Bell’s Opisthotonos

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

This is probably the most famous image of opisthotonos, due to the extrapyramidal lesion caused by tetanus, created 75 years before the discovery of its causative bacteria Clostridium tetani. The painting was the creation of Sir Charles Bell (1774-1842), a Scottish surgeon, anatomist, physiologist, neurologist, artist & philosophical theologian, who gifted medical world the terminologies like Bell’s Palsy, Bell’s phenomenon, and Bell’s law etc. The horror and anguish of Clostridium tetani was depicted by Sir Charles Bell in his paintings, in which he illustrated a soldier locked tight due to agonising tetany.

In 1809, for the purposes of studying gunshot wounds, Bell volunteered to operate on battle-tested soldiers in the Battle of Corunna, one of many in the long saga of the Napoleonic Wars. Bell flourished not only a scalpel, but also a pencil, making detailed sketches of the wounds caused by bayonets, cannon-balls and musket fire. He would later elaborate this work into thirteen colored lithographs for a series – “The Wounded Following the Battle of Corunna.” One of these prints, the above image – “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 complications from a bullet. Bell captures the clinical presentation of tetanus flawlessly, as described by I. Harrison, a physician, who treated an infant sickened with tetanus in 1859. 

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

129 years after Bell’s famous illustrated work, the effective, inactive Tetanus Toxoid was discovered and was proven to be successful when it was used to prevent tetanus in the military during World War II. DTaP vaccine was introduced in 1992, post DTP regime (1948 – 1991). In the 1940s, before the vaccine, there were about 550 cases of tetanus per year in the United States, which has decreased to about 30 cases per year in the 2000s after the introduction of the vaccine. Until a few decades ago, India reported 150,000 to 200,000 neonatal tetanus cases annually, before the decline to about 31,500 neonatal tetanus deaths in 2005, and below 500 in 2013 and 2014. This is against the backdrop of a cohort of 26 million births every year in India.

In the recent past, in 2017, a boy aged 6 years who had received no immunizations sustained a forehead laceration while playing outdoors on a farm; the wound was cleaned and sutured at home. Six days later, he had episodes of crying, jaw clenching, and involuntary upper extremity muscle spasms, followed by arching of the neck and back (opisthotonus) and generalized spasticity. Later that day, at the onset of breathing difficulty, the parents contacted emergency medical services, who air-transported him directly to a tertiary pediatric medical center. The boy subsequently received a diagnosis of tetanus.

This is the first pediatric tetanus case in >30 years in Oregon (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 $11,143 for a U.S. pediatric hospitalization. From 2009 to 2015, 197 tetanus cases and 16 tetanus-associated deaths were reported in the United States. Unvaccinated or inadequately vaccinated persons are at risk for tetanus, irrespective of age, and recovery from tetanus disease does not confer immunity.

Routine administration of a 5-dose DTaP series is recommended for all eligible children at 2, 4, and 6 months of age, then a dose at 15–18 months of age, and a fifth dose at 4–6 years of age. Booster doses of diphtheria and tetanus toxoids are recommended every 10 years throughout life.


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