Tetanus

Summary

Stuff You Missed in History Class: Tetanus
Hosted by Holly Fry and Tracy V. Wilson
Release Date: May 12, 2025

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Introduction to Tetanus

In the episode titled "Tetanus," hosts Holly Fry and Tracy V. Wilson delve deep into the history, biology, and societal impact of tetanus—a disease that has plagued humanity for centuries but remains a significant health concern in certain parts of the world.

Holly Fry opens the discussion by setting the stage:

"Tetanus has probably been around for most of human history, possibly even longer." [05:20]

Ancient Descriptions and Early Understanding

The conversation begins with an exploration of tetanus in ancient medical texts.

Tracy V. Wilson references the Edwin Smith Surgical Papyrus, dating back to around 1500 BCE, describing a patient with symptoms resembling tetanus:

"His mouth is bound, both his eyebrows are drawn, while his face is as if he wept." [06:05]

Holly Fry adds context, clarifying that while the papyrus describes symptoms similar to tetanus, some manifestations like bleeding from the ears or nose were likely due to head trauma rather than the tetanus infection itself.

"Tetanus doesn't cause bleeding from the ears or nose. That was probably a product of the patient's head trauma, not the tetanus that followed it." [06:05]

Further, they discuss the Sashruta Samhita from around the 6th century BCE, a foundational text of Ayurvedic medicine, which describes a disease analogous to tetanus:

"This disease rarely yields to medicine and is cured in rare instances only with the greatest difficulty." [07:47]

Tracy also touches upon the Yellow Emperor's Classic of Internal Medicine, noting that while it doesn't explicitly mention tetanus, its descriptions align closely with tetanus symptoms:

"Opisthotinous stiffness in the back, convulsive spasms, paleness, and spontaneous sweating. Once that sweating stops, the patient dies." [08:42]

Greek and Roman Contributions

The hosts highlight Hippocrates' detailed accounts of tetanus in his treatises.

Holly cites Hippocrates' description:

"Jaws are fixed and he is unable to open his mouth. His eyes shed tears and look awry." [09:36]

Tracy elaborates on the different types of tetanus Hippocrates identified, emphasizing the severity and often fatal outcomes of the disease:

"He described this disease as severe and requiring immediate attention and in many cases, fatal." [10:31]

Tracy also references Roman author Aulus Cornelius Celsus' depiction of tetanus:

"There is no disease more distressing and more acute than that which by a sort of rigor of the sinews..." [11:35]

Medieval to Early Modern Period

The discussion moves through centuries of European medical understanding, noting that treatments largely remained symptomatic and ineffective.

Holly remarks on the continuity of tetanus descriptions:

"Many physicians based their work on Hippocrates. Even if Hippocrates wasn't cited, they still usually described tetanus as following a wound." [12:08]

19th Century Breakthroughs

Significant advancements in understanding tetanus arose in the 19th century.

Tracy discusses Luigi Carlo Ferrini's 1838 experiments with electricity in treating tetanus:

"The application of direct current to the body of a patient who had developed tetanus after a gunshot wound seemed to interrupt the spasms." [17:04]

Holly and Tracy continue by highlighting Antonio Carle and Giorgio Rittone's 1884 experiments demonstrating the contagious nature of tetanus in animals, even though tetanus itself isn't transmitted person-to-person:

"Clostridium tetani can survive freezing and being autoclaved at high temperatures." [18:34]

Tracy introduces Arthur Nicolier, who identified the tetanus bacillus in soil:

"He concluded that the bacillus produced a poison that acted similarly to strychnine." [19:16]

Kitasato Shibasaburo and Emil von Behring’s Contributions

The episode underscores the pivotal work of Kitasato Shibasaburo and Emil von Behring in isolating the tetanus bacillus and developing antitoxins.

Holly explains Kitasato’s challenges and breakthroughs:

"Clostridium tetani is an anaerobic microorganism. So doing this required Kitasato to develop new methods for growing bacteria while also keeping them isolated from the air." [20:33]

Tracy details their collaborative research:

"The immunity of rabbits and mice which have been immunized against tetanus depends on the ability of the cell-free blood fluid to render harmless the toxic substance which the tetanus bacillus produces." [21:26]

Holly further describes their experiments:

"Every rabbit remained healthy. These rabbits could withstand a dose of toxin that was 20 times higher than what it would take to kill an untreated rabbit." [22:02]

Despite their groundbreaking work, von Behring received the first Nobel Prize in Physiology or Medicine in 1901 solely for his work on diphtheria, with no mention of Kitasato’s contributions.

"Since the Nobel Prize committee was focused on diphtheria and not tetanus, Kitasato was not included in the award or mentioned in the speech." [23:09]

World War I and the Rise of Antitoxin Use

The narrative transitions to the application of tetanus antitoxins during World War I.

