5 Junie 1954 S.A . T Y D S KR I F V I R G E NEE S K U N DE 473
surgical cause-eontrolled by the usual short and from the gall-bladder into the duodenum within 2 hours,
passing nature of the attack. without any resulting jaundice.
A localized liver-swelling in an attack with jaundice A small gallstone, up to 1/5 inch in diameter, is likely
is almost certainly surgical. to pass into the duodenum in about 8 hours, and to be
Biliary attacks with a localized liver-swelling are more followed by a 3-days very light jaundice. There is no
commonly met without jaundice. Such a liver-swelling change in the colour of the faeces, as a rule. , I
is likely to be the gall-bladder. A gallstone t inch in diameter may pass into the
A diffuse liver-swelling is more likely in medical cases, common duct, but will probably be arrested there, and
but may be present later in some of the chronic surgical give rise to a light jaundice lasting 7-10 days. So long as
ones. the stone does not pass into the duodenum, recurrent
A diffuse liver~swelling with jaundice is commonly attacks due to it are identical with tbis. There is likely
the liver itself, though an enlarged gall-bladder may be to be whitening of the faeces with the attack.
added to it. (Example-Carcinoma blocking common Large gallstones are unlikely to leave the gall-bladder
duct.) during the attacks, and so present no accompanying
A reduction in size of the liver in the presence of jaundice, except on the development of cholangitis. In
jaundice indicates a medical cause. such cases the jaundice is never very deep. It commences
to fade after 3 weeks. It is gone in 6 weeks. The faeces
Jaundice in relation to the Faeces continue to contain bile.
No change in colour of the faeces in a case of jaundice A primary or virgin common-duct stone gives the
means no persisting complete biliary obstruction and typical attack with a 7-10 day jaundice, but there is an
usually a medical condition; whereas change to a whitish accompanying enlarged distended gall-bladder. Faeces
colour means persisting complete obstruction and a are pale with the attack.
surgical condition. The passage of a daughter hydatid cyst through the
A transient biliary obstruction of short duration, e.g., common duct gives an attack identical with that due to a
with the passage of a stone, although surgical, usually primary common duct stone. There is usually evidence
produces no change in the colour of the faeces. of associated hydatid disease.
In other words: The presence of bile in the faeces in a A dumb-bell calculus, even of large size, with half the
case ofjaundice is more in favour of a medical condition, stone in the common duct and half in the duodenum,
the absence of bile strongly in favour of a surgical one. may give rise to no clinical manifestations at all.
(N.B.-The calibre of the cystic duct naturally plays an
Jaundice in relation to Wasting important part in the possible passage ofstones, according
Absence of wasting suggests a recent jaundice and to size.)
non-malignancy. Previous loss of weight suggests
malignancy or persistent infection. Jaundice in relation to Site of Origin
Blood jaundices are almost all medical.
Attacks, with and without Jaundice, in relation to the Duct jaundices (large ducts) are all surgical.
Size of accompanying Gallstones Liver jaundices (including minute ducts) may be either
A pin-head gallstone, 1/10 inch in diameter, can pass medical or surgical.
"TETANUS IN SOUTH AFRICA *
ROBERT SLOME, M.D.
Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town
Tetanus is a common disease in South Africa to-day. TABLE 1. DEATHS FROM TETANUS A.ID A UAL DEATH RATES PER
Tbis is in striking contrast with its rarity during the Boer MILUON LIVING; SOUTH AFRICA, E 'GLAND AND WALES: 3 YEARS
War. Whereas Makins,l a consultant surgeon, was
aware of only one member of the South African Field 1946-48
Force who developed the disease (and tbis in wartime No. of Deaths Annual
when tetanus used to flourish), the Department of Country (3 years) Death Rate
Health 2 reports that during the 5 years 1946-50 1019 South Africa 563 ]6'1
deaths from tetanus were notified in the Union; more England and Wales 203 1 ·6
than 200 deaths each year. This represents a death rate
which is extremely bigh in comparison with the death Because tetanus is not notifiable it is impossible to
rate in England and Wales 3 (Table I). establish whether this high death rate results from a low
* From the Thesis entitled The Treatment of Tetanus, a Review recovery rate, but it will be shown elsewhere 4 that, in
of 156 Cases, with a Clinical and Experimental Study of the Use of Cape Town at lea~t, the recovery rate compared favour-
Cortisone, which was accepted for the degree of M.D., Cape Town,
1953. ably with those reported from other countries.
