A research paper on tetanus neonatorum in the 1950's Southern Rhodesia

Gelfand, Michael

English

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CENTRAL AFRICAN
JOUPvNAL
OF
MEDICINE
Vol. I. No. a SE PTE M B E R , 1»55
O R IG IN A L  A R TIC L E S
The A rt o f D iagnosis D. H u n te r ............................ 207
Tetanus N eonatorum  Treated w ith
Chlorprom azine M. G eljnnd ............................ 216
Volvulus o f  the Stom ach W. Shepherd Wilson - - - 218
B lackw ater F ever in an A frican  Child / /.  F. T h eron ....................... 220
A frica, But Not So Dark 0 . R obertson ........................221
Chem otherapy in Pulm onary Tuberculosis A. I. L. Turnbull - - - - 228
Pulm onary H aem oslderosis J. K. Harries - - - - - -  235
Im pending C oronary Throm bosis A. D iva ris .............................239
T h e R ight Base T. Fane Tierney - - - - -  243
A frican  Vital Statistics J. R. H. S h a u l ................. 246
The M anagem ent o f  Syphilis R. R. W i l l c o x ..................250
The N ganga M. G e l f a n d .......................255
E D ITO R IA LS
R ugby Football In juries 259
T he A ge o f Retirem ent 261
The Quack 262
Corresponde.net.............................................. 263 B anquet In H onour o f Lord M alvern
and Professor Drennan - - - 266
The Journal L ibrary 264 Annual Congress o f  the M edicalA ssociation o f  S. Rhodesia - -  267
PU BLISH ED  BI-M O N TH LY, AN N U AL SU BSCRIPTION  £2 2s. M .
Sei'te.mi;eii, 1955 T i l l .  I . I . M r M .  A h i i i . a  t 
J i i l l i M i .  u .  M n u i . l M .
Three Cases of Tetanus 
Neonatorum
SUCCESSFULLY TREATED WITH UHLOR- 
PROMAZINE, TETANUS ANTISERUM AND 
PENICILLIN
BY
MICHAEL CEL I AND, o .b .e ., \i .i>.,
Consulting Physician, Salisbury African Hospital.
Allhough 1 have seen many cases of tetanus 
neonatorum admitted to the Salisbury African 
Hospital, it was exceptional lor one to recover 
despite the various treatments adopted. 1 have 
not used curare and other muscle relaxanls, but 
relied mostly on tetanus antiserum usually given 
by the intramuscular route and occasionally 
intrathecally or intravenously. In addition, 
sedatives were administered and more recently 
antibiotics, but the results were invariably dis­
appointing.
It is known that tetanus assumes a far more 
serious form in the infant than in the adult. 
Jelliffe (.1952) in Nigeria and Slome (1954) 
from South Africa report on its seriousness, but 
they do not provide figures of the mortality rate 
in the new-born. The reason for the bad out­
look in tetanus in the new-born may be because 
of its short incubation period. Most of the 
cases that 1 have seen occur on about the sixth 
or seventh day after birth. Bodman (1954) has 
shown that the prognosis of tetanus is extremely 
poor where the incubation period is less than 
eight days.
The method of delivery by the African mid­
wife accounts for the frequency with which 
tetanus neonatorum is met. After the placenta 
has separated from the uterus, the cord is cut 
with any sharp instrument such as a knife, blade, 
razor or reed. It is not sterilised and is simply 
kept by the midwife along with her other uten­
sils, and it is nol surprising, therefore, that dirt 
and spores are introduced on to the cord.
On learning that chlorpromazine hydrochlo­
ride lLargactil) influences nervous activity in 
man both centrally and peripherally, and that 
experimentally in animals it shows an antagon­
ism to the effects of certain central convulsants, 
such as nicotine, I decided to determine its 
efficacy in tetanus.
In this paper 1 am reporting three successes 
out of nine eases treated with Largactil during 
the last three months, and. since recovery had 
previously been exceptional in my hands, 1 
believe these findings worthy of publication with
Page Two Hundred and Sixteen
the hope that others may use it and report their 
results.
I j.i.ustkative Cases
Case 1.—Mutindiza was a male baby born at bis 
mother’s home. After the placenta was expelled the 
cold was tied with cotton and cut with a razor, and 
no dressing was applied. The child was perieetly well 
