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SECTION I
GENERAL SURGERY
CHAPTER X
TETANUS
The
incidence of tetanus in the American Expeditionary Forces was decidedly
low; so
low, indeed, as to warrant the statement that, as a disease, we had no
real clinical experience
with it: only 36 cases were reported as being associated with 176,132
battle injuries, or a rate of
0.014 per thousand.1 This fact in itself is worthy of more
than passing notice and is but a further
exemplification of our good fortune in being able to profit by the
experiences of our Allies.
The
relationship of soiled gunshot wounds and the occurrence of tetanus was
well
understood prior to the beginning of the war in 1914, and such injuries
occurring on the highly
fertilized ground of the battle fields of France were inevitably
followed by a high incidence of
tetanus. However, the Allies did not anticipate any such number of
cases of tetanus as occurred
in the first few months following the beginning of the war. Even had it
been otherwise, there was
neither organization nor adequate material for proper administration of
antitoxin. Within a very
few months, however, the British ordered that a preventive dose of
antitetanic serum be given to
every wounded man.2 The results of this order were
reported to be excellent; in the latter half of
the year 1915 only 36 cases of tetanus developed among those who
received a preventive dose of
antitetanic serum within 24 hours of receipt of injury.2 This measurable, though not entirely
complete, control is graphically shown in Chart VI, which is a
compilation of Maj. Gen. Sir
David Bruce, chairman of the British war committee for the study of
tetanus, to show the ratio
per thousand among the cases of tetanus.3
The
case incidence shown in Chart VI refers to cases of tetanus arising in
hospitals in
England among the wounded arriving there from the battle fields, and it
does not have to do with
the cases occurring in France; however, another study by Cummins4 which combined the
incidence figures for the British Expeditionary Forces and those used
by Bruce, shows a very
similar curve.
The
elevations in the incidence curve as shown in Chart VI may be
ex-plained as being
partly due to periodic, increased battle activities, and partly to the
occurrence of trench foot.
More especially is this true, in so far as trench foot is concerned, in
1916, to which further
reference is made below. What is of greater interest, as regards the
American Expeditionary
Forces, is the almost uniform flattening of the curve during 1918, at a
time when we were
actively engaged with the enemy.
VARIETIES OF TETANUS BACILLUS
Tulloch, 5 by means of serological tests, identified four classes of
tetanus bacilli. Twenty-three strains of the tetanus bacillus were
obtained from war wounds of men not suffering from
tetanus. Seventeen of these strains belonged
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to Type I, 3 to Type II,
2 to Type III, and 1 to Type IV. This relationship of type incidence
did
not obtain, however, in organisms from cases of tetanus: whereas 74 per
cent of the tetanus
bacilli obtained from nontetanus cases belonged to Type I, only 41 per
cent of tetanus among
the wounded could be attributed to Type I.3
CHART VI.-Incidence of
cases of tetanus. Ratio of cases per thousand wounded, by months
PREVENTION
SERUM PROPHYLAXIS
Once
the necessity for the administration of antitetanic serum to all
injured men was fully
appreciated, the belligerent nations so organized their medical forces
as to insure the
administration of the serum at the earliest possible moment following
the injury. This meant the
serum must be as readily available, and practically as far forward, as
was the first-aid packet;
some means of rapidly determining, by a mark-usually an iodine-painted
cross on the forehand
286
or by ticketing,
whether or not an acutely injured man had received an adequate dose of
the serum; and finally a checking up at the operating hospitals to
insure protection in cases in
which, through inadvertence, the administration of the serum had been
omitted.
The
British adopted 500 units as the preventive dose, to be given
subcutaneously at a
distance from the wound; the French, 10 c.c. (equivalent to about 600
units). 2
It
was expected that this routine injection of serum would bring about the
lowest
possible incidence rate of tetanus; however, when, with the occurrence
of large numbers of
trench foot, it was observed that with such a condition tetanus
frequently was associated, it was
realized that the portal of entry into the body by the tetanus bacillus
need not necessarily be an
open wound.6 Therefore all cases of trench foot were
included with battle injuries for which the serum was to be
administered as a matter of routine, with the result that in trench
foot the
occurrence of tetanus was prevented.
