History and Geography

The term tetanus is from the Greek verb tano, meaning "to stretch." Hippocrates described three varieties of the infant disease. Aristotle noted infant convulsions that occurred before the seventh day. Galen first named the disease trismus. Moschion (Muscio), writing about three centuries later, claimed that it was caused by stagnant blood in the umbilical cord, as did André Levret and others some 1,500 years after Galen. Indeed, by the early nineteenth century, doctors were still attributing neonatal tetanus to this cause as well as a variety of others, including irritation within the intestinal canal, poverty, filth, poor diet, falls, impure atmosphere, rough handling, a vaginal disease, cold or sea air, costiveness, smoke from chimneys, and mismanagement by female mid-wives. In 1793 M. Bartram of South Carolina ascribed the disease to the umbilicus, and his theory generated much debate. Some physicians urged cleanliness and washing the umbilicus with a weak solution of silver nitrate and dressing the area with an ointment formed of lard and lead acetate.

But attention strayed again from the umbilicus. A study at the Dublin Lying-in Hospital in 1782 noted that of 17,650 infants born, 2,944 died within a fortnight from neonatal tetanus. The institution's impure atmosphere and poorly ventilated chambers were blamed for the high rate. In 1846 J. Marion Sims concluded that a depression of the occipital bone during birth caused the disease, and he urged his colleagues to observe bone formation closely in newborns.

In 1818 Abraham Colles, however, first noted the similarity between neonatal tetanus and tetanus and attributed its incidence to inflammation and ulceration of the umbilicus. He suggested that air be purified, that the umbilicus be dressed with spirits of turpentine, and that the baby be plunged into cold water. Efforts were made to bleed patients to remove the noxious influences and produce relaxation. During the nineteenth century, accounts demonstrate a

99 percent fatality for those who were affected. No disease of infancy was more fatal, and few parents saw any reason to call a doctor.

The bacterial theories of Louis Pasteur and Robert Koch have been important in eradicating the disease in the twentieth century. In 1884 Arthur Nicolaier found the bacillus in soil, and was able to produce the disease in animals. He found the same bacillus in human wounds. Shibasaburo Kitasato (1889) obtained the germ in pure culture. The tetanus toxoid was first used effectively during World War II. Immunization, along with the benefits of urbanization and industrialization, and a rise in the standard of living, have helped to eradicate the disease from developed nations.

Another preventive measure evolved when in 1923 C. T. Broeck and J. H. Bauer showed that tetanus antitoxin could cross the placenta. L. Nathan-Larrier, G. Ramon, and E. Grassett (1927) suggested that this could protect the newborn from tetanus by providing passive immunity. Later F. D. Schofield, G. R. West-brook, and V. M. Tucker (1961), studying the disease in New Guinea, and K. W. Newell and others in Colombia (1964), proved that immunizing a pregnant woman with two or three injections of tetanus toxoid would decrease incidence of the disease. Unfortunately, it is difficult to provide such medical services to the people who need it most.

The World Health Organization continues to monitor the incidence of neonatal tetanus, to survey mortality rates of home and clinic deliveries, and to hold worldwide conferences to discuss means for improving the care of newborns. Its goal is to eradicate neonatal tetanus by the year 2000.

Sally McMillen

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