Tetanus in P.R. Croatia from the epidemiological and clinical point of view

Tetanus predstavlja u Jugoslaviji kao poljoprivrednoj zemlji važan problem u nacionalnoj patologiji, jer po svom mortalitetu dolazi na prvo mjesto među akutnim zaraznim bolestima. Na temelju analize 360 slučajeva tetanusa, koji su liječeni u Bolnici za zarazne bolesti u Zagrebu od 1939.-1954., pokušalo se osvijetliti epidemiologiju i kliniku tetanusa u NR Hrvatskoj, a i u ostalim dijelovima Jugoslavije. Tetanus je najviše proširen u nizinskim dijelovima Jugoslavije s razvijenom poljoprivredom i stočarstvom. Od njega obolijevaju većinom (u 78% slučajeva) seljaci i njihova djeca, a od gradskog stanovništva oni s periferije, koji se bave i sitnom poljoprivredom. No od tetanusa obolijevaju kod nas i industrijski radnici te ljudi zaposleni u nekim obrtima (stolari, krojači, postolari i t. d.). Tetanus pokazuje kod nas izrazito sezonsko kretanje i javlja se, kad ljudi rade, većinom bosonogi, u polju i vrtu. Prema dobi tetanus je često oboljenje novorođenčadi te mladih dobnih skupina (od 5-20 godina). U mlađim dobnim skupinama je mnogo češći kod muških nego kod ženskih, svakako zbog češćih povreda kod muške omladine. Kudikamo najveći broj naših bolesnika se zarazio ubodom na različite predmete (trn, trijeska i t. d.), a najčešće mjesto povrede je bila noga. Ukratko je izneseno moderno shvaćanje o patogenezi tetanusa. Prema kliničkoj slici daleko najveći broj slučajeva je pripadao generaliziranom tetanusu, no bilo je i nekoliko slučajeva lokaliziranog tetanusa. Analiziran je odnos letaliteta prema lokalizaciji povrede, dužini inkubacije i dužini intervala između prvih simptoma bolesti i pojave reflektornih grčeva. Letalitet je u analiziranom materijalu iznosio 30,55%. Opširnije se raspravlja o terapiji tetanusa, naročito o modernoj primjeni relaksantnih sredstava. Spominje se uspješna terapija kroničnog tetanusa cijepljenjem tetalpanom. U profilaksi tetanusa se najviše preporučuje aktivna imunizacija ljudi, kod kojih postoji veća vjerojatnost povreda i infekcije.
Yugoslavia is an agricultural country and tetanus is of great importance in the national pathology since: 1. it has one of the highest mortality rates among acute infectious diseases, 2. the disease has a fatality rate of 43% and 3. it has shown a steady increase during the last years. This paper presents an analysis of 360 cases of tetanus which were treated in the Fever Hospital, Zagreb, from 1939-1954 (table 1). This analysis is intended to show the epidemiological and' clinical aspects of tetanus in P.R. Croatia and other parts of Yugoslavia. The highest regional incidence of tetanus is in the northern agricultural parts of Yugoslavia. In the great majority of cases (78%) it is a disease of peasants and their children. Among inhabitants·of towns it is a disease of those from the peripheral parts who are occupied with some agricultural work as well. Industrial workers and some tradesmen (joiners, tailors, shoemakers etc.) also suffer from tetanus (table 4). Tetanus has a characteristic seasonal incidence and the great majority of cases occurs between May and October (table 2) i. e. in the season when people do agricultural work in fields and gardens (table 3). It is of great importance that most of our peasants work bare-footed on manured soil. Tetanus very often occurs among newborns and younger age groups (from 6-20 years of age). In this age group the occurrence is more common in males than females (126:53) because of the much greater exposure to injuries of male youth during their work, play and sport (table 5). In 47,51% of cases the type of injury was a puncture (table 6) with different instruments (thorn, wooden splinter etc. - table 7). The most common site of injury was the foot (table 11). Modern concepts of pathogenesis of tetanus are briefly described. Most of our cases of tetanus presented themselves as a generalised tetanus (table 8) of moderate severity, whereas there were only a few cases of localised tetanus, all of them mild. The number of cases of tetanus in the newborn is small because these cases have been admitted to our hospital only since 1952. The number of cases of gynaecological tetanus is also small; this is probably due to the unreliable data. The .case fatality rate depended on the clinical form of the disease and was the highest in the cephalic and gynaecological forms and in tetanus of the newborn (table 9). Clinical relation of fatality rate to incubation period (table 10), location of injury (table 11) and interval between the first signs of tetanus and first spasms (table 12) is analysed. The average fatality rate in the analysed material was 30,55%. The treatment of tetanus is discussed in more detail. Since 1953 all moderate and severe cases of tetanus were given muscle relaxant Tolserol beside the usual therapy (antitoxic serum. hypnotics, narcotics, antibiotics etc.). The best results with this drug have been achieved in moderately severe cases as regards the subjective state of the patients, by facilitating the intake of food and fluids. In some patients with retention of urine this condition was overcome by the drug. In most of the severe cases, however, Tolserol was not able to control reflex spasms and save the life of the patient. In cases with spasm of the pharyngeal muscles we have also used a gastric tube for feeding and drug administration. The tube was maintained in position for a period of several days. In two cases with chronic tetanus satisfactory therapeutic result has been obtained with active immunisation. Seroprophylaxis and active immunisation against tetanus are briefly discussed. Active immunisation of people most exposed to infection with tetanus is recommended.