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1.4 Tetanus Neonatorum. r. Wright

1.4 Tetanus Neonatorum. r. Wright

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R.
WRIGHT,
M.B.,CH.B.,
MedicalRegistrar,Department
of
Medicine,University
of
alal,
and
KingEdward
VJlI
Hospital,Durban
111
240--72030--180
I
2t--l
00
30--180
5--
40
24
hours.or
1st
DRUG
COMB1NATlO
SAD
DOSAGESUSED
Size
01
DoseDailyRange
(mg.
intramuscularly)(mg.)
25
100--200
60
60--300
TABLE
I.
Drug
ChlorpromazinePhenobarb.sod.Pbenobarb.sod.'"
+
chloralhydrate..
120
orallyPhenobarb.sod.
..
30--60
+
chlorpromazine
12-§---25
Phenobarb.sod.
..
30--60
+
acetylpromazine5--10
*300
mg.
(intramuscularly)maximum
large
number
of
casesin
an
attempt
toreducethetoxiceffects
of
bothdrugs.TableIshowstbevarious
combinations
and
thedosage
of
thedrugsused.
When
oncespasms
had
beencontrolled,particularlyinthephenothiazine-barbiturategroups,thedosagerequiredwasusually
at
the
minimum
of
thedailyrange.
Tracheotomy.
Tracheotomywasperformed
on
]7patients,
13
of
whom
were
comparedin
a
random
clinicaltrialwithaconservativemethod,amixture
of
chlorpromazine
and
barbiturateforsedationbeingused
in
both
groups.adequatenutritionduring
lhe
stage
of
reflexspasm
and
rigidityresulted
in.
deathfrom
mara
mus
and
bronchopneumoniaaslateasthe5th
or
6thweek.
Sedation.
Chlorpromazinehas
been
compared
withbarbiturates
and
amixture
of
barbiturateand
chloralhydrate
in
two
random
trialswhichhavebeen
reported
elsewhere.
7
,8
Chlorpromazine
(or
acetylprornazine,
another
phenothiazinederivative)wasused
in
combination
witha
barbiturate
ina
DISCUSSION
Incidence.
It
isdifficultto
compare
accuratelytheincidence
of
tetanus
neonatoruminDurban
and
districtwith
that
elsewhere.
Table
II
hasbeenconstructedfromreportsinthelitera-
TABLE
n.
INCIDENCE
OF
TETANUSNEONATORUM
Area·
Period
under
Review
No.
01
Deaths
or
Cases
GreatBritain"1938--47
36
deatbsUnitedStates
'O
"
1951--55
370
deathsSingapore"..1946--50
254
casesIbadan
12
1953--56
141
casesDurban1956--59
246
cases
ture
toemphasizethealarminglyhighincidence
atDurban.
Table
III
showsthefiguresforthe
past
yearfor
neonatal
deaths
in
KingEdward
VIII
Hospital,
Durban,
in'dicating
that
tetanusisone
of
the
major
killers.Because
of
the
rapid
period
of
onset
and
earlydeath
if
spasmsareuncontrolled,it
is
likely
that
many
more
infantsdiebeforereachinghospital.
jletiologicalfactors.
Though
no
specificcustom
or
method
of
delivery
can
beincriminated,
about
a
third
of
themothers
gaveahistory
of
theapplicationtotheumbilicus
of
a
'black
powder'obtainedfromawitch-doctor,
and
inafewcaes
Clostridium-tetani
has
beencultured
from
th.is
substance.Confinement
on
a
mat
in
a
hutor
shack
with
an
earthen
floor,
and
theuse
of
anunsterilized
razor
blade,
pair
of
scissors
or
sharp
reedfor
cutting
the
cord,
hasnotsurprisinglyresultedinumbilicalsepsis.However,quitefrequentlythe
-:-
.
TETANUSNEONATORUM*
S.A.
TYDSKRIFTIR
GENEESKUNDE
Februade
1960
Despitethehighincidence
of
tetanus
neonatorum
inSouthAfricaalarge
series
of
cases
has
not
beenrecorded.Friedlander,l
and
Klenerman
and
Scragg,2drew
attentiop
tothefrequency
of
the
condition
in
Durban,and
therehavealsobeenreportsfrom
the
other
large
centres.
35
During
the3-yearperiod
May
1956toApril1959,246cases
of
tetanus
neonatorum
wereadmittedto
King
Edward
VIII
Hospital,
Durban.
Of
these,217,
admitted
toaspecialtetanusunit,
are
thesubject
of
thisreport.
Race,
sex
and
"age.
The
averageage
on
admissionwas7days.Therewere-
198
Africanand
19
Indian
infants,aratio
of
approximately10to
1,
and
males
outnumbered
femalesby129to89.
The
seasonalincidencewas
not
striking,
though
there
wasaslightincrease
during
the
summer
months.
Infection.
The
organismwasrarelyisolated,buttheum
bilkus
wasalways
presumed
tobethesource
of
infection,
thoughin
afewinstancesit
did
riot
appear
septic.
