114 S.A.
MEDICAL JOURNAL 8 February 1964
holics, all of whom were gravely ill, and 3 died; jaundice
was noted in 2 of these fatal cases and was thought to be
due to cardiac failure and pre-existing liver disease. Two
patients were known diabetics and 2 suffered from gout.
The serum-cholesterol level was measured in 26 patients
and was found to be above 300 mg. per 100 rnI. in 8
patients.
Laboratory investigations. The white blood count,
ESR and serum transaminase were estimated in most
patients but, as the specimens were taken at varying times
after the onset, the results have not been used to assess
the severity of illness.
Deaths. The total mortality was 18 cases (24%). The
average age in the fatal cases was 64 years, compared
with 59 years for the survivors. Seven patients died within
24 hours of admission and another 7 during the first
week; the other 4 fatalities occurred between the 8th and
42nd days. Necropsies were performed in 7 cases and re-
cent infarction was confirmed in all. Cardiac failure was
found in all 7 necropsies, pulmonary infarction in 1, rup-
ture of the left ventricle in 1, and rupture of an aneurysm
of the ascending aorta in 1. The 11 fatal cases in which
necropsy was not performed all showed unequivocal
clinical evidence of myocardial infarction. Two patients
developed a generalized bleeding tendency while taking
anticoagulant drugs and were thought to have died from
intracerebral haemorrhage.
Discussion
The reported mortality from myocardial infarction
varies widely,'" and ranges between 10 and 40%. This
variation is probably due to differences in diagnostic cri-
teria and in case material as well as the natural history
of the illness.
In this series the most important prognostic factor was
a history of previous infarction. Recurrent infarction was
associated with a mortality of 33% whereas only 17% of
the initial attacks were fatal. Shock, cardiomegaly and
cardiac failure were also associated with an increased
mortality, particularly among those with recurrent infarc-
tion. The age of the patient and the duration of symp-
toms before admission did :lot appear to be important.
STAINING OF CHILDREN'S TEETH BY TETRACYCLINE
RONALD P. BENSON, M.B., CH.B. (CAPE TOWN), M.R.C.P. (EDIN.), D.C.H., Port Elizabeth
From recent literature'" it has become apparent that the
primary teeth of a number of premature and full-term
infants may become discoloured because of tetracycline
administered to tlIese babies during the neonatal period.
The discolouration varies from bright yellow to yellow-
brown. When such teeth are examined under an ultraviolet
lamp they show a bright yellow fluorescence.' Wallman
and Hilton' demonstrated that the ultraviolet spectra of
solutions of the extracted tooth pigment gave an absorp-
tion band at 270 mll, and tetracycline hydrochloride suit-
ably suspended showed absorption bands at 220, 270, and
The results in initial episodes are similar to those re-
corded by Master et a/.4 in 1939 and by Jacobs' in 1951.
These authors reported mortality rates of 23% and 19%
respectively. Honey and Truelove' reviewed a large series
of cases of myocardial infarction treated between 1943
and 1956 and found that the mortality had remained
fairly constant during this period. Comparison of the re-
sults of different series of cases is difficult because of
differences in case selection as well as possible regional
variation in the incidence and severity of the disease.
Nevertheless, the results now presented show how little
improvement there has been during the last 20 years. As
this series is small and there were no controls, no attempt
has been made to evaluate the use of anticoagulant drugs.
Pulmonary emboli were recognized in 9 patients (12%)
but appeared to contribute to only 1 death. Small emboli
were probably missed in the absence of gross signs, but
there was no evidence at necropsy that this had occurred
frequently. The relative infrequency of pulmonary emboli
as a cause of death in myocardial infarction has recently
been commented on by Hilden et al."
It is concluded that in Durban the mortality from this
disease is similar to that reported overseas and remains
considerable, particularly in recurrent episodes.
Summary
An unselected series of cases of myocardial infarction
treated in a general hospital is reviewed. A history of
previous infarction is the most important prognostic fac-
tor. The mortality remains similar to that reported 20
years ago.
I wish to thank Dr. J. V. Tanchel, Medical Superintendent
of Addington Hospital, and Dr. N. A. Rossiter, under whose
care these patients were admitted, for permission to publish
this re port.
REFERENCES
I. DressIer, W. (1959): Arch. Intern. Med .. 103, 28.
2. Toohey, M. (1958): Brit. Med. J., 1. 252.
3. Honey, G. and Truelove, S. C. (1957): Lancet. 1, 1155.
4. Master, A. M., Dack, S. and Jaffe, H. C. (1939): Arch. Intern. Med.,
64, 767.
