standard:
Moderate
Severe
No. of
cases
deaths
24 6 16
0 0 0
-
Partial
paralysis (triethylcholine) Local tetanus with dysphagia; no tracheostomy Aged over 70; palliative treatment only Refused early treatment; oversedated Died in ambulance; not intubated Aged over 70; not curarised for 9 days and oversedated
Aged
over
treatment
Totals
No. of
70; palliative only
-
46
0
2
1
2
0
5
5
1
1
1
1
1
1
1
1
13
10
circulatory complications. Criteria for this forecasting divide the cases into three severity grades requiring (1) general nursing management ; (2) tracheostomy and tube feeding, and (3) curarisation and artificial ventilation. Paraldehyde in full doses is recommended as (a) an effective sedative without side-effects exaggerating the respiratory and circulatory embarrassment due to the disease, (b) a preventive of the dangerous sympathetic overactivity of severe tetanus. We wish to thank the many physicians and surgeons, past and present, of Addenbrooke’s, the West Suffolk, and Newmarket General Hospitals who have permitted us to see patients under their care or allowed us to treat them. We also thank particularly Sister P. M. Mountford, the sister-in-charge, and the staff of the intensivetherapy unit at Addenbrooke’s Hospital. Requests for reprints should be addressed to L. C., 15 Fitzwilliam
Street, Cambridge.
(references overleaf))
1020
Letters
to
the Editor
TEACHING OF PSYCHIATRY SIR,-While generally concurring with your leader of March 1 (p. 451), I would take issue with your advocacy of clerkship on an inpatient psychiatric unit as the method of training students how to relate to patients. While I agree that this is better than nothing, my experience is that this too can become an unrewarding attempt to seduce the non-psychologically minded from their disdain of such issues. The problem here is that it is all too easy for the students simply to obtain factual details of the " patient who occupies a bed " in a hospital, and to continue to use existing models. Too often the hospital setting promotes either somewhat dreary listing of symptoms, signs, and differential diagnoses, or sterile speculation about psychodynamics. During the past year an attempt has been made here to teach medical students under two rather different conditions; and, although I suspect they retain as much formal psychiatric knowledge as before, virtually all seem interested and excited by what they are doing. The first step was to move away, at least in part, from formal teaching on the wards, and to make use of the psychiatric home treatment service of the Boston State Hospital.l Two fourthyear students, assigned to the rotation for 4 weeks, visit people referred to this service in their homes, in the company of a nurse or social worker from the service, and a psychiatrist. One student evaluates the patient, while the other student may listen in or (after learning something of the problem) interview other members of the family. Depending on the skill of the student, guidance is necessary to make points about such factors as interviewing techniques, clarification of history, and the use of specialised questions to demonstrate psychiatric syndromes. The bulk of the definitive psychiatric evaluation is performed by the student, who is responsible for note-taking and for presentation at the weekly intake conference. On leaving the patient’s home, the team discuss the problem in the light of the total social picture. Wherever possible follow-up visits are made by the student. If, as is usual, a longer period of treatment is required, close liaison between the student and the permanent staff of the service ensures a smooth transition. At conferences, notes need seldom be consulted, for the details are made memorable by the impact of the visit. With hospital patients, a promising method has been to use similar techniques in interviewing patients in a general hospital ward. The aims here are to help the student to feel the emotional impact that any illness has on the patient and his family and to demonstrate many other aspects of physical and 1.
Becker,
A. Home Treatment.
Pittsburgh,
1968.
REFERENCES
mental illness, from the delineation of emotional factors as precipitants of physical illness to the normal ego’s defence against stress. In this setting the defences of the student who professes irritation with psychological concepts rapidly disappear. It is
hard for him to refute the evidence of what has been made apparent by his own interview or to be unimpressed by his own skill when a patient spontaneously tells him that the headache that was oppressing him all morning has gone, now that he has got some things off his mind. These methods seem easily transferable to the British scene. Commonwealth of Massachusetts PETER L. AGULNIK. Department of Mental Health, Boston State
Hospital.