It
was appreciated by the British that 500 units of antitoxin was in many
instances too
small a dose, and on July 4, 1917, modified instructions required the
use of 1,000 to 1,500 units
"in all deep wounds in those which are contaminated with dirt, and in
those in which there is
fracture of bone." 3 The size of the dose, however, was not
fully determined as late as
December, 1918. Bruce at that time announced his preference for
multiple and smaller doses,3 an attitude that was based upon the fact that the antitoxin disappears
within the body within a
relatively few days.
DURATION OF PASSIVE IMMUNITY
With
the view of determining the duration of immunity conferred by
antitetanic serum,
MacConkey and Homer7 carried out a series of experiments
on guinea pigs. In these
experiments it was found that immunity from the minimum dose was
considerably diminished at
the end of 10 days, and at the end of 2 weeks it had about disappeared;
immunity could not
materially be prolonged without increasing the dosage of serum to a
degree impractical in man.
They concluded, therefore, that it is necessary, in order to maintain
immunity, to repeat the usual
protective doses about once a week during the danger period.
As
stated above, the British, in 1917, required an increase of the initial
dose in certain
classes of wounds, from 500 units to 1,000-1,500 units. The British
tetanus committee, in the
same year, recommended that, additional thereto four doses, each of 500
units, should be given
at intervals of seven days. This latter recommendation was responded to
variously, from 40 to
90 percent,3 consequently, it is impossible to say
definitely what influence multiple doses of
serum had upon the lowering of the incidence of tetanus. During the
fall of 1918 the strength of
the primary dose to be given at the front was increased to 1,500 units,
with the hope that a higher
degree of immunity might be obtained. Second, third, and fourth doses
were to be given at
weekly intervals, the strength of each to be 500 units.3 Since the war ended soon after this last
change in the administration of the serum inadequate time remained to
determine whether or not
any improvement resulted from it. What is of particular interest,
however, is the fact that, with
the increase of the number of multiple injections, the
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mortality rate
progressively decreases in those contracting tetanus. There is a
relationship
between prophylactic injections of antitetanic serum and the
prolongation of the incubation
period of tetanus, which must be taken into consideration in the
present connection, for it is
possible the decreased mortality mentioned above might to a certain
extent be attributable to
cases with lengthened incubation periods; a long incubation period goes
hand in hand in hand
with low mortality. According to Bruce, 3 the average
incubation in days in1914-15 was 13.4;
1915-16, 31.2; 1917-18, 46.19.
SURGICAL PROCEDURES
The
tetanus bacillus being an anaerobe, thriving best on putrescent tissue,
it follows that
the early and absolute excision of such tissue, as well as foreign
bodies, ranks first as a
prophylactic. This was one of the great surgical lessonswhich the war
taught and was not
appreciated thoroughly until 1917, and after other and much less
satisfactory methods had been
tried out. It is true that tetanus was only one of the several kinds of
wound infection for which
wound excision was devised, nevertheless the agreement is general that
thorough wound
excision had a material influence on the incidence of tetanus following
its general adoption in
the spring of 1917. On the other hand, nothing occurred during the war
to change the opinion
obtaining prior thereto that operation should be avoided in cases of
tetanus, for by the time
tetanus symptoms appear there is already a general toxic condition.
Because
it was recognized so frequently during the war that tetanus bacilli
could lie
dormant for surprisingly long periods, only to light up on surgical
interference, the
administration of a prophylactic dose of antitetanic serum was
generally practiced prior to
secondary operation on war wounds and upon manipulations incident to
the reduction of
compound fractures.
MODIFIED
TETANUS
With
the widespread use of antitetanic serum for the prophylaxis of tetanus,
classical
forms of the disease occurred less commonly than the modified (local
tetanus). Burrows 8 states
that this localized tetanus may be splanchnic, cephalic, or seated in
the limbs, and explains its
occurrence on the basis of laboratory experiments with animals. These
experiments showed that
the tetanus toxin gains access to the nervous system either by the
general blood stream or by the
motor nerves. The injection of antitoxin in cutting off approach by the
blood stream permits the
toxin to find access only along the motor nerves. Hence it can cause
only local spasticity.
