Wounded Australian soldiers receiving tetanus antitoxin outside a medical dressing station. 1918, Australian War Memorial E05242, Campbell, Australia. From: Shanks, Dennis. How World War 1 changed global attitudes to war and infectious diseases. New York: The Lancet, 2014.
By Karley Carter
Note: Essay 6 in a series, all from Dr. Amanda McVety’s Spring 2019 class on Medicine and Disease in Modern Society
Tetanus has been a well known disease for thousands of years, with its effects becoming devastating at times when treatment was unknown. Due to developments of the late nineteenth and early twentieth centuries, there were revolutionary improvements in the way the disease was handled. While tetanus carried with it a lack of social stigma due to its non-communicable nature, the fear of tetanus during war time prior to the twentieth century was real. With the discovery of both the tetanus antitoxin and toxoid, tetanus transformed from being a killer in war to something that was less than an afterthought in the minds of soldiers and the general population.
Tetanus has been regarded in history all through time, with documents noting tetanus symptoms found from 1500 BC in Ancient Egypt, but are thought to have been copied from as early as 3000 BC.[1] While there was a general understanding that the disease came from something infecting an open wound, many ideas for treatment were not beneficial, such as early Chinese physicians needling patients above the ears around 300 BC, Hippocrates’ ideas in Ancient Greece of promoting sweating through drinking strong wines and being wrapped in oil soaked cloths, and ideas in the Renaissance of covering the patient with manure.[2] The 19th century was revolutionary for tetanus research, as the disease was first replicated in 1884 through producing tetanus in animals, and pure cultures of tetanus bacillus were acquired soon after to study.[3] These studies led to Kitasato and Emil von Behring among others discovering the tetanus antitoxin in 1891, something that greatly reduced deaths due to tetanus after being administered in World War I.[4] In 1924, the first tetanus toxoid was developed and was given to all U.S. soldiers prior entering World War II, being eventually widely administered as the tetanus vaccine in the late 1940’s.[5] National report of tetanus cases began in the 1940’s as well, allowing the decline in tetanus cases over the next half century to be noted.[6]
Tetanus was relatively well understood in the early twentieth century. With the new discoveries found between the 1880’s and 1920’s, tetanus was known to be caused by the bacteria tetanus bacillus, which is an anaerobic organism that enters the body through subsurface wounds.[7] In addition, there was knowledge of contraction of tetanus being through contamination of the wound with soil, due to puncture wounds, wounds entering joints, or through other subsurface wounds, such as surgical incision sites, that were not properly treated.[8]
While there was ability to destroy the bacteria through antiseptics, it was known to be unable to be destroyed in spore form, due to its ability to live through a wide range of temperatures.[9] This information is relatively true to today, with most discrepancies between the times being small, such as many of the articles of the early to mid-twentieth century referring to tetanus as tetanus bacillus, with few calling it Clostridium tetani as it is officially referred to as today. There is also a wider description of causes today as risks and dangers in society have changed, such as contraction due to non-sterile needles in drug use, body piercing, and tattooing.[10] Recent articles also provide more information on the different kinds of tetanus, being general, local, cephalic, and neonatal, describing the specifics of each as well as how common each one is.[11]
The experience of having tetanus, if acquired, is very painful and incessant. After contraction of the disease, the incubation period is around 2-21 days, with symptoms tending to start around the seventh or eighth day.[12] The first symptoms would be spasms in the muscles near the location of the wound, or tightness in the jaw, in which the spasms would spread throughout the body as the bacteria travel through the bloodstream.[13] Swallowing can become difficult and stiffness and pain may occur in the muscles of the shoulders, neck, and back, with additional spasms possibly spreading to the muscles of the arms, legs, and abdomen.[14] There can be other symptoms too, including fever, sweating, high blood pressure, and rapid heart rate.[15] In some cases, the spasms can be so strong that they causes fractures and muscle tears, as well as ones in the throat that cause difficulty breathing and can sometimes lead to brain damage.[16] These symptoms tend to lessen after around 17 days, but spasms can continue for three to four weeks, and in some cases a recovery can take months.[17] The prognosis for the disease can be dire, with twenty-five percent of people with the disease dying if not properly treated, and around ten percent of people with the disease dying when properly treated, even into modern day.[18]
The treatments for tetanus created in the early twentieth century completely altered the prevalence of the disease. The discovery of the tetanus antitoxin completely changed its effects in war, with soldiers in battle being the primary victims to the disease prior. In the Civil War, one of every 500 men died of tetanus by sustaining wounds during battle and then becoming infected with tetanus.[19] In World War I, there was less than one case that occured for every 5000 wounded, due to the fact that every wounded soldier in the U.S. troops received a prophylactic injection of the tetanus antitoxin.[20] To create the antitoxin that was distributed, a tetanus toxin was injected into horses who form antitoxins to protect themselves from the poison.[21] The resulting antitoxins created a serum that could be obtained from the horse containing the antitoxin and be used for treatment in humans.[22] This was the primary way to treat tetanus until the development of the tetanus toxoid in 1924.[23] While it was not commonly used in the thirties, the toxoid was administered to all U.S. soldiers in World War II to protect them from contracting the disease.[24] It was then used for the vaccine that was administered to the public, most commonly together with the Diphtheria and Pertussis vaccine, which created the DTP vaccine.[25]
Unlike many communicable diseases, tetanus did not have a strong social stigma, as it was not contagious from person to person. Although there was no stigma, there was still a fear of tetanus in people up until the antitoxin and toxoid became widely available, for soldiers in battle, in cases of surgical procedures gone wrong, and even on the Fourth of July.[26] Tetanus cases on the Fourth of July were extremely prevalent due to injuries by blank cartridges, firecrackers, and other Fourth of July festivities.[27] This caused the Fourth to become nicknamed the Bloody Fourth, due to the amount of deaths it caused due to tetanus.[28] While this was devastating in the 1800’s due to lack of treatment, articles of the 1900’s urged those injured on the Fourth to seek treatment to prevent the onset of tetanus, eventually reducing the number of deaths.[29] In addition, there was little regulation by public health officials of tetanus due to it not being contagious. When looking at the sanitary code from New York City in 1940, tetanus was mentioned as a communicable disease, but there were no specific regulations for it, unlike the majority of other communicable diseases.[30]
The discovery of the tetanus antitoxin and toxoid transformed tetanus from being devastating in war to becoming one less trepidation in the minds of soldiers and the general population. This was tremendously helpful during both World Wars, as it greatly reduced deaths which created a better morale for both soldiers and their families. The advancements in science during the late nineteenth and early twentieth centuries caused this disease to become something extremely uncommon in places where vaccines are easily accessible, which helped to manifest the current health system that we know today.
