The warning signs that a patient is going to get tetanus are irritability, insomnia, increased muscle reflexes, a sore throat, dysphagia and difficulty starting urination. Tremors and spasm if the muscles near his wound follow. If he is fortunate, his disease remains localized, If it spreads, he has trismus, risus sardonicus, respiratory distress, and perhaps hyperpyrexia. Severe convulsions may follow even minor stimuli. Finally, he dies in opisthotonus with widespread muscle rigidity.
The method which follows is mainly that of Sanders and his colleagues from the Duncan Hospital in Bihar. They showed that the addition of low doses of intrathecal horse antitetanus serum (immune globulin was not available) to the standard regime could reduce the mortality from about 15% to about 5% in a crowded district hospital serving some of the world’s poorest people. This regime is more likely to be practicable and may be as effective as attempting to paralyse a patient and ventilate him with intermittent positive pressure respiration (IPPR). If you can keep a patient alive for a month, he will probably recover, but you must sedate him and nurse him well.
Aim to: (1) Remove the source of the toxin by toileting his wound. (2) Sedate him heavily to control his spasms. (3) Nurse him devotedly for as long as is necessary, usually 3 to 4 weeks. (4) Minimize the stimuli which may cause spasms by putting him in a quiet ward and disturbing him as little as possible. (5) Prevent aspiration pneumonia by trying to stop him aspirating his saliva and stomach contents, and by giving him penicillin. This will also prevent Cl. tetani from multiplying.