5. Jacobs, T. P. (1951): Ann. Intern. Med .. 34. 114.
6. Hilden, T., Iversen, K., Raaschou, F. and Schwartz, M. (1961): Lan-
cet, 2, 327.
350 mll. The same authors discuss the frequent association
of enamel hypoplasia with discolouration of the teeth in
their series.
CASE HISTORIES
Four case histories are described to illustrate these features.
Case 1
M.V. was born at 30 weeks gestation and weighed 2 lb.
10 oz. She was asphyxiated at birth, but soon breathed
spontaneously. She received prophylactic tetracycline phos-
phate complex ('tetrex') intramuscularly for the first 6 days
of life to a total of 300 mg., and a further 125 mg. at intervals
during the following 2 weeks by mouth and by intramuscular
8 Februarie 1964 S.A. TYDSKRIF
injection. She received no further tetracycline during her first
year of life. Other antibiotics used in the neonatal period to
treat a lung infection were streptomycin, chloramphenicol, and
ampicillin ('penbritin'). She developed mild physiological jaun-
dice. She received 35 ml. of blood by scalp vein for mild
anaemia at the age of 2 months. Her subsequent progress was
satisfactory, and she was discharged from hospital 2t months
after birth weighing 5 lb. 1t oz. She cut her first tooth at the
age of 10 months. At 13 months there were 7 teeth which
were well formed and showed no apparent signs of enamel
hypoplasia, but they were all uniformly canary yellow in
colour. There was no evidence of pigment staining of her
skin, sclerae or nails. At the age of 15 months she weighed
25 lb. Her milestones were normal, and 8 teeth were present.
The cutting edges of the teeth were sharp and thin. They were
dull yellow in colour with irregular brown mottling of the
enamel. Under ultraviolet light the teeth gave a yellow
fluorescence which was especially noticeable in the distal half
of the teeth.
Case 2
E.E. was the first of twins who were born prematurely.
Birth weight was 4 lb. 4t oz. The infant was blue and limp
at first. He slowly improved, but 3 hours after birth respiratory
distress developed. Physical signs showed cyanosis and
moderate sternal recession and poor air entry over the lower
zone of the right lung. Treatment included a total of 225 mg.
of tetracycline phosphate (tetrex) intramuscularly over a period
of 3t days. The baby improved and was discharged 22 days
later weighing 5t lb. Only slight icterus neonatorum was
observed.
He was breast fed for 6 months. The first tooth erupted at
5 months. He was seen at 16 months for acute bronchiolitis.
He weighed 26 lb. He had 12 teeth which were yellow in
colour. The anterior molars were noticeably yellow, but there
was no evidence of enamel hypoplasia. The teeth fluoresced
under ultraviolet light. An iron-deficiency anaemia (Hb=65%)
was treated at the same time as the chest.
Case 3
E.E. was the second twin and brother of Case 2. He weighed
4 lb. 14t oz. at birth and he also showed signs of respiratory
distress. He received 275 mg. of tetracycline phosphate
(tetrex), 75 mg. of which was given intramuscularly and 200
mg. orally. He made an uneventful recovery. At 16 months
he had 12 teeth which were bright yellow in colour, slightly
hypoplastic, and they also fluoresced under UVL.
Case 4
T.T. was a full-term infant born after a perfectly normal
delivery. Several hours after birth he became cyanosed and
distressed, and atelectasis was diagnosed. Treatment included
6 days of intramuscular and oral tetracycline phosphate com-
pound (tetrex).
The parents noticed that the infant's teeth were yellow when
they first erupted. At the age of 4 years the child had 20
teeth. All the teeth were discoloured brown, particularly at
their distal ends. The enamel of the bicuspids was hypoplastic
so that the cusps appeared sharp and saw-like. The canines
were narrow, sharp and hypoplastic. Several dental caries were
also present. The teeth gave a slight yellow fluorescence under
UVL In comparison, the teeth of his 2 older sisters were
well-formed, unstained, and relatively free of caries.
