Locked jaw

By Tedler D. Depaynos, MD

“ Children are very prone to wound infections as they play on the grounds so that tetanus immunization is part and parcel of pediatric health programs. For those with children or “apos” who are below 7 years old and are not immunized, better consult your pediatrician. Prevention is far better than cure…”

It was a surprise call from a prominent coffee mate who just retired and presently busy developing his newly acquired beach house that reminded me of the tetanus case I saw decades ago. He accidentally hurt himself with a rusted metal and because of the possibility that he might get infected with “tetanus”, he rushed himself to a nearby Hospital Emergency Room. It was then that he called me up inquiring about the treatment that he received if it was adequate. He appeared jittery so I had to assure him that his treatment was excellent.
I was still in medical school which seemed not so long ago when I saw a patient with the classical “Tetanus” I could not forget. We were rotating then at San Lazaro Hospital in Metro-Manila as part of our exposure to medical cases which were absent or rare in our medical school hospital.
The patient had a “locked jaw” and appeared to be continuously “smiling” despite a tongue depressor placed in between his teeth to prevent him from biting his tongue. He was having severe spasm of his facial muscles. His neck and back muscles were likewise severely contracting so that he was fully stretched in bed. His eyes were widely open staring blindly at us and despite the muscle relaxants and mild sedating medicines given to him his spastic muscles were still obviously making his breathing laborious relieved only by the oxygen tubes inserted in his nostrils. A tracheostomy tube and instruments however were placed on the bedside in case of emergency. The ward was darkened and no visitors allowed and we were warned to only whisper and not cause unnecessary noise or else the patient’s spastic condition would worsen..
The above classical manifestations were due to the exotoxin called “tetanospasmin” secreted by the anaerobic bacteria called Clostridium Tetani. In simple layman’s terms, the patient had “Tetanus”. The bacteria in the form of “spores” are found in soil and in the feces of domestic animals and humans. In an anaerobic or unoxygenized environment, they easily germinate. A simple dust may be contaminated and if it lands on an opened wound, the patient may get infected. We heard of newly delivered babies dying of the disease because of the use of unsterilized instruments in cutting the cord. Some elderly rural practitioners recall that they encountered cases of umbilical cord being cut with bamboo sticks being done by “hilots” after delivering the babies. The belief was that the cutting should not be done by metallic instruments. Obviously, this is no longer a practice and besides, there is already extensive rural deployment of doctors, nurses, midwives and other rural health practitioners trained in delivering babies .
As a rule therefore in preventing not only infection but the more serious “tetanus”, traumatic wounds are cleansed of foreign bodies and debrided to remove the devascularized and necrotic tissues which may provide an anaerobic environment. Since the bacteria are anaerobic, their exposure to oxygen maybe fatal to them. Deep penetrating wounds like stab wounds are then more prone to this anaerobic infection. Antiseptics are routinely applied but manual wound cleansing is more effective and should be done the earliest possible time because the incubation period of the disease from our old standard textbooks may be as early as 3 days and as late as 20 days.
Immunizations then routinely follow. Passive immunization is done by using human immunoglobulins and active immunizations by using horse serum. The former directly attack the Clostridial toxins while the latter stimulates the body to produce antibodies that would eventually attack the remaining toxins. Hence, both are usually given at the same time but through different injection sites.
The use of antibiotics is mainly for the other bacteria expected to infect the wound but if ever an antibiotic is used against the tetanus bacilli, the drug of choice is one that is effective against the anaerobes and an example is the classical metronidazole. At present, however, expensive but more effective antibiotics may be prescribed by younger MDs which was done to my inquiring coffeemate .
Children are very prone to wound infections as they play on the grounds so that tetanus immunization is part and parcel of pediatric health programs. For those with children or “apos” who are below 7 years old and are not immunized, better consult your pediatrician. Prevention is far better than cure. My coffeemate was with smiles because he still had no “apo”. **

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