Karley Carter is a freshman majoring in Architecture with a minor in History.
Bibliography
Chalian, William. “An Essay on the History of Lockjaw.” Bulletin of the History of Medicine.
Vol. 8, No.2. Baltimore: The Johns Hopkins University Press, 1940. JSTOR.
City of New York’s Department of Health, Provisions of the Sanitary Code of the City of New York and Regulations Relative to Reportable Diseases and Conditions and Control of Communicable Diseases. Washington DC, 1940.
Coleman, George E. “Investigating Tetanus. (Lockjaw).” The Scientific Monthly. Vol 31, No. 6. Washington DC: American Association for the Advancement of Science, 1930.
Faulkner, Amanda E. and Tejpratap S. P. Tiwar. “Manual for the Surveillance of Vaccine-Preventable Diseases.” Centers for Disease Control and Prevention. November 17, 2017. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.html
Huber, John B. “Tetanus and the Glorious Fourth.” Scientific American, Vol. 101, No. 1.
New York: Scientific American, a division of Nature America, Inc., 1909. JSTOR.
Krantz, C. John. Fighting Disease with Drugs. Baltimore: Williams & Wilkins Co., 1931.
Lerner, Brenda Wilmoth and K. Lee Lerner, Infectious Diseases: In Context. Detroit: Gale, 2008. Gale Virtual Reference Library.
Spaeth, Ralph. “Tetanus.” The American Journal of Nursing, Vol. 42, No. 7. New York:
Lippincott Williams & Wilkins, 1942. JSTOR.
United States Surgeon General’s Office. FM 21-10 Military Sanitation and First Aid.
Washington,1940. https://archive.org/details/FM2110/page/n121
Vyas, M. Jatin et al. “Health Information from the National Library of Medicine.” MedlinePlus, Accessed March 1, 2019. medlineplus.gov/.
Image:
Wounded Australian soldiers receiving tetanus antitoxin outside a medical dressing station. 1918, Australian War Memorial E05242, Campbell, Australia. From: Shanks, Dennis. How World War 1 changed global attitudes to war and infectious diseases. New York: The Lancet, 2014.
[1] William Chalian, “An Essay on the History of Lockjaw,” Bulletin of the History of Medicine. Vol. 8, No.2 (1940): 173. JSTOR.
[2] Ibid., 175, 179, 193-194.
[3] Ralph Spaeth, “Tetanus.” The American Journal of Nursing, Vol. 42, No. 7, (1942), 733. JSTOR.
[4] Ibid., 733.
[5] Amanda E. Faulkner and Tejpratap S. P. Tiwar, “Manual for the Surveillance of Vaccine-Preventable Diseases,” Centers for Disease Control and Prevention.
[6] Ibid.
[7] United States Surgeon General’s Office, FM 21-10 Military Sanitation and First Aid (Washington, 1940), 115. https://archive.org/details/FM2110/page/n119
[8] Ibid., 115.
[9] Ibid., 115.
[10] Ed. Brenda Wilmoth Lerner and K. Lee Lerner, Infectious Diseases: In Context (Detroit: Gale, 2008), 816, Gale Virtual Reference Library.
[11] Ibid., 817.
[12] Ibid., 816.
[13] Ibid., 816.
[14] Ibid., 816.
[15] Ibid., 816.
[16] Jatin M Vyas, et al. “Health Information from the National Library of Medicine.” MedlinePlus, accessed March 1, 2019, medlineplus.gov/.
[17] Lerner, Infectious Diseases: In Context, 816.
[18] Vyas, “Health Information from the National Library of Medicine.”
[19] Krantz, C. John. Fighting Disease with Drugs. (Baltimore: Williams & Wilkins Co., 1931), 107.
[20] Ibid., 107.
[21] Ibid., 103.
[22] Ibid., 103-104.
[23] Faulkner and Tiwar, “Manual for the Surveillance of Vaccine-Preventable Diseases.”
[24] Ibid.
[25] Ralph Spaeth, Tetanus, 738-739.
[26] United States Surgeon General’s Office, FM 21-10 Military Sanitation and First Aid, 115.
[27] John B. Huber, “Tetanus and the Glorious Fourth,” Scientific American, Vol. 101, No. 1 (1909), 8, JSTOR.
[28] Ibid.
[29] Ibid.
[30] City of New York’s Department of Health. Provisions of the Sanitary Code of the City of New York and Regulations Relative to Reportable Diseases and Conditions and Control of Communicable Diseases. (Washington D.C., 1940).