and sucked satisfactorily for the first six days, alter 
which lie began to develop stiffness of the limbs, trunk 
and neck. The rigidity increased so rapidly that by 
the next day the infant could be held up by one of 
his arms without being able to ilex any part, llis back 
was arched forwards and neck thrown backwards. The 
least stimulus, noise or touch provoked a series ol 
generalised twitchings. He could not suck. He was 
so stiff that no lumbar puncture could be done and 
the mouth could not be opened beyond a few millimetres.
From tlte umbilical site a dirty greyish discharge 
issued. Hie child was well-nourished and did not 
show any evidence of anaemia. His temperature on 
admission was 101' 1\ The anterior fontanelle did not 
bulge. Idle heart was not enlarged and the lungs were 
clear on X-ray. The respirations were mainly abdominal 
ill typo and no oedema was present. The urine was 
dear of albumin and sugar.
The child was desperately ill when on 7th April, 1955, 
treatment was started. It consisted of 40,000 units ol 
tetanus antiserum (A.T.S.) intramuscularly b.d. and 
kargactil (diluted three times with normal saline.) 
25 mg. b.d. intramuscularly. In addition, 300,000 units 
of procaine penicillin were given each day. All were 
continued in these dosages until 13th April, when the 
child began to show distinct signs of recovery. By 
the third day after treatment the spasms had mostly 
ceased, although generalised stiffness was still marked 
and the inlant s back was arched forward. I tie stiff­
ness passed off very slowly. On the 21st April the 
facial muscles had become less stiff, and by 2nd May 
he was able to suck. Before that lie could only he 
fed from a spoon with expressed breast milk, which 
was later (18th April) changed to half strength cow’s 
tnilk. as insufficient breast milk was available. By the 
4th May the baby was able to suck from the mothers 
breast, when the milk flow was re-established under the 
stimulus of sucking. The fever lasted five days— the 
first and second days it was 101° F., but after that it 
rapidly returned to normal.
The infant began to put oil weight. We could no 
longer persuade the mother to stay in hospital and she 
left on the 12th May. Three weeks later the mother 
brought the child to hospital to report progress, and 
we were delighted with his recovery. I he stiffness 
had almost completely cleared.
Case 2.— Manwera, a male African infant aged seven 
days, was admitted to the Salisbury African Hospital 
on tlte 4th June, 1955. He was born in primitive sur­
roundings on a farm near Salisbury, being the third 
child. The delivery was normal and the umbilical 
cord was rut by a Native midwife with a razor and 
tied with cotton. H ie baby sucked well until it became 
ill, when the first symptoms wire cough and inability 
to suck. On admission, the infant had the typical 
appearance of tetanus, with numerous and frequent 
spasms of the facial and limb muscles. Between spasms 
the whole musculature was stiff. Any noise near the 
baby or a touch of the hand would provoke a series 
of spasms. The umbilical cord was septic. The tem­
perature was 101° F., but on the second day it had
September. 1955 TETANUS NEONATORUM T h e  C e >
.JOI- HNAI
A f r ic a n
M epic.in k
reUirned normal and remained si'. The anterior
fon’ imell.' was a little sunken. There was no sign of 
anaemia and tile lungs were clear.
The treatment adopted remained unchanged tor six 
days, after which it was withdrawn. It consisted of
10.000 units of A.T.S. twice a day and 300,000 units 
procaine penicillin once daily. These were given 
intramuscularly.
The infant was unable to suck and the mother fed 
it with expressed breast milk from a spoon. On 5th 
dune the infant still quivered at the slightest stimulus 
and no improvement could he noted, hut by the next 
day it showed signs of improvement. This progress 
was maintained the following day. On the 10th June 
the baby was definitely on the way to recovery, although 
generalised rigidity was still present. Nevertheless it 
could he touched without producing convulsive or 
twitching movements. On the seventh day it was de­