Clinicalfeatures.
The
appearanc.e
of
an
establishedcaseisunmistakable.
The
faceis
pursed
up
in
risussardonicus
and
thelimbs
arepartly
flexed
and
stiff,withfistsclenched
around
the
thumb
and
toes·plantar-flexed.There
is
usuallysomedegree
of
opisthotonus
and
characteristicallystiffness
of
the
abdominal
muscles.Byplacing
onehandon
the
infant's
abdomen
and
the
other
overtlfespinalmuscleswehavefoundthesimultaneous
contraction
of
theseantagonisticmusclegroupstobeasign
pathognomonic
of
reflextetanicspasms.
Diagnosis.
This
pictureis
S9
characteristic
that
weagreewithJelliffe
6
that
there
is
novaliddifferentialdiagnosis,
and
differentiation
,from
conditionscausingconvulsions
in
theneonatalperiodiseasy.Somedifficulty
may
occur
intheminority
of
patients(7
%-
in
thisseries)whoare'
not
havingtypicalreflexspasmswhenfirstseen.Infantssufferingfrommeningitis,birth
tr<;luma
or
scleremahaveshownsufficientresemblancetotetanus
to
be
admitted
withthis.diagnosis.Necropsieswereperformedinalldeaths
and
in
none
of
themwastheclinicaldiagnosis.
of
tetanusdisproved.
Treatment.
The
generalprinciples
of
treatment
remained
constantthroughout
theseries.
One
hour
aftersedationasingledose
of
50,000
international
units(i.u.)
of
antitetanusserumwasgivenintramuscularly.BenethaminePenicillin,300,000i.u.,wasinjectedbythesame
routeand
rePeatedeverythirddayunlesssigns
of
pneumonia
supervened,when
soluble'
penicillin
or
a-
broad-spectrumantibioticwassubstituted.Local
treatment
of
theumbilicuswasrestricted
to
cleaningwithhydrogenperoxide
and
theapplication
of
merthiolate.
Feeding.
When
spasms
had
beenreasonablywellcontrolled,
an
intragastric
rubber
or
polyethylenetubewaspassedbythenasal
or
oral
routeand
feeds
of
expressedbreastmilkgiven.However,because
poor
absorption
and
aspiration
of
feedsoccurredquitecomtnonly,intravenousfeedingbyintermittentscalp-veininfusion
has
beenrecentlyattemptedinafewinfants.Most
of
thesewerehypothermic
and
theirfluidrequirementslow,
so
that
overhydrationwiththedevelopment
of
oedemawasaconstantdanger.Difficultyinproviding*Paperpresentedatthe42ndSouthAfricanMedicalCongress(M.A.S.A.),EastLondon,c.P.,September-October
1959.
 
112
S.A.
MEDICAL
JOURNAL
6
February
1960
TABLEID.
NEO
ATAL
DEATHSAT
KING
EDWARD
VIIIHOSPITALFOR
THE
YEAR
EJ','OED
30
J
E
1959
deliverytookplaceinalocation
or
domesticervant'squarters,
and
some
of
themothers,occasionallywithteaching
or
nursingexperience,
had
obviously
made
someattempt
at
an
hygienicconfinement,
or
hadevenbeendelivered
in
hospital.
Prognosticcriteria
and
criteria
of
severity.
Spivey
etal.
13
haveuseda7-dayincubationperiodasthecriticallevelforprognosis.
In
thepresentseriesonly7%
of
deaths
had
an
incubationperiodgreater
than
7days
and
only8%aperiod
of
onset
of
more
than
24
hours.Whileashortincubationperiod
and
ashort
period
of
onsetusuallyindicatea
poor
prognosis,asmanyas24
%
of
therecoverieshad
an
incubationperiod
of
lessthan6days,
and
30
%
a
periodof
onset
of
under
6hours.
The
mostusefulprognosticsign
is
theseverity
of
reflexspasms
on
admission;only1
of
64casesinwhichtheywere
spontaneous
recovered,whereas12
of
the
15
infantswhowere
not
havingtypicalspasmsonadmissionsurvived.
In
8
of
these,reflexspasms
as
describedabovewereneverobserved,
but
stiffness
and
facieswere
so
typical
that
theyareclassed
in
asmall
group
corresponding
to
mildtetanusinnon-neonatalpatients.
The
existence
of
thistype
of
case,aswellas
another
smallgroup
in
whomspasmswereonlymoderatelysevere,thoughtogethercomprisingless
than
10%
of
the
series,neverthelessemphasize
the
needtorandomizewhencomparingdifferenttreatmentgroups.
Complicationsandmechanism
of
death.
Wehave
found
considerabledifficultyindeciding
onthe
exactcause
of
death
in
themajorityofcases.
In
generaltermstherewould
appeartobe
4groups,viz:
1.