DISCUSSION
Discolouration of teeth was reported several years ago in
children who suffered from mucoviscidosis and who were
on long-term tetracycline therapy.3.' It is now known that
tetracycline can be deposited in bone and in the dentine
and enamel of teeth, possibly by forming complexes with
calcium ions. Yellow-staining of bones caused by tetracy-
cline and cWortetracycline has been shown to develop in
animals; and stunting and malformation of bones in chick
embryos have been demonstrated when tetracycline was
VIR GENEESKUNDE 115
adrninistered"·: However, there is no evidence of terato-
genic effect in the human embryo.
Enamel hypoplasia, pitting of the enamel, and mal-
formed cusps may go hand-in-hand with yellow or brown
discolouration of childrens' teeth after tetracycline therapy
(Case 4). This usually follows in teeth where the yellow
staining is at first intense. Whether tetracycline deposition
causes enamel hypoplasia in every instance is uncertain,
since enamel hypoplasia without discolouration may be
observed in premature infants who have never received
tetracycline' Proved tetracycline-stained teeth may show
no evidence of enamel hypoplasia, as in Case 2.
According to Wall man and Hilton' the severity of pig-
ment discolouration of the teeth is related to the high
total dosage of tetracycline rather than to the duration
of therapy. Another observation is that the more prema-
ture the baby, the greater is the extent of enamel involve-
ment. The colour of the teeth varies according to the age
of the child. The younger the child, the brighter the yellow
pigment, while in older children the pigment is more
brownish. The teeth change from yellow to brown with
the passage of time, and eventually parts or the whole of
the brown-discoloured teeth may lose their fluorescence.
This change in colour is probably brought about by the
oxidation process of the tetracycline compound in the
teeth.
Tetracycline is slowly removed from teeth and bones
of affected children, and any ill-effects of prolonged re-
tention of the drug in these and in other organs are as
yet unknown. Teratogenic effects, which are reported to
occur in the chick embryo: should nevertheless not be
overlooked in humans.
The permanent teeth are unlikely to be affected by tetra-
cycline administered during the newborn period or later
in infancy, since the evidence is that the chief risk of
tetracycline pigment deposition occurs during the period
of rapid development of the tooth bud. Once the enamel
is laid down and the teeth are mature, there is little like-
lihood of significant tetracycline deposition. Tetracycline
is thus unlikely to damage the teeth of children over the
age of 6 months. On the other hand, the more immature
the infant, the greater the chances of tetracycline deposi-
tion in growing teeth and bones. It is unlikely that the
poor glomerular filtration rate of the immature kidney of
the premature baby causes higher blood levels of tetracy-
cline and consequently greater tissue penetration.
Administration of tetracycline during pregnancy has not
definitely been shown to affect the teeth of the foetus,
but if given during the last trimester of pregnancy in big
doses and for long periods, that possibility can arise.·
Tetracycline passes freely through the placental barrier to
the foetus.
Great care should be taken in the choice of antibiotics
for prophylactic and curative therapy in premature as well
as full-term infants. The number of ide-effects of anti-
biotics is increasing, and alarming results are seen from
time to time. Chloramphenicol, for instance, may cause
the 'grey syndrome' owing to the inability of the imma-
ture liver to metabolize and detoxicate the drug as rapidly
as the mature liver. Novobiocin may give rise to yellow
pigmentation of the skin and eyes and occasionally to liver
116 S.A. MEDICAL
damage." The sulphonamides, e.g. sulphafurazole ('gant-
risin') are not without dangers in premature infants since
they elevate the unconjugated form of bilirubin in the
blood, and this in turn may lead to kernicterus in suscep-
tible babies.
Tetracycline is normally a bright yellow compound. It
stains the skin when handled and it turns the urine yellow.
We can now add to these minor drawbacks the more
serious ones of staining the teeth, hypoplasia of the
enamel, and the staining of bones and certain other organs,
e.g. the eye, particularly in premature infants. Other
effects, such as malformation of bones and stunting of
growth, are not certain," but Bevelander' reports that
when newborn infants are given tetracycline in doses of
100 mg. / kg. for 10 days, the result is a decrease of up to
40% in the linear growth of the fibula as compared to the
normal growth rate. After cessation of drug therapy the
rate of growth returns to normal. He also attributes a
number of cases of dental caries in children to tetracycline
administration during infancy which has led to enamel
hypoplasia.
Tetracycline is otherwise safe and popular and it has
a wide antibiotic spectrum. Its use should not be lightly
discarded in the newborn period, but before prescribing
any antibiotic in this age group, the dosage and side-effects
of this antibiotic preparation should be carefully con-
sidered. Wall man and Hilton' pointed out that oxytetracy-
cline did not produce staining of teeth in their cases.