474 ,' S.A. MEDICAL JOURNAL 5 June 1954
TABLE n. DEATHS FROM TETANUS AND DEATH RATES PER MILLION LIVING. BY RACE. SOUTH AFRICA, 5 YEARS, 1946-50
European Asiatic Coloured Native
Year No. of Death No. of Death No. of Death No. of Death
Deaths Rate Deaths Rate Deaths Rate Deaths Rate
1946 24 10 ·0 11 37 ·8 55 59·1 80 10·2
1947' 18 7·5 9 30·0 68 70·9 93 11 ·5
1948 17 6·8 9 29·0 84 85'7 95 11 ·7
1949 16 6'2 . 1 3 ·0 85 84,8 103 12·4
1950 16 6'1 9 25·7 85 77·3 141 13·6
Total 91 39 377 512
Race Incidence and Recent Trend of Mortality Sex and Age Incidence
Table IT and Figure 1 compare the deaths from the Table IV shows the deaths and annual death rates by
disease in the 4 races which make up the Union's sex and age for the 4 races combined, during the 5 years
population, and the corresponding death rates. 1946-50. These death rates are illustrated in Fig. 2.
TABLE rv. DEATHS FROM TETANUS M'D MEAN ANl'.'UAL DEATH RATES
PER MILLION BY SEX A 'D AGE. ALL RACES: 5 YEARS 1946-50
z Afaks Femaks
:> ".------............... Age Group o. of Death No. of Death
, ,,1 ................ COLOURED
:::i 80 Deaths Rate Deaths Rate
Q .' 0-1/12
12r 102,2 244}
J " I- 31J 18 .
~ -,'" S- 57 15·6 20 5·6
a.. 20- 20 8'2 6 2·6
w 25- 24 9,4 8 3·6
~ 40 3D- 19 8·8 4 2·0
a: ...... ...... 35- 21 10·8 5 3·0
..... 0---__ -0, 40- 16 10'2 8 5·4
.. ,PASIATIC 45- 16 12·4 6 5·2
o 20 ..".. ,"
65- 2 4·2 2 4·2
'0' EUROPEAN 70- 7 11 ·6 2 2·8
O+--~--....,r----r-----, Total 649 370
1946 1947 1948 1949 1950
YEAR 73-8 J
Fig. I. Death rates per million living, by race (all ages).
The death rate in every year was highest in the
Coloured race and lowest (with a single exception) in '2
the European. The exception occurred in 1949 when >: I1
only one death was notified among Asiatics. Z 10
It is probable that the mortality from tetanus among o
Natives is under-estimated owing to omissions ·in the -'
registration of deaths. The total deaths and death
rates among Europeans (and perhaps Asiatics) has shown ..
a tendency to decline during the 5 years; no such trend
is observable among the Coloured and Native races.
Indeed, the incidence of deaths from tetanus among the ~ 5
Coloured increased during the years 1946-50. This is o 4
also reflected in a comparison with deaths from all 3
causes (Table Ill).
TABLE rn. DEATHS FROM TETANUS EXPRESSED AS A PERCE ITAGE OF
ALL DEATHS, BY RACE
European Asiatic Coloured
Year No. % of all No. % of all No % of all 0. 5- 10_ 15_ 20- 25- 30- 35- 40- 45- 50- 55- llO- 65- 10+
Deaths Deaths Deaths AGE AT DEATH (YEARS)
1946 24 0·12 11 0·32 55 0·29 Fig. 2. Mean annual death rates per million living. Males and
1947 18 0·08 9 0·24 68 0·35 females by age. All races. 1946-1950.
1948 17 0·08 9 0·22 84 0·39
1949 16 0·07 1 0·003 85 0·37
1950 16 0·07 9 0·22 85 0·39 The largest number of deaths and the highest death
Figures for ative Race not available. rate occurred in infancy and early childhood. Of the
5 Junie 1954 S.A. TYDSKRIF VIR GENEESKUNDE 475
1,019 persons who died of tetanus in the 5 years, 617 with a resultant decrease in the number of cases and
(60.5 %) were under 1 year of age, and, of these, 94.6 % deaths.
were under 1 month. Clearly the high death rate in A similar investigation into the tapes and dressings
children under 5 years (higher than in any other age used by midwives on new-born infants in this country
group) is attributable to the relatively large number of would be justified, if only to stress the importance of
neonates, among whom the disease has a notoriously asepsis in the care of umbilical stumps. The authorities
high mortality. should also consider making tetanus a notifiable disease
to draw the attention of the medical profession to its
PREVE'TION high incidence.