Holly recounts the severe impact of tetanus on soldiers:

"There had been 505 reported cases during the U.S. civil War with a mortality rate of 89%." [25:32]

Tracy emphasizes the advancements made by Edmond Nocard in producing and distributing antitoxin serum:

"By 1918, the institute had nearly 1,500 horses, producing more than 600,000 vials of antitoxin per month." [31:10]

Holly discusses the treatment protocols developed:

"Treatment started with treating the wound itself, excising all wounds and removing all the damaged tissue, ideally within 12 hours of the injury." [32:48]

They highlight the effectiveness of antitoxins in reducing tetanus cases among soldiers:

"By the end of the war, tetanus rates among injured soldiers had been almost completely eliminated." [36:45]

Development and Impact of the Tetanus Vaccine

The discussion moves to the creation and implementation of the tetanus vaccine.

Holly introduces Gaston Ramon's development of the first tetanus vaccine in 1924:

"This vaccine is known as tetanus toxoid. A toxoid is a toxin that's been inactivated so that it's no longer dangerous." [36:45]

Tracy explains how the vaccine works and its widespread adoption during World War II:

"During World War II, tetanus toxoid became a routine vaccine administered to soldiers, and then it became more widely available to the general public after the war was over." [37:10]

Decline of Tetanus in Developed Countries

With the introduction of vaccines, tetanus cases began to decline sharply in wealthier nations.

Holly notes:

"Deaths from tetanus have decreased by 99% in the US since 1947." [37:47]

Tracy discusses the current state of tetanus prevention:

"Today, the World Health Organization recommends a six-vaccine series that stretches over a person's infancy, childhood, and adolescence." [39:14]

Persistent Challenges and Global Impact

Despite significant progress, tetanus remains a major health issue in poorer regions and in specific contexts.

Holly points out that tetanus cannot be eradicated due to its ubiquitous presence in soil and resilience of its spores:

"Tetanus spores are basically all around all the time, and recovering from tetanus doesn't make you immune to it later on." [39:14]

Tracy highlights the ongoing challenges faced in eliminating maternal and neonatal tetanus:

"Even with the success of the Maternal and Neonatal Tetanus Elimination Initiative, around 25,000 newborns still died of neonatal tetanus in 2018." [42:08]

Conclusion

Holly and Tracy wrap up by emphasizing the importance of continued vaccination efforts and public health initiatives to combat tetanus, especially in vulnerable populations and regions lacking robust healthcare systems.

Tracy reflects on the global efforts:

"Between 1998 and 2018, tetanus rates in newborns dropped by about 97% around the world thanks to these programs." [42:08]

Holly concludes:

"The closest thing to eradication is ensuring broad vaccine coverage so that people who are exposed to tetanus bacteria don't develop the disease." [39:14]

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Notable Quotes

• "Tetanus has probably been around for most of human history, possibly even longer." — Holly Fry [05:20]

• "This disease rarely yields to medicine and is cured in rare instances only with the greatest difficulty." — Tracy V. Wilson [07:47]

• "There is no disease more distressing and more acute than that which by a sort of rigor of the sinews..." — Aulus Cornelius Celsus [11:35]

• "Every rabbit remained healthy. These rabbits could withstand a dose of toxin that was 20 times higher than what it would take to kill an untreated rabbit." — Holly Fry [22:02]

• "By the end of the war, tetanus rates among injured soldiers had been almost completely eliminated." — Tracy V. Wilson [36:45]

• "Deaths from tetanus have decreased by 99% in the US since 1947." — Holly Fry [37:47]

• "Tetanus spores are basically all around all the time, and recovering from tetanus doesn't make you immune to it later on." — Holly Fry [39:14]

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This episode provides a comprehensive overview of tetanus, tracing its historical accounts, scientific breakthroughs, and the ongoing efforts to combat it globally. Through engaging dialogue and detailed research, Holly and Tracy illuminate the strides made in understanding and preventing tetanus, while also shedding light on the areas that still require attention.

Transcript

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[Holly Fry]

Welcome to Stuff youf Missed in History Class, a production of iHeartRadio.

[Tracy V. Wilson]

Hello and welcome to the podcast. I'm Tracy V. Wilson.

[Holly Fry]

And I'm Holly Fry.

[Tracy V. Wilson]

Hey, I'm thinking about vaccines a lot right now for reasons including rapidly growing measles outbreak that we have happening in the US right now. I originally had numbers of cases here in the outline, but that number increased by like 200 just in the time that I was working on this.

[Holly Fry]

Yeah, it's impossible to track. By the time this comes out, those numbers would be woefully outdated.

[Tracy V. Wilson]

Yeah, two more weeks are going to pass before this is out, so those numbers would be wrong anyway by then. Also, just a lot of upsetting and alarming developments happening in the U.S. department of Health and Human Services and the National Institute of Health. We have already done an episode on measles that came out on February 28th of 2024 and that's a little bit more recent than we would typically rerun as a Saturday classic. So I decided to take a look at another disease that's preventable today thanks to vaccines, which do not cause autism. Not any vaccine, not forensic disease, none of them cause autism. The disease though is tetanus. Since this is an episode about a medical development, of course there will be some medical experiment stuff in the episode, including some experiments involving animals. I really don't think any of that is particularly graphic, but just in case.