While chlortetracycline is known to stain the bones of
animals; there is no reliable evidence to date that this
drug and related demethylchlortetracycline can affect the
teeth and bones of infants." Demethylchlortetracycline is
normally broken down in the body with the release of
chlortetracycline or free base.
The soluble salts of penicillin, streptomycin, erythromy-
cin, and the newer penicillins," e.g. ampicillin, methicillin
A CASE OF SELF-MUTILATION BY MEANS OF PINS
B. PARKER, M.B., CH.B., Oranje Hospital, Bloemfontein*
Elizabeth B. is a 37-year-old White imbecile, an inmate
of Witrand Institution, Potchefstroom. She has contrac-
tures of her knees and a paretic left upper limb.
From 1952 onwards, her folder contains frequent notes
about superficial areas of inflammation, e.g. 'multiple
boils', 'cellulitis', 'furunculosis', etc. As witness
to this, she has numerous scars on many parts of her
body. In December 1962 she developed an inflammatory
swelling of her left forearm.
On X-ray examination her forearm was seen to contain
21 pins (Fig. 1). Subsequently, the rest of her body was
X-rayed, revealing 202 foreign bodies in her tissues. Most
appeared to be pins, of which the heads had been broken
off, but sewing-machine needles, darning needles, and
pieces of wire were also present. These objects were seen
* Previously of Witrand Institution, Potchefstroom
JOURNAL 8 February 1964
and cloxacillin, are well tried and relatively safe antibiotics
and few infections of the neonatal period fail to respond
rapidly and completely when these antibiotics, singly or
in combination, are given.
SUMMARY
The case histories of 4 children are presented whose
primary teeth were discoloured yellow from past tetracy-
cline therapy in the newborn period.
Their teeth frequently show enamel hypoplasia which
may be an important factor in the development of dental
caries later on in childhood.
Antibiotics are often needed for the treatment and pre-
vention of infections in the neonatal period. Great care
should be exercised in the choice of an antibiotic for in-
fants of this age group. Side-effects may be harmful, while
the correct dosage of the antibiotic should be ascertained
before prescribing the drug.
Tetracycline-stained teeth are not only unsightly but
they may also be costly because of the dental attention
required later. It would appear that tetracycline should be
given with great circumspection to infants under the age
of 6 months, considering the complications of tetracycline.
REFERENCES
I. Wallman. I. S. and Hilton, H. B. (1962): Lancet. I, 827.
2. Davies. P. A., Little, K. and Aherne. W. (1962): Ibid., I, 742.
3. Zegarelli, E. V., Denning, C. R., Kutscher, A. H., Juoti, F. and Di
Sant'Agnese, P. A. (1960): Pediatrics, 26, 1050.
4. Shwachman, H., Fekete. E., Kulozycki. L. L. and Foley. G. E.
(1958 - 59): Antibiotics Annual, p. 502. New York: Medical Encyclo-
paedia Inc.
5. Buyske. D. A., Eisner, H. J. and Kelley, R. G. (1960): J. Pharmacol.,
no, 150.
6. Bevelander, G., Nakahara, H. and Rolle, G. K. (1959): Nature (Lond.),
184, 728.
7. Bevelander, G. (1963): Brit. Med. J., I, 54.
8. Rendle-Short, J. (1962): Lancet, I, 1188.
9. Miller, J. (1962): Ibid., I, 1072.
10. Hargreaves, T. and Holton, J. B. (1962): Ibid., I, 839.
I!. Leading article (1962): Ibid., I, 847.
12. Stewart, G. T. and Holt, R. J. (1963): Brit. Med. J., I. 308.
in both lower limbs, buttocks, left upper limb, neck,
face, breasts, and within the thoracic cavity (Fig. 2).
The patient herself, on account of her partial paralysis,
is unable to search for pins where they are likely to be
found. It has been discovered that several other imbecile
patients have made a practice of collecting sharp objects
and presenting these to the patient. One was discovered
in the act of taking a cigarette-box to her filled with rusty
nails.
There is no doubt that the patient herself introduced the
pins, since she is well able to defend herself against attack
by others, and her sound arm is conspicuously free of
pins.
When accused of having pushed pins through her skin,
the patient denied it, and was quite unruffled. She became
very angry when a superficially situated pin was removed
under local anaesthesia. She reacts normally to painful
stimuli administered by other people.