Tetanus in children and adults. Active and passive
immunization have each been tested on a large scale SUMMARY
in one of the two world wars. Whereas the use of tetanus
1. During the 5 years 1946-50 1,019 deaths from
antitoxin carries the risk of dangerous serum sensiti-
zation, experience in the British and United States tetanus were notified in the Union of South Africa. This
Armies during the last war showed that tetanus toxoid represents a death rate 3.4 times as high as that of
England and Wales.
produced effective active immunity and rarely caused
local or general reactions. Conybeare and Logan 3 2. In each year the death rate was highest among the
have advocated active immunization of population- Coloured race and lowest i'n Europeans, and whereas
groups selected by age, place of residence or occupation. the total deaths and death rate among Europeans (and
This has been attempted in a selected age-group in perhaps Asiatics) has tended to decline among Coloureds
France,5 where, since 1940, it has been obligatory for and Natives the tendency has been to measure.
tetanus toxoid to be given at the same time as immuniza- 3. The highest mortality occurred in persons under
tion against diphtheria-before the age of 18 months; 5 years of age, attributable to the large number of neo-
no decline in the death rate from tetanus among French natal deaths.
children has been noted as yet. In Denmark Lassen 6 4. It is suggested that the following measures should
advocated active immunization of civilians working with be adopted to lower the incidence of tetanus in this
soil, namely farmers, gardeners and labourers, and those countrv:
(a) -Tetanus should be made notifiable.
with chronic leg ulcers. The high death rate in children
(b) An investigation should be made of umbilical
under lO years in South Africa adds weight to Conybeare
and Logan's suggestion that children should be actively tapes and dressings used by midwives.
(c) Active immunization should be advised in children
immunized against tetanus when they receive the
'boosting' inoculation against diphtheria at the time of of school-going age.
entry to school-that is about 5 years of age; wounds I gratefully acknowledge my indebtedness to Professor M. van
sustained subsequently could be treated with single doses den Ende of the Department of Bacteriology, University of Cape
of toxoid. This is undoubtedly the ideal practice. How- Town, for his encouragement, stimulating interest and valuable
ever, until such a programme is widely adopted, extensive advice; to Dr. J. F. Wicht, formerly Medical Superintendent of
the City Hospital, Cape Town, for his expert advice and help;
use of antiserum with due precautions against its potential and to Dr. J. H. Mason of the South African Institute for Medical
dangers appears to offer the best chance of reducing the Research, Johannesburg, and Dr. R. J. van Rensburg of the
incidence of tetanus in children and adults. Department' of Health, Pretoria, for the assistance they have
Tetanus neonatorum. Conybeare and Logan reported given me. I am also grateful to Professor A. H. Hales and Pro-
fessor E. Batson for the advice on statistical method.
that 36 infants died of tetanus in England and Wales
in the lO-year period 1938-1947. In comparison, 67 REFERENCES
cases of tetanus neonatorum were treated.at the King 1. Makins, G. H. (1901): Surgical Experiences in South Africa,
Edward Hospital, Durban, during the 6 years 1946, 1899-1900. London: Smith Elder and Co.
195F; and in Cape Town,4 19 cases were admitted to 2. van Rensburg, B. J. (1953): Personal ro=unication.
two hospitals in the past 6 years. This reflects poorly 3. Conybeare, E. T. and Logan, W. P. D. (1951): Brit. Med. J.,
on neonatal care in these areas. Chapin 8 reported that 1,504.
4. Slome, R. (1954): In press.
the number of deaths from tetanus in children under 5. Ramon, G. (1950): La Princ. des anatoxines et ses applications.
1 year in Havana decreased from 128 in the year 1901 to Paris: Masson.
18 in 1908. This followed the discovery that 5 of 6 6. Lassen, H. C. A. (1949): Acta med. scand., 136. Suppl. 234,
samples of cotton wick used by midwives for tying the 214.
7. Friedlander, F. C. (1951): J. Pediat, 39, 448. .
umbilical cord were infected with tetanus. Sterile 8. Chapin, C. V. (1910): The Sources and Modes of InfectIOn.
material was then furnished by the Department of Health, ew York: John Wiley and Son.