[Holly Fry]

Yeah, I can handle it based on my read through, which is a pretty low bar of getting upsetness. So I think we're safe. But if not, I'm sorry. Tetanus has probably been around for most of human history, possibly even longer. It's caused by the bacterium Clostridium tetani, which is present in the environment in a lot of the world. It's described with words like ubiquitous. In the words of John Sundwal in a lecture given under the auspices of the Kansas Academy of science in 1917. This germ has a wide distribution and its spores are found wherever there is dirt. Barnyards are veritable repositories for them. Rusty nails appear to be rendezvous. Even the dirt that besmears the healthy living child may contain millions of these spores of tetanus bacilli. The spores can only grow when they gain deep entrance into the body and are shut off from oxygen.

[Tracy V. Wilson]

One of the oldest known medical texts in the world is the Edwin Smith Surgical Papyrus, named for Edwin Smith, who bought it in 1862. This Egyptian medical text dates back to about 1500 BCE, and it includes a description of somebody with a head injury that penetrated all the way through the sutures of the skull. Afterward, according to one translation, the cord of his mandible is contracted, his he discharges blood from both his nostrils and from both his ears, while he suffers with stiffness in his neck. As this patient's condition progresses, his mouth is bound, both his eyebrows are drawn, while his face is as if he wept.

[Holly Fry]

This earliest description is usually translated and interpreted as describing a case of tetanus, but it doesn't entirely convey what tetanus is like as an illness. Tetanus doesn't cause bleeding from the ears or nose. That was probably a product of the patient's head trauma, not the tetanus that followed it. Beyond that, without getting into a lengthy backgrounder on neurotransmitters, clostridium tetani produces two toxins, and one of them, called tetanospasmin, interferes with neurotransmitters that control motor neuron activity. The nerves start firing uncontrollably, which causes intense muscle spasms. These can be excruciating and powerful enough to cause compression fractures or other breaks in a person's bones. Tetanus can also lead to suffocation and heart failure. Even with medical treatment, tetanus is fatal between 10 and 20% of the time, and without treatment, the fatality rate goes up to 85% or even more.

[Tracy V. Wilson]

It sounds awful.

[Holly Fry]

Yes, it does.

[Tracy V. Wilson]

The muscles in the face and the jaw are often affected in tetanus, and that can cause a person to look like they are grinning. The spasms also cause trismus, also known as lockjaw, and that can make it difficult or impossible for the person to open their mouth. The Edwin Smith Papyrus offers a way to try to deal with this lockjaw. That's by placing a wooden brace padded with linen in the patient's mouth to try to keep it open enough that they can be fed a liqu diet while being kept upright.

[Holly Fry]

Tetanus also appears in the Sashruta Samhita, which dates back to about the 6th century BCE and is one of the foundational texts of Ayurvedic medicine. We did an episode on sashruta in January of 2019 in a chapter on diseases of the nervous system. The Sashruta Samhita describes one caused by enraged or agitated vayu. That's the air element in Ayurvedic medicine. This disease rarely yields to medicine and is cured in rare instances only with the greatest difficulty, its characteristic symptom being a paralysis of the jawbone, which makes deglutition extremely difficult. This disease in the text is described as bending the body like a bow, and in its extreme form, fixing the eyes in their sockets, paralyzing the jaw and breaking the sides.

[Tracy V. Wilson]

The Chinese medical text known as the Yellow Emperor's Classic of Internal Medicine is attributed to a semi mythical figure who's described as living around 2600 BCE, but it was probably written more than 2000 years later than that. Traditional Chinese medicine incorporates the idea of energy channels or meridians in the body. The translation of the Yellow Emperor's Classic that I had access to for research didn't use the word tetanus anywhere, but it describes the collapse of the qi in the bladder and small intestine meridian as causing opisthotinous stiffness in the back, convulsive spasms, paleness, and spontaneous sweating. Once that sweating stops, the patient dies. Aposthotinous is the extreme, very arching spasms that are associated with tetanus.

[Holly Fry]

The first thing we'd think of as a really clear clinical description of tetanus from a more Western medical perspective is from Greek physician Hippocrates, written around the 5th century BCE. In a treatise on internal afflictions, Hippocrates describes three types of tetanus. First, when it follows a wound, Hippocrates says the patient's quote, jaws are fixed and he is unable to open his mouth. His eyes shed tears and look awry. His back becomes rigid, he cannot bend his legs, nor his arms and spine. Hippocrates describes this disease as severe and requiring immediate attention and in many cases, fatal. For treatment, Hippocrates advises anointing the patient with warm oil infused with wormwood, bay leaves or henbane seed with frankincense soaked in white wine.

[Tracy V. Wilson]

According to Hippocrates, the second type of tetanus is similar, but it starts with angina, also pronounced angina, that's chest pain, or with a staph infection or separation of the tonsils. And occasionally it can also start with a wound. This patient is drawn backwards and cries aloud from the pain in his back and chest. He is drawn so forcefully that the attendants can hardly prevent him from falling out of bed. Bed. Then the third form is less lethal, arising from some of the same possible causes or from having fallen backward.

[Holly Fry]

Another work by Hippocrates, called On Epidemics, also includes several examples of tetanus cases. One developed after a surgery, another after a javelin wound, after a person's finger was crushed by an anchor after an ankle injury whose treatment involved irritating the wound after being injured by a piece of wood from a missile thrown by a catapult.