rided to withhold all treatment as the spasms had 
ceased, although the generalised stiffness had persisted. 
The following day tilth  June! the infant emitted a 
few cries for the first time since this illness. On tile 
12th June the mother absconded with the child and 
returned to the farm, where no other treatment was 
given. The infant was seen one month later by a 
nearliy doctor, who reported that he had fully recovered.
Case 3.— \ female infant was brought into hospital 
with tetanus. She was six days old when the mother 
noticed she could no longer suck, cried readily and 
soon after developed spasms. On admission to hospital 
the ha by was completely rigid. The whole body was 
fixed and could lie lifted in one piece. Spasms were 
frequent and the infant was seriously ill. The tem­
perature was 100.4° F., hut it soon returned to normal. 
The umbilical cord was sentic and a blackish liquid 
discharge exuded from it. The slightest noise provoked 
an attack of spasms. The lungs were clear on X-ray 
and the heart was normal.
The infant was put on the following regime: A.T.S.
40.000 units twice daily as well as chbirpromazine 35 
mg. b.d. by intramuscular injection for five days. After 
this the A.T.S. 140.000 units) and Lartraetil 135 m g.'
were given once daily, as by then the child was clearlv 
recovering and a reduction of the dose seemed justifi­
able. The spasms gradually diminished and were much 
reduced by the eighth day. On the sixth day the infant 
was able to suck from a bottle, whereas before it had 
to he fed (Inertly from a spoon. Bv the twelfth day 
she was sucking well and was beginning to put on 
weight. The next day the mother disappeared with her 
baby and trace of both was lost.
D iscu ssion
T am not certain how often chlorpromazine 
has been employed in the treatment of tetanus. 
So far, I have read of one case of tetanus in 
which it was used. Andersen. Johansen and 
Mouys (1955) report a case of severe tetanus 
in a Danish child aged 10 years who was treated
for three weeks with chlorpromazine and tubo- 
curarine. The outcome was fatal, the authors 
being unable to report any control of the con­
vulsive attacks. They used chlorpromazine 
because they found experimentally in animals 
that it was a very effective agent in controlling 
convulsions in animals showing localised tetanus.
The prognosis of adult tetanus is much better 
than that in the new-horn, and antiserum alone 
often effects a cure in the former. In the infant, 
however, antiserum alone is most disappointing 
and therefore Largactil deserves a fuller trial. 
Treatment should be continued for as long as 
the spasms are present, hut as soon as they cease 
both the Largactil and antiserum may he tapered 
off or stopped. 1 have observed that the stiffness 
takes many days— often weeks— to pass off, an 
interesting feature of which 1 was not previously 
aware. Two useful signs denoting probable 
recovery are a return of the sucking reflex and 
disappearance of the spasms.
S u m m a r y
1. Three African cases of tetanus neonatorum, 
who recovered after chlorpromazine. tetanus 
antiserum and penicillin had been given, are 
described.
2. As this is a disease which usually carries 
a grave prognosis, it is suggested that chlorpro­
mazine he tried.
3. Prior to employing chlorpromazine, it was 
exceptional to meet with a recovery, and three 
out of nine cases having survived is encouraging, 
and with further experience it may he possible 
to arrive at an optimum dosage.
Acknowledgment
1 wish to thank Dr. R. M. Morris, o.b.e.. 
Federal Secretary of Health, for permission to 
publish this paper.
REFERENCES
Andersen, W. E„ Johansen. S. H. & Houcs, W. (1955'.
Danish Med. Bull.. 2. 84.
Rodman. R. J. (19541. T.aneet. 2. 1234.
JeixikfE, D. B. (19521. Trans. Roy. Roe. Trap. Med.
and Hyg., 46, 13.
Si.ome. R. (19541. 5. Air. Med. J .. 28, 473.
Page Two Hundred and Seventeen
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Three cases of tetanus neonatorum

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Three cases of tetanus neonatorum

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