Uncontrolledspasms,usuallyin
those
dyingwithinthefirst48hours,anoxia
and
exhaustionbeinglargelyresponsible.
2.
Respiratoryfailure,occurringbetweenthe3rdday
and
the
end
of
the
2ndweek;theaction
of
the
toxin
on
themedullarycentres,over-sedation
and
pulmonaryinfection
and
atelectasisbeingfactorsinitscausation.3.Marasmus
hterminalbronchopneumoniabetweenthe3rd
and8th
weeks.4.
A
miscellaneous
group
includingtracheo-oesophagealfistula
from
prolongedtubefeeding,neonatalperitonitis
and
aspiration
of
feeds.Tecropsies
on
thosedyingearlyusually
show
acutecongestion
of
thelungs
and
liverwithintra-alveolarhaemorrhages
and
cerebraloedema.Histologicalevidence
of
bronchopneumonia
was
present
in
37
%
of
deaths,itsincidencebeingdirectlypro
portional
tothesurvivaltime.Two
of
theinfantswhorecovered
showed
radiologicalevidence
of
compression
of
themid-thoracicvertebrae.
Comparison
of
sedativesllsed.
Table
IV
showsthemortality,
and
theaveragesurvivaltime,inthosedyingwithin
14
days
inthe
differenttreatmentgroups.Experimentallythepheno-
TABLE
v.
COMPARJSON
OFMORTALrrY
WITH
THAT
IN
OTHER
LARGE
SERIES
thiazinederivativeshavebeenshownbyLaurence
and
Webster
14
tohaveapotentantitetanicaction
in
animals,
and
thishasbeenconfirmedclinicallyinnon-neonataltetanus.'·
Treatment
COMPARJSO.
Of
DJFFERENf
TREATMENT
GROUPS
Per-SurvivalcelltageTime·Mortality(days)
72
2
.
94
0
90
3·8
76
0
74
2
lOO
4·1
92
-82·5
BarbiturateChlorpromazineBarbiturate
+
chloralhydrateChlorpromazine
+
barbiturate
..
Acetylpromazine
+
barbiturate
..
TracheotomyMiscellaneous(Recoveries
38)
TABLE
IV.
o.
of
Cases
17
34
20
77
341718
217
Per-SeriesNo.
of
Sedative
IIsed
centage
Cases
Mortality
Present
series
217
acetylprornazine
82·5
chlorpromazinebarbiturateetc.Jelliff
et
alP
26
barbiturate
96
Spivey
13
25
paraldehyde
77
chloralhydrateLoh
Siew
Gek
ll
174
paraldehyde
92
chloralhydrateSarrouy
et
al.
18
~
20
chlOrPromazine
80
barbituraterelaxantPinheiro
19
..
256
barbiturate
84
chloralhydratemyanesinTompkinsJ!
141
paraldehyde
89·6
chloralhydratebarbiturateEarle
etapo
32
barbiturate
25
chlorpromazine
Average
survivaltime
in
deathsunder
14
days.
In
two.clinicaltrialsinthepresentseriesphenothiazinederivativesusedalonehave
not
beeneffective
in
controllingreflexspasmsin
75
%
of
cases,evenifgiveninlargedoses,
and
themortality
has
beenhigh
and
thesurvivaltimeshort.
In
thisrespect'Wehave
not
beenable
to
confirmthefindings
of
other
workers.
15
,16
Whentheyhavebeencombinedwith'barbiturates,spasmshave
been
controlledinall
but
30%
of
cases,withsomereductioninmortality,
but
ingeneral
death
fromuncontrolledspasmswithinthefirst48hours
has
been
replacedby
death
fromrespiratoryfailureafewdayslater.
In
TableV
our
averagemortality
throughout
theseriesiscomparedwith
that
in
otherlargeseriespublishedrecently.
With
onesurprisingexception,20
in
whichfulldetails
of
cases
are
not
given,
the
similarity
of
theresultswithdifferentconservativemethods
of
treatmentsuggests
that
there
is
littletochoosebetween
the
sedativesused.
In
an
attempt
to
reduce
the
mortalityfromrespiratoryfailure,a
random
trialwasconducted
to
assessthevalue
of
tracheotomy
in
preventingpneumonia
and
anoxia.
The
sedativeusedwasabarbiturate-chlorpromazinecombination
and
tracheotomywasperformedunderlocalanaesthesia,a
metal
tubebeinginsertedthroughawindow
cut
in
thetrachea.Oxygenwasadpllnisteredwhenrequired
by
means
of
afunnel
or
catheter
but
withoutartificialrespiration
or
humidification
of
the
inspired
air.
Onlyveryseverecaseswereselected
for
%
26·214·2
13·2
12·4
11·3
6789
167
90
8779
72
61
49
1812
635
otal
..
Prematurity
..
TetanusAsphyxianeonatorumandatelectasisBronchopneumonia
..
Gastro-enteritisMiscellaneousHaemorrhagicdisordersCerebralhaemoIThageMeningitisandsepticaemia

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