War Surgery and Medicine
CHAPTER 6 — Tetanus
FIRST WORLD WAR
THE distribution of tetanus spores in the soil varies to a marked degree over the world. In the First World War most cases were infected in France and Belgium. Few cases were reported in British armies in other areas—seven in Mesopotamia, six from Gallipoli (all in cases of trench foot), four in Salonika, and three in Italy. Lack of recorded cases suggested there were few cases in Egypt. In 1 NZEF the number of cases is not known, but there were three deaths. Among the British troops in France the rate of infection at the beginning of the war was over eight per 1000 wounded, but this was reduced by the giving of injections of anti-tetanic serum after wounding from the end of 1914, so that the over-all rate for the period of the war was 1·47 per 1000 wounded. The total number of British cases was 2529. Mortality was 50 per cent in these cases, but death was not necessarily due to tetanus alone.
SECOND WORLD WAR
In the Second World War active immunisation of all troops sent overseas was practised, and the results proved the value of inoculation. There were few cases of tetanus recorded among New Zealanders, although it is not known that any of the soil over which they fought was highly infected.
The procedure for prophylaxis was for each man, shortly after mobilisation, to be inoculated with two doses of 1 ccm. of tetanus toxoid at an interval of six weeks. After a further interval of at least six months a third dose of 1 ccm. was given, with further doses at intervals of a year or less.
As soon as possible after an injury was inflicted each wounded man was given a dose of 3000 international units of anti-tetanus serum (ATS). This was intended to cover any gaps in the protection offered by active immunisation.
There are three reports of cases in 2 NZEF during the war. Captain Borrie recorded two deaths from tetanus at Kokkinia prisoner-of-war hospital in Athens. One was a Maori, but the force to which the other belonged was not stated.1 Both had severe page 134 wounds, no adequate surgery, and had had no ATS after wounding. Both had had tetanus toxoid a year previously. Boyd and Maclennan, RAMC pathologists, in 1942 recorded two cases, both Maoris, one of whom died. The Consultant Surgeon CMF recorded two New Zealand cases in a total of 42 Allied cases in Italy. Both survived. There are no other reports of cases in the 2 NZEF.
This gives a total of a certain five (and possibly six), with two (or three) deaths during the whole period of the war. Two, or possibly three, were wounded in Crete and had no ATS and inadequate surgery. Three were Maoris, two of whom were wounded in Crete, and two died. The report of 2 General Hospital on the Maori who developed tetanus in the hospital eight days after being wounded in Crete stated that a complete recovery followed massive injections of ATS intramuscularly and intravenously.
It would appear that the lack of prophylactic ATS, associated with lack of adequate surgical treatment, together produced a dosage of toxin in the body sufficient to overwhelm the protective barrier produced by the tetanus toxoid injections.
There may also be a relative lack of immunity in the Maori race, but as there appear to have been no further cases after July 1942 this can hardly be a matter of much importance.
Boyd and Maclennan emphasized that early diagnosis must be based on clinical signs and symptoms as bacteriological examination gives no timely positive assistance. They consider that immunisation by tetanus toxoid in three doses has proved eminently satisfactory, but that prophylaxis by ATS and particularly adequate surgical treatment are both still necessary and that massive production of tetanus toxin in the body can still be fatal in spite of immunisation and prophylaxis.
Case Report of Maori Death
CASE 18: New Zealander, Maori. Tetanus toxoid 12 January and 26 February 1941 and 13 April 1942. 14 July 1942 reported sick, with temperature. Later wounded by shrapnel in left arm. No ATS given. Evacuated via Casualty Clearing Station to General Hospital. Temperature at one stage 103° F. 18 July, operated on. Large foreign body removed from arm. Wound dressed with sulphonamide vaseline. 19 July, given 8 grammes sulphonamide. 20 July, transferred to another hospital. Wounds looked clean, arm in sling; noisy and excited. 21 July, again noisy and irritable. Left arm swollen and painful, condition suggestive of cellulitis. Wounds explored with sinus forceps, no frank pus. 22 July, attempted to hit anyone who came near him. Foments applied to left arm. 23 July, more excited, got out of bed and tried to hit another patient. Complained of pain page 135 in chest. Slight twitching of the arm noticed. Temperature 102° F. 24 July, mild toxic spasms began which increased during the day. At 7 p.m. temperature had risen to 107°. Died at 7.45 p.m.
Casualties in reception tent of MDS near Sidi Rezegh, November 1941
Wounded at 5 MDS, Alamein, 24 October 1942
5MDS near Cassino, March 1944
Wounded in the jungle, Nissan Island, January 1944
Bren carrier with wounded at RAP, Senio, APRIL 1945
Patients on stretcher-jeep near Cassino, April 1944
Abdominal case transported with intravenous saline and gastric suction, sedada, Tripolitania, January 1943
Air evacuation, Tunisia, April 1943
Mobile Surgical Unit equipment van, Maadi
1 NZ Field Surgical Unit team amputating a mangled leg in Italy
2 NZ Field Transfusion Unit collecting blood from donors at Tobruk, November 1942
Resuscitation room at 4 MDS, Faenza, January 1945
Application of a Thomas splint and use of Macintosh anaesthetic apparatus, 6 MDS, Cassino, April 1944
Bomb casualty, Alamein, showing traumatic amputation
Abdominal operation, Alamein, 24 October 1942 showing suction apparatus
Operation on severe leg injury, 1 NZ CCS
Nursing sister in tented ward in 1 NZ CCS at Tarnet in January 1943
Tobruk splint applied for fracture of femur, 6 MDS, April 1944
Saline bath unit, 1 NZ General hospital, Helwan, Note precautions against secondary infection
X-ray Department, 3 NZ General Hospital, Beirut
Examples of calipers and splints made by prisoners of war at Lamsdorf
28 NZ Battalion taking showers, Cassino, March 1944
Lecture to anti-malaria squads from New Zealand units in Italy, May 1944
Malaria Control Unit spraying pools, Guadalcanal, 1944
Treatment: ATS on 24 July at 4.30 p.m., 60,000 units partly intravenously partly intramuscularly; at 6 p.m. 90,000 units intramuscularly.
Autopsy: Left forearm and arm greatly swollen; two large wounds on posterolateral aspect of left arm with superficial healing; spiral fracture of middle third of humerus, and all deep muscles showed extensive necrosis, almost colliquative; no actual pus or gas present; liver and kidneys showed toxic changes. Portions of muscle from the upper and lower thirds of triceps, and the deep surface of the trapezius, and a portion of bone-marrow from the humerus all yielded a growth of Cl. tetani, type III. Other anaerobes were present, but have not yet been identified.
J. S. K. Boyd and J. D. MacLennan Lancet, 26 December 1942.
1 Believed to have been an Australian.