Sir Charles Bell and the first ever image of Opisthotonos (1809)

The extrapyramidal lesion known as opisthotonos that results from tetanus is most likely best represented by this image. It was created 75 years before the bacteria Clostridium tetani was found to be the cause. Sir Charles Bell (1774–1842) was a Scottish surgeon, anatomist, physiologist, neurologist, artist, and philosophical theologian who gave the medical world terms like Bell’s palsy, Bell’s phenomenon, Bell’s law, and so on. Sir Charles Bell depicted the horror and anguish of Clostridium tetani in his paintings, depicting a soldier locked tight due to agonizing tetany. 

Bell helped soldiers who were hurt in the Battle of Corunna in 1809 so he could learn more about how to treat gunshot wounds. This was one of many battles fought during Napoleon’s long reign. Bell excelled not only with a scalpel but also with a pencil, sketching in detail the wounds caused by bayonets, cannonballs, and musket fire. He would later develop this work into a series of thirteen colored lithographs titled “The Wounded Following the Battle of Corunna.” One of these prints, “Tetanus Following Gunshot Wounds,” is the most well-known and harrowing of the series, and serves as a striking testament to one of the more deadly and excruciating consequences of a bullet. 

I. Harrison, a doctor who treated a tetanus-infected infant in 1859, described the clinical presentation of tetanus, which Bell perfectly captures. 

This drawing tells the wrinkled forehead; the elevated brow; the closed eye; the dilated nostril; the rigid masseter; the fixed jaw; the closed mouth; the corrugated lips; the bubbling saliva; the retracted head; the shortened neck; the starting cervical muscles; the turgid veins; the arched spine; the raised chest; the troubled breathing; the catching diaphragm; the heaving abdomen; the separated arm; the squared elbow; the bent wrist; the clenched fingers; the incurved thumb; the extended and separated legs; the bent down toes; the livid surface; the whole figure rigid as wood – a pitiful sight.

I. Harrison
“Tetanus Following Gunshot Wounds” by Sir Charles Bell (1809).

The effective, inactive Tetanus Toxoid was found 129 years after Bell’s famous illustrated book. During World War II, the military used it to keep soldiers from getting tetanus. Following the DTP regime, the DTaP vaccine was introduced in 1992. (1948–1991). Before the vaccine, there were approximately 550 cases of tetanus per year in the United States, which decreased to approximately 30 cases per year in the 2000s after the vaccine was introduced. Until a few decades ago, India reported 150,000 to 200,000 neonatal tetanus cases per year before dropping to around 31,500 deaths in 2005 and under 500 in 2013 and 2014. This is against a backdrop of 26 million births in India each year. 

In 2017, a 6-year-old boy who had not been immunized received a cut on his forehead while playing outside on a farm. At home, the cut was cleaned and stitched. Six days later, he began to cry, clench his jaw, and experience uncontrollable upper-extremity muscle spasms. Next came neck and back arching (opisthotonus), then generalized spasticity. Later that day, when his breathing became difficult, his parents called emergency medical services, who airlifted him to a tertiary pediatric medical center. The boy was eventually diagnosed with tetanus. 

This is Oregon’s first pediatric tetanus case in more than 30 years (unpublished data, Oregon Health Authority, 2018). The health-care costs to treat this child’s preventable disease were approximately 72 times the mean (2012) cost of a pediatric hospitalization in the United States. In the United States, 197 tetanus cases and 16 tetanus-related deaths were reported between 2009 and 2015. Unvaccinated or inadequately vaccinated people, regardless of age, are at risk for tetanus, and recovery from tetanus disease does not confer immunity. 

All eligible children should receive a 5-dose DTaP series at 2, 4, and 6 months of age, followed by a dose at 15–18 months of age and a fifth dose at 4-6 years of age. Every ten years, booster doses of diphtheria and tetanus toxoids are recommended.

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