[Tracy V. Wilson]

In the words of Roman author Alice Cornelius Celsus in the first century CE quote there is no disease more distressing and more acute than that which by a sort of rigor of the sinews, now draws down the head to the shoulder blades, now the chin to the chest, now stretches out the neck, straight and immobile. The Greeks call the first Aposthotonous, the next Empress Thotinus, and the last tetanus, although some with less exactitude use these terms indiscriminately.

[Holly Fry]

For centuries after this, European medical writing on tetanus tended to be really similar. Many physicians based their work on Hippocrates. Even if Hippocrates wasn't cited, they still usually described tetanus as following a wound. Most commented on how often the condition was fatal, and many of the recommended treatments related to things that one might hope would relieve the spasms, like being rubbed with oils or wines or liniments, or wrapped in warm dressings or given warm baths. In the 16th century, past podcast subject Amboise Par developed an instrument to open a tetanus patient's mouth so that they could be fed. Overall, the focus was on trying to get the muscles to relax and supporting the patient with the hope that they would recover, but often a certainty that they would not.

[Tracy V. Wilson]

Knowledge of the cause of tetanus and how to treat and prevent it didn't really start to advance until the 19th century, which we will get to after a sponsor Breaking News T Mobile Network.

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[Tracy V. Wilson]

As we said before the break, people figured out that tetanus was connected to wounds thousands of years ago. But it wasn't until the 19th century that we started to get a sense of exactly what was happening inside those wounds and elsewhere in the body. In 1838, Luigi Carlo Ferrini gave an address before the Medical Churchical Society of Bologna in which he described the use of electricity in the treatment of tetanus. He had based this on the work of Carlo Medici, who was experimenting with electricity and frogs. Farini found that the application of direct current to the body of a patient who had developed tetanus after a gunshot wound seemed to interrupt the spasms. Unfortunately, this effect was temporary. It lasted only about 30 minutes. This didn't really provide a breakthrough in the understanding of tetanus, but it was connected to the electrical activity of the neurons that is part of the disease.

[Holly Fry]

Several discoveries were made in 1884. Italian scientists Antonio Carle and Giorgio Rittone had both studied medicine in Turin. They exposed a rabbit to fluid from a sore from someone who had died of tetanus. And that rabbit also developed tetanus. This showed some kind of contagion was causing the disease. But to be clear, tetanus is not transmitted from person to person.

[Tracy V. Wilson]

You would have to really do something on purpose like this. Also in 1884, Arthur Nicolier, who was a 22 year old medical student in Germany, identified a bacillus in the soil. If you look at this bacillus under a microscope, it looks kind of like a tiny straight pen. There's this rod like bacillus with a knob on the end. That knob is the spore. Today we know that these spores are incredibly hardy, they are resistant to most disinfectants, and they can survive freezing and being autoclaved at a temperature of 121 degrees Celsius, or 249.8 Fahrenheit for 10 or 15 minutes.

[Holly Fry]

Nicolier induced tetanus in mice by injecting them with soil that was contaminated with this spore forming bacillus. He concluded that the bacillus produced a poison that acted similarly to strychnine. Within a few years, multiple researchers all concluded that this bacillus could produce a toxin.

[Tracy V. Wilson]

While Nicolier was able to find the tetanus bacillus in the soil, he was not able to isolate it in a lab. Credit for that goes to Japanese physician and bacteriologist Kitasato Shibasaburo in 1889. Kitasato was born in Japan and had earned his medical degree from the University of Tokyo Medical School in 1883. Two years later, the Japanese government had sent him to the Institute of Hygiene in Berlin to study bacteriology and infectious diseases with groundbreaking microbiologist Robert Koch. It was while in Berlin that Kitasato isolated the tetanus bacillus. Clostridium tetani is an anaerobic microorganism. So doing this required Chitasato to develop new methods for growing bacteria while also keeping them isolated from the air.

[Holly Fry]

Kita Sato started working with physiologist Emil von Behring, who is from West Prussia in what's now Germany. While Kita Sato was studying tetanus, von Behring was studying diphtheria. We have talked about diphtheria in our episode on the gnome serum run that ran as a Saturday classic on January 22, 2022. These diseases have some similarities. They're both caused by bacteria producing toxins, rather than by those bacteria reproducing and proliferating within the body. This is one reason why still today, there's no definitive lab test for tetanus once a person has developed symptoms. Tetanus bacteria are found in their wound only about 30% of the time. And the bacteria can also be present in the wounds of people who have no symptoms and never develop the disease.

[Tracy V. Wilson]

In 1890, Kitasato and von Behring published a paper titled the Mechanism of Immunity in Animals to Diphtheria and Tetanus. This paper described a method they had found to prevent tetanus in healthy animals. From an English translation of the paper, they summed it up in a sentence, quote, the immunity of rabbits and mice which have been immunized against tetanus depends on the ability of the cell free blood fluid to render harmless the toxic substance which the tetanus bacillus produces.