MEMORANDUM ON
TETANUS, AMERICAN EXPEDITIONARY FORCES
Based
upon the facts outlined above, the following information was
promulgated to the
medical officers of the American Expeditionary Forces for their
guidance in the prevention and
treatment of tetanus : 9
Spores of the tetanus bacillus are
universally distributed in soil that has been cultivated and manured.
In
consequence they are virtually constant throughout the battle fieldsof
France. And since the soil inevitably gets upon
the clothes and bodies of soldiers, all wounds must a priori be
regarded
as probably contaminated with tetanus.
Tetanus spores
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in such wounds may at any time develop into
tetanus bacilli and produce tetanus toxin,with consequent development
of symptoms of the disease.
The
tetanus bacillus thrives particularly on injured tissue. Wounds with
tissue destruction, especially if
there are pyogenic infection and blood clots, are particularly
dangerous. Wounds may appear clean and heal by
primary intention and nevertheless harbor tetanus bacilli; or tetanus
spores may remain latent in such wounds, and
when secondary operation produces tissue death or small blood clots
they may develop and cause tetanus.
Tetanus antitoxin.- Tetanus
antitoxin neutralizes, multiple for multiple, the toxin of the tetanus
bacillus.
However, it must be remembered that the toxin produced by the bacillus
becomes very rapidly attached to the nerve
cells which it injures, and toxin which has become fixed in this manner
is amenable to the neutralizing action of the
antitoxin to a very slight extent only or not at all.
For
this reason, the prophylactic value of tetanus antitoxin has been
established beyond doubt, but the
success of its therapeutic use depends largely upon an early diagnosis
and proper administration.
Prophylactic use of tetanus antitoxin.- A prophylactic of 1,000 units of tetanus
antitoxin will be given to all
wounded, whatever the nature or severity of the wound. This should be
done as soon as possible after infliction of
the wound, preferably at the battalion aid station. Some of the
antitoxin will be furnished in syringes, but it is
impossible to provide all of it in this form. Care will be taken,
therefore, that battalion aid stations and other
advanced dressing stations be provided with a supply of sterilizable 10
c.c. syringes and suitable needles for serum
provided in bottles.
Since
tetanus antitoxin is eliminated by the body within 10 to 14 days and
since the incubation time of the
disease varies greatly, depending upon fortuitous circumstances, such
as the extent of tissue death and secondary
infection, at least one subsequent dose of 1,000 units will be given
after an interval of 7 days. It is recommended that
officers giving these repeated doses take cognizance of the memorandum
on anaphylaxis and be guided in their
serum administration thereby.
Tetanus
antitoxin will also be administered as a routine measure in the
following conditions: 1. Upon the
recognition of "trench foot" with or without skin abrasion. 2. In case
of frost bite. 3. During operations performed
under conditions of unsatisfactory asepsis, e. g., emergency
operations, operations for hemorrhoids, fistulte, or any
conditions where fecal contamination is a possibility. 4. During
secondary operations necessary in the course of
treatment of wounds received 7 or more days previously. 5. Following
the manipuations incident to the reduction
of compound fractures or dislocations, after the removal of adherent
drains or any other procedure resulting in
disturbance of the healing process in a woundl 7 or more days old.
The
antitoxin will be administered subcutaneously, preferably over the
lower abdomen by or under the
immediate supervision of a medical officer.
All
injections, with amounts and dates, signed by the officer
administering them, will be entered on
patient's field medical card.
In
addition to the above regulations for the routine administration of
tetanus antitoxin, medical officers are
advised that two injections may not be sufficient in all cases. In severe injuries
where prolonged suppurative
processes persist, especially when fecal contamination of the wound per
rectum or through intestinal fistulae is
present, and when much tissue necrosis occurs, three or even four doses
may be indicated. The attending medical
officer must bear this in mind and exercise judgment accordingly in the
individual case.