FAILURE OF CERVICAL CYTOLOGY? SIR,-The increasing use of diagnostic cytology in England in the past ten years has not lowered the death-rate from cancer of the cervix. The accompanying figure shows cohort deathrates at certain ages for total cancer of uterus since 1911 and cancer of cervix since 1950. The death-rates at successive age-groups of each cohort are plotted on the same ordinate. The lines join the same age-specific death-rates in successive cohorts. The diagram confirms the approximate validity of the rule: " The death-rate from cancer at one age-group always bears a constant ratio to that of any other age-group in every cohort ".11
Cancer of uterus, England and Wales. Annual death-rates from total uterine cancer and cancer of cervix in certain age-groups in generation-cohorts of women.
The death-rate from total uterine cancer (and presumably of of the cervix, which forms the bulk of uterine cancers under the age of 50), fell at all ages until 1945-50. Then the trend of death-rates at the younger ages was reversed to reach a secondary peak for 30-34 years in 1957 with a rapid fall to the pre-existing-trend level.The women affected by this rise were born between about 1915 and 1925. They should, by the rule, continue at subsequent ages to have a death-rate higher than women born earlier or later. These women are now aged 40-50, at which age the death-rate has risen appreciably since 1956. The fall in cervical-cancer death-rate at the younger ages is Corbett, J. L., Prys-Roberts, C., Crampton-Smith, A., Spalding, claimed to be due to the cytology service. Will its supporters " J. M. K. (1968) Lancet, ii, 236. explain " the rise at age 40-50 years-at which the value of (1969) ibid. i, 542. Knott, F. A., Cole, L. (1951) in British Encyclopædia of Medical Practice; cytology should now be maximal ? vol. £11, p. 40. London. 2nd ed. Division of Laboratories, Lassen, H. C. A. (1953) Lancet, i, 37. Department of Health, Bjørneboe, M., Ibsen, B., Neukirch, F. (1954) ibid. ii, 1040. Charlottetown, Macrae, J. (1967) in Symposium on Tetanus in Great Britain; p. 11. Leeds. T. W. LEES. Prince Edward Island, Canada. Ann. N.Y. Acad. Sci. 121, 898. Mollaret, P., Pocidalo, J. J. (1965) Pearce, D. J. (1967) in Symposium on Tetanus in Great Britain; p. 31. 1. Lees, T. W. Trends in Cancer: The Wave Theory of Cancer Leeds. Mortality. Unpublished; Lancet, 1965, i, 1116. Spalding, J. M. K. (1966) Proc. R. Soc. Med., 59, 29. 2. Registrar-General, England and Wales; Annual Reports and Statistical Vaishnava, H., Goyal, R. K., Neogy, C. N., Mathur, G. P. (1966) Lancet, Reviews, 1911-1966. H.M. Stationery Office, 1912-1968. 1371. ii,
(1967) in Proceedings of a Symposium on Tetanus in Great Ablett, J. J. Britain (edited by M. Ellis); p. 1. Leeds. Adams, E. B., Holloway, R., Thambiran, A. K., Desai, S. D. (1966) Lancet, ii, 1176. Bowman, W. C., Rand, M. J. (1961) ibid. i, 480. Cole, L. (1945) Br. med. J. i, 219. Youngman, H. R. (1968) Lancet, ii, 567. Cox, A. C., Knowelden, J., Sharrard, W. J. W. (1963) Br. med. J. ii, 1360. Dundee, J. W., Gray, R. C. (1967) in Symposium on Tetanus in Great Britain; p. 17. Leeds. Ellis, M. (1963). Br. med. J. i, 1123. Horton, J. A. G. (1967) in Symposium on Tetanus in Great Britain; p. 25. Leeds. Kerr, J. H. (1967) ibid. p. 49. L.
—
—
—
—
—
—
—
—
cancer