[Holly Fry]

In their experiments, these two men exposed animals to a weakened version of the toxin, gradually building up their immunity. Then they did a series of experiments to show that the blood serum of these animals could neutralize the toxins in other animals. In other words, the Serum contained antitoxins, also called antibodies.

[Tracy V. Wilson]

Kitasato and von Behring injected rabbits with serum that contained these antibodies, and then they exposed the rabbits to an amount of tetanus bacteria that had previously been proven to be fatal. Every rabbit remained healthy. And then the same was true if the treated rabbits were injected with tetanus toxin instead of with the bacteria that produce it. These rabbits could withstand a dose of toxin that was 20 times higher than what it would take to kill an untreated rabbit. Kitasato and von Behring also said that the serum from these immune animals could be used as a therapeutic treatment on animals that had already developed tetanus.

[Holly Fry]

A week after this paper was published, von Behring published another paper on his own, which was focused only on diphtheria, and the work he started eventually led reliable treatment for that disease. He was awarded the Nobel Prize in Physiology or Medicine for this work in 1901, the first time that prize was ever awarded. Since the Nobel Prize committee was focused on diphtheria and not tetanus, Kitasato was not included in the award or mentioned in the speech.

[Tracy V. Wilson]

Side note. Kitasato left Germany in 1891, returning to Japan and establishing his own laboratory that was later subsidized by the Japanese government. Then, in 1894, he was sent to Hong Kong during an epidemic of bubonic plague. There, he isolated and identified the bacillus that was causing that disease. A couple of days before, Swiss researcher Alexandra Yersin made the same discovery. Although Kitasato published his work on this first, Yersin's was seen as more conclusively linking the disease to the bacillus. And that bacillus today is known as Yersinia pestis after him.

[Holly Fry]

Kitasato and von Behring had made definitive connections between tetanus bacteria, the toxin it produced, and the protective value of blood serum from animals that had developed an immunity to that toxin. But their work was with small animals like rabbits, guinea pigs and mice. It didn't immediately lead to workable treatments for humans with or for other large animals.

[Tracy V. Wilson]

That started to change in 1895, when Edmond Nocard reported success with horses. Tetanus bacteria really thrive in horse manure, so tetanus could be a serious problem for cavalry units, farmers, basically anywhere that there were lots of horses. Nelcard was a veterinarian, a veterinary professor and a biologist who had worked with Louis Pasteur. After his initial success, Nocard produced about 7,000 vials of anti tetanus serum, and he distributed it among his veterinary colleagues. The first anti tetanus serums used in humans followed not long afterward.

[Holly Fry]

Throughout history, one of the groups most at risk for tetanus infection has been newborn babies. But among medical researchers in the late 19th century, tetanus was more often thought of as a hazard on the battlefield. There had been 505 reported cases during the U.S. civil War with a mortality rate of 89%, and 350 reported cases during the Franco Prussian War with a mortality rate of 90%. Tetanus became a bigger threat during World War I, which started about 20 years after no card's discoveries. And we'll get into that after a sponsor break.

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[Therapy Gecko]

Use as directed.

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Individual results may vary.

[Therapy Gecko]

I found out I was related to.

[Talkspace Advertiser]

The guy that I was dating. I don't feel emotions correctly.

[Holly Fry]

I am talking to a felon right.

[Tracy V. Wilson]

Now and I cannot decide if I like him or not.

[Therapy Gecko]

Those were some callers from my call in Podcast Therapy Gecko. It's a show where I take real phone calls from anonymous strangers all over the world as a fake Gecko therapist and try to dig into their brains and learn a little bit about their lives. I know That's a weird concept, but I probably promise it's pretty interesting if you give it a shot. Matter of fact, here's a few more examples of the kinds of calls we get on this show.

[Tracy V. Wilson]

I live with my boyfriend, and I found his piss jar in our apartment. I collect my roommate's toenails and fingernails.

[Talkspace Advertiser]

I have very overbearing parents. Even at the age of 29, they don't let me move out of their house.

[Therapy Gecko]

So if you want an excuse to get out of your own head and see what's going on in someone else's head, search for therapy gecko on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts. It's the one with the green guy on it.

[Talkspace Advertiser]

This week on Dear Chelsea with me, Chelsea Handler. Connie Britton is here. I think you should encourage your friend.

[Tracy V. Wilson]

To go ahead and not be holding out for any man to have her babies. If she is passionate about becoming a mother and she has her eggs frozen.

[Talkspace Advertiser]

And she has her life together, go for it. She could be waiting another 10 years before she finds the right guy. Connie didn't meet her right guy until you were what, 50, Connie?

[Tracy V. Wilson]

How long have you guys been together? Yeah, no, 52. 52. 52. I adopted my son as a single mom because I kept thinking, oh, I'm going to meet the guy. I'm going to meet the guy. I'm going to meet the guy. I finally was like, what am I waiting for? And I did it. And I'm just so glad that I did. I want to change the narrative about single parents and also help to create a community for single parents so that they can not feel alone in it. One of the big things is it's so hard, especially for women to ask for help.