Early
diagnosis.- As stated above, the success of specific treatment in
tetanus depends primarily upon early
diagnosis. For this reason surgeons should be constantly on the alert
for local manifestations which often precede the
development of generalized tetanus. Since the toxin is conveyed to the
central nervous system by way of the nerve
trunks, there may be early rigidity,
spasticity, or even twitching of the muscles surrounding the
wound--which
occasionally may be accompanied by pain and a local increase of
reflexes. These symptoms,as well as "sore throat,"
"stiff neck," early trismus, and in head wounds, facial paralysis,
should be constantly watched for and nurses should
be instructed to keep this in mind whenever dressing a wound or doing
other services for patient.
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By
conscientious attention to early manifestations of this nature life may
be saved. Immediate treatment should be instituted in all doubtful
cases.
Treatment
with antitoxin.- When the early symptoms of tetanus have been
recognized or
when the disease has distinctly manifested itself, energetic treatment
with antitoxin should
immediately be instituted. There are many different ways of
administering the antitoxin, and it is
by no means plain as yet whether the subcutaneous, intravenous, or
intrathecal method will
eventually prove to be the most efficacious. However, it would seem
that in cases recognized
early a combination of immediate intrathecal and intramuscular
injections is advisable.
In
every case strongly suspected of being tetanus at least 5,000 units of
tetanus antitoxin should be given intrathecally as soon as possible.
This is done by lumbar puncture, preferably under an anesthetic. The
serum should be injected slowly and in volume should about replace the
amount of spinal fluid withdrawn. When little or no spinal fluid flows,
as occasionally happens, a relatively small volume of serum should be
injected (about 5 c. c.), and this very slowly. In all cases
intrathecal injections should be done slowly, either by gravity or
directly with a syringe, and repeated within 12 hours if the first
volume injected does not contain 5,000 units. After such injections it
is a good plan to raise the foot of the bed and remove the pillows. At
the same time 8,000 to 16,000 units of antitoxin should be administered
intramuscularly, with observance of all precautions spoken of in the
circular dealing with dangers of anaphylaxis. The intrathecal injection
will often give rise to meningeal irritation and turbid spinal fluid,
which, however, need cause no alarm.
Both
the intrathecal and intramuscular injections may be repeated daily for
two or three days. It is rarely necessary to inject subsequent to this,
because any effect the antitoxin will produce results from the first
injection, since antitoxin is not completely absorbed for several days
and is not eliminated completely for 10 or 12 days.
Supplementary
treatment.-Morphine and other sedatives should be
given with the
idea of resting the patient, and they should be administered in doses
sufficient to give the most adequate physiological effect compatible
with safety.
As
soon as the diagnosis of tetanus is made the case will be reported by
telegram to the chief surgeon, A. E. F.
REFERENCES
(1) Sick and Wounded Reports to the Surgeon
General. On file, Historical Division, S. G. O.
(2) McConkey, A. T.:
The Prophylaxis of Tetanus. British Medical Journal, London,
December 11, 1915, ii, 849.
(3) Bruce, Major General Sir David: Tetanus. War
Medicine, Paris, 1918-19, ii, No. 5, 724.
(4) Cummins, S. L., and Gibson, H. Graeme: An
Analysis of Cases of Tetanus Occurring in the British
Armies in France between November 1st, 1916, and December 31st, 1917. Lancet,
London, March 1, 1919, i,
325.
(5) Tulloch, W. J.: Report of Bacteriological
Investigation of Tetanus Carried out on Behalf of the War Office
Committee for the Study of Tetanus. Journal of Hygiene,
Cambridge, 1919, xviii, No. 2, 103.
(6) Bruce, Major General Sir David:
Importance of Early Prophylactic Injection of Anti- tetanic Serum in
Trench Foot. British Medical Journal, London, January 13, 1917,
i, 48.
(7) McConkey, A. T., and Homer, Annie: On the
Passive Immunity Conferred by a Prophylactic Dose of
Antitetanic Serum. Lancet, London, February 17, 1917, i. 259.
(8) Burrows, H.: Modified Tetanus. Lancet,
London, January 27, 1917, i, 139.
(9) Bulletins on Transmissible Diseases and
the use of Therapeutic Sera, American Expeditionary Forces,
May, 1918.
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