[Talkspace Advertiser]

Listen to Dear Chelsea on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

[Tracy V. Wilson]

Earlier in the episode, we read from a lecture given by John Sundwal in 1917. Here is something else that lecture had to say about tetanus. Quote. It is known as the Fourth of July bacillus. It was once a custom to exhibit our copious and excessive patriotism with every form of pyrotechnic art. Frequently, premature explosions of the firecrackers, etc. Drove the accumulated dirt on the hand with its numerous spores deep into the skin. And as a rule, the obituary column of the local press within a few days would announce the subsequent fate of many of our little patriots.

[Holly Fry]

This basic idea also applied to the battlefield during World War I. Advances in munitions and explosive meant that more soldiers were being struck with shrapnel and debris that could drive tetanus spores deep into their bodies a lot more often. The proliferation of trench warfare also meant that more soldiers were developing conditions like trench foot and frostbite, both of which could lead to breaks in the skin that could provide an entry point for tetanus bacteria. Over the course of the war, doctors also concluded that infections with aerobic bacteria could facilitate tetanus infections by consuming the oxygen in a wound, leaving an environment that was hospitable to the anaerobic tetanus bacillus.

[Tracy V. Wilson]

In the years before the war, researchers had started producing tetanus antitoxin for use in humans by building up the immunity of horses and then harvesting their serum. By the time the war started, the Institut Pasteur was preparing about 80,000 vials of tetanus antitoxin for humans, using about 300 horses. By 1918, the institute had nearly 1,500 horses, producing more than 600,000 vials of antitoxin per month. The Institut Pasteur was not the only place that was doing this. That's just what I had the numbers for.

[Holly Fry]

Over the course of the war, essentially through trial and error, civilian and military doctors and surgeons worked out treatment and prevention protocols for tetanus in injured soldiers, and that was through use of these serums. Ultimately, the treatment started with treating the wound itself, excising all wounds and removing all the damaged tissue, ideally within 12 hours of the injury. This was because doctors found a clear connection between the presence of tetanus bacteria in the wounds of soldiers whose injuries were surgically treated and those who weren't. Like we said earlier, it's often not possible to find bacteria in the wounds of people who develop tetanus, but there was still a clear correlation there. Tetanus rates were lower in soldiers whose wounds had been excised, even if that first excision didn't lead to satisfactory wound healing and it had to be redone.

[Tracy V. Wilson]

And then, after their wounds were excised, the soldiers were treated with tetanus antibody serum, both as a prophylactic measure if there was enough available, and as a treatment if they started developing signs of tetanus. One bulletin from the UK War Office Committee for the Study of Tetanus advised nurses to be alert for symptoms. All nursing sisters engaged in dressing wounds should be warned to give the alarm if the muscles round the wound are found to be harder or more rigid than the muscles of the uninjured limb or side.

[Holly Fry]

Over the course of the war doctors also developed standard doses of tetanus antitoxin. By 1919, the prophylactic dose was 500 units contained in 3 cubic centimeters or less of horse serum. A unit was 10 times the least quantity of anti tetanic serum necessary to save the life of a 350 gram guinea pig for 96 hours against the official test dose of a standard toxin furnished by the hygienic laboratory of the Public Health and Marine Hospital Service. A super easy unit of measure.

[Tracy V. Wilson]

I'm assuming that the Germans had a different standard. Probably at this point, maybe not. Under ideal circumstances, an injured soldier was given the first prophylactic dose by injection as soon as he had been removed from the line of fire. Subsequent injections were shown to significantly reduce the risk of developing tetanus. But whether soldiers actually got those additional doses just really depended on whether there was enough serum available and whether the medical staff had the capacity to do it. If they were just really overwhelmed, it might not happen. Even when soldiers only got one injection, though, they tended to have milder or more localized cases of tetanus if they still developed it. Doses of antitoxin for treatment rather than prophylaxis could be much higher, ranging from 50,000 to 100,000 units in the early days of treatment, depending on whether the patient's body seemed to be responding to it.

[Holly Fry]

One of the reasons for working out the lowest effective dose of antitoxin was of course, to conserve a limited supply. But another was the risk of severe allergic reactions to the horse serum, which was known as serum sickness. This risk seemed to be higher at higher doses. For example, a 1919 report by the UK War Office Committee for the Study of Tetanus reported that 2 million prophylactic doses of anti tetanic serum had been administered to soldiers being treated in England, and there had been 11 cases of shock related to the serum. All of those patients did recover. But in the 1400 cases of tetanus that were treated with therapeutic doses in England, there were 49 cases shock or 3.5% of the patients. Among those patients, 12 died, or 0.8% of those 1400 cases. But some of those deaths likely were not related to the antitoxins, so this was rare, but it could happen.

[Tracy V. Wilson]

The development of tetanus antitoxin almost completely eliminated tetanus among injured soldiers by the end of the war. For example, in France at the start of the war, about one and a quarter percent of the soldiers who were admitted to the hospital developed tetanus, and all of those patients died. After the tetanus antitoxin serum was introduced, that number of tetanus cases dropped to zero. Results were pretty similar across other armies involved on both sides of the war.

[Holly Fry]

While tetanus antitoxin could be administered to soldiers prophylactically after they were injured, it wasn't a vaccine that could offer more long term resistance to the disease. But in 1924, another French veterinarian and bacteriologist, Gaston Ramon, developed the first tetanus vaccine. Ramon had previously developed a similar vaccine for diphtheria.

[Tracy V. Wilson]

This vaccine is known as tetanus toxoid. A toxoid is a toxin that's been inactivated so that it's no longer dangerous, so the immune system learns to produce antibodies to the toxin before it encounters the real thing. This vaccine can also help prevent tetanus from developing if it's administered to an otherwise unvaccinated person after they have sustained an injury. During World War II, tetanus toxoid became a routine vaccine administered to soldiers, and then it became more widely available to the general public after the war was over.

[Holly Fry]

It seems like deaths from tetanus started to drop as soon as the vaccine was put into use, but there isn't consistent data on that. In the U.S. for example, tetanus did not become a reportable disease until 1947. So before that point, we don't have an exact number for how many people contracted tetanus. But the largest number of tetanus cases reported in the United states was in 1948, and from there, the numbers declined. Deaths from tetanus have decreased by 99% in the US since 1947.

[Tracy V. Wilson]

The vaccine that was being used when it was first introduced targeted three illnesses. Tetanus, diphtheria and pertussis, all of which are caused by toxin producing bacteria. Today, in the United States, the two versions of the tetanus vaccine that are most widely used are tdap, which targets all three of those diseases, and td, which targets only tetanus and diphtheria. Tetanus antitoxin is still also used to treat people who do develop symptoms of tetanus and to prevent it in people who sustain some kind of injury and have not been vaccinated. It's usually called tetanus immune globulin, and it can be made using horse serum or serum from donated human blood, which carries less of a risk of serum sickness.

[Holly Fry]

Because tetanus exists in the soil and forms very hardy spores, it isn't a disease that could be eradicated like smallpox or rinderpest. At least not with any technology that exists today. We do have episodes about the eradication of both smallpox and rinderpest. For more information on those Tetanus spores are basically all around all the time, and recovering from tetanus doesn't make you immune to it later on. So the closest thing to eradication is ensuring broad vaccine coverage so that people who are exposed to tetanus bacteria don't develop the disease. Today, the World Health Organization recommends a six vaccine series that stretches over a person's infancy, childhood and adolescence. This six shot series is close to 100% effective. Some countries, including the United States, also recommend a booster every 10 years.

[Tracy V. Wilson]

Tetanus is rare in wealthy parts of the world where there are robust vaccine programs and where the vaccine is also available in places like doctor's offices, urgent care centers and emergency rooms for people who sustain some kind of injury and need that vaccine. But it is still a major cause of death in poorer countries and regions where that's not the case. Tetanus cases can also spike after major natural disasters like earthquakes, tsunamis and hurricanes.

[Holly Fry]

Today, the majority of tetanus cases and deaths are in newborns, babies who are born in surroundings that aren't sanitary or whose umbilical cords are cut with instruments that are not sterile, or whose umbilical stumps are covered in non sterile dressings. People can also contract tetanus after giving birth in these kinds of environments.

[Tracy V. Wilson]

In the 1980s, the World Health Organization and other organizations embarked on the Maternal and Neonatal Tetanus Elimination Initiative. This initiative was then relaunched in 1999 and it involves multiple strategies, including improving access to skilled birth attendants who use hygienic practices during delivery, and newborn care and vaccine programs, including immunizing people during pregnancy. When somebody is immune to tetanus, that immunity passes to their child and it protects the newborn during their first weeks of life until they can get their own vaccines. Same thing is true for pertussis and diphtheria, which are the other two diseases prevented by the TDAP vaccine. This transfer of maternal tetanus antibodies was studied back in the 19th century when German physician Paul Ehrlich conducted experiments with mice and goats and their offspring.

[Holly Fry]

Between 1998 and 2018, tetanus rates in newborns dropped by about 97% around the world thanks to these programs. But even with that success, around 25,000 newborns still died of neonatal tetanus in 2018. Numbers have not changed much since then, in part because of disruptions caused by the COVID 19 pandemic. In 2021, which is the most recent year that statistics are available, an estimated 24,000 newborns died of tetanus. And as of 2024, there are 10 countries where maternal and neonatal tetanus have not been eradicated yet.

[Tracy V. Wilson]

I tried to track down whether the various funding cuts to foreign aid and foreign health programs that's been happening in the US Is affecting this particular project, and I do not know the answer. That's what I know about tetanus, though.

[Holly Fry]

Do you have some listener mail that may or may not have antibodies in?

[Tracy V. Wilson]

Kind of does have antibodies in it. I Instead of reading one email, I just wanted to thank the enormous number of people who sent us emails and Facebook comments and Instagram comments, even a couple of comments on X that used to be Twitter and on Blue sky, which I don't think we've ever said out loud on the podcast that we're on Blue sky now in response to the beginning of our Spring Unearthed episode, I have not responded to any of these emails or comments. I did read all of them. The response was truly, truly overwhelming. I was going to make a list of everybody's names and just say thank you everybody. But even that got overwhelming and I was also afraid I would miss people. And like we said at the beginning of the episode, a couple of weeks are going to pass between recording this and it coming out. We'll probably get more emails during that time. Basically we got a really, a lot of really, really great email and so thank you everyone for that. A lot of people expressed concerns that we were going to get a lot of hate or flack or be hassled in some way. I just wanted to say thank you all very much for your concerns. This was a reasonable concern. I feel we got almost no flack. I was really braced for impact. We only got good impact. We got a giant, ongoing, multiple weeks long impact of hugs, basically with minimal badness in all of that.

[Holly Fry]

Hooray.

[Tracy V. Wilson]

Which was great, honestly, because I was afraid that was not going to be what would happen because like we said, we don't typically make just explicitly direct political statements on the show. So we've gotten way worse response to way more oblique things than we've said before, honestly. Again, thank you so much to all of you. I've read and appreciated all of your stuff. Also, I wanted to say so many people in your emails said that the beginning of that episode made you feel less alone. So I just wanted to say, hey, you are not alone. We heard that from so many people in the emails, it's clear that a lot of people are feeling really alone right now. But it's obvious to me from that response that none of us are alone in this moment, even if we might feel feel alone in some way like the big hands off March marches across the country and the world. Honestly, on April 5, I saw some criticisms of those marches for like not having a clear objective set out from the beginning and not being disruptive. But one of the things I thought was really good about them was showing how there were crowds of hundreds of people even in tiny little towns where people were probably feeling like they were only one or only a handful. So I just wanted to say I absolutely empathize with the feeling of aloneness. Living in Massachusetts right now, I don't feel very alone. I feel like I'm surrounded by angry people taking action. But having lived previously in North Carolina and Georgia, I didn't always feel that way. So again, you're not alone. And thank you again for all of these lovely, lovely emails and Facebook comments and Instagram comments and all of that that we have been getting over the last couple of weeks. Now, if you would like to send us a note about this or any other podcast, we're at history [e-mail] you can subscribe to our show on the iheartradio app and anywhere else that you like to get podcasts. Stuff youf Missed in History Class is a production of iHeartRadio. For more podcasts from iHeartRadio, visit the iHeartrade radio app, Apple Podcasts, or wherever you listen to your favorite shows.

[Talkspace Advertiser]

This podcast is sponsored by Talkspace. May is Mental Health Awareness Month, and Talkspace, the leading virtual therapy provider, is telling everyone let's face it in therapy by talking or texting with a supportive licensed therapist at Talkspace, you can face whatever is holding you back, whether it's mental health symptoms, relationship drama, past trauma, bad habits or another challenge that you need support to work through, it's easy to sign up. Just go to talkspace.com and you'll be paired with a provider, typically within 48 hours. And because you'll meet your therapist online, you don't have to take time off work or arrange childcare. You'll meet on your schedule. Plus, talkspace is in network with most major insurers and most insured members have a zero dollar copay. Make your mental health a priority and start today. If you're not covered by insurance, get $80 off your first month with Talkspace. When you go to talkspace.com and enter promo code SPACE80. That's S P A CE80. To match with a licensed therapist today, go to talkspace.com and Enter promo code SPACE80.

[Therapy Gecko]

I found out that was related to.

[Talkspace Advertiser]

The guy that I was dating. I don't feel emotions correctly.

[T-Mobile Advertiser]

I collect my roommate's toenails and fingernails.

[Therapy Gecko]

Those were some callers from my call in Podcast Therapy Gecko. It's a show where I take phone calls from anonymous strangers as a fake gecko therapist and try to learn a little bit about their lives. I know that's a weird concept, but I promise it's very interesting. Check it out for yourself by searching for Therapy gecko on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

[Holly Fry]

I want you to ask yourself right now, how am I actually doing? Because it's a question that we rarely ask ourselves. All of May is actually Mental Health Health Awareness Month, and on the psychology of your 20s, we are taking a vulnerable look at why mental health is so hard to talk about. Prepare for our conversations to go deep.

[Tracy V. Wilson]

I spent the majority of my teenage years and my twenties just feeling absolutely terrified. I had a panic attack on a.

[T-Mobile Advertiser]

Conference call knowing that she had six months to live. I was no longer pretending that this was my best friend.

[Holly Fry]

So this Mental Health Awareness Month, take that extra bit of care of your well being. Listen to the psychological theology of your 20s on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

[Talkspace Advertiser]

Hey, I'm Jay Shetty and I'm the host of the On Purpose podcast and I'm excited for my next episode with Khloe Kardashian.

[Tracy V. Wilson]

God, I've been through so many things that at this point I would rather not feel than feel because feeling is too much for me to handle.

[Holly Fry]

I am Khloe Kardashian.

[Therapy Gecko]

Khloe Kardashian, everybody.

[Holly Fry]

Khloe Kardashian.

[Tracy V. Wilson]

No one understands how it's. I'm not just a TV show.

[Talkspace Advertiser]

Listen to On Purpose with Jay Shetty on the iHeartRadio app, Apple Podcasts, or wherever you get your podcasts.

[Therapy Gecko]

You're listening to an iHeart podcast.