I had served at the Military Hospital, Ambala in Haryana State of India from July 1970 to September 1971. That was my very first posting upon joining the Indian Army Medical Corps. I met Major M P Dhir, AMC, the Senior Surgical Specialist at that Hospital on the first day of my duty. He suggested to me that I should know each patient as a person and not as a disease entity. During medical practice, we interrogate the patients to know their medical history. He had advised me to go beyond that. During his Surgical Ward rounds, he would expect me to brief about the condition of each patient as if each is a personal friend of mine. The only way I was able to accomplish it was by spending extra time with each person and know them directly by conversing with them. The medical practice in the Armed Forces is different from the average experience at a civil clinic or hospital. Writing a prescription quickly and sending away the patient promptly is not our first concern. Very often, we medically examine individuals, who have no illness to report, to make sure that they are in Good Health. In Army Medical Practice, the emphasis is on the individual.

During 1971, an evening at about 8.30 P.M., I was in the Hospital Medical Inspection Room with my friend Lt. M L Dubey, AMC while he was on duty. A young lady aged about 17 years accompanied by her father walked into the Clinic. Her father had earlier served in Indian Army. They were passengers traveling in a bus and they discontinued their bus journey and got down on the Grand Trunk Road near the Military Hospital and were concerned about her feeling unwell. Her medical history was very brief. Her initial evaluation did not reveal any particular sign of any illness. Her temperature, pulse, respiration, heart, lungs, abdomen were within expected normal limits. She had no cough or cold. No suggestion of a malarial fever or urinary infection. As she walked in, I had noticed the expression of concern on her face. I had continued my conversation with her and her father while I continued to search for clues to understand her symptom of being unwell. While looking at her face, I had recognized her jaw muscles known as 'masseters' were taut and appeared to be stiff. She was not experiencing any difficulty or stiffness. She was able to open her mouth very easily and her throat and teeth appeared normal. This spasticity of the jaw muscles is associated with a terrifying disease known as Tetanus caused by infection with Clostridium tetani bacilli. These bacilli live as commensals in the intestines of humans and several animals. The infection is caused when the Tetanus spores enter the body through wounds and injuries, generally dirty wounds, and penetrating or puncture wounds caused by splinters, nails or farm equipment. The possibility of Tetanus was shocking. She was again checked thoroughly, her skin was intact and there were no scabs or signs of any kind of injury.

Tetanus manifests itself in the facial muscles. It is called LOCK JAW and produces a sign called TRISMUS which describes a difficulty in opening mouth or of chewing food. She was not yet experiencing that problem. Later, Tetanus produces a sign called 'RISUS SARDONICUS' which could be described as a 'WRY SMILE'. The angles of the mouth would be drawn forcing the appearance of a smile and the forehead muscles also contract raising the eye brows. She was not displaying the signs of established Tetanus. The Tetanus bacilli excrete a very powerful neurotoxin which enters the bloodstream and acts on the synthesis and release of Acetylcholine, a chemical which has a key role in the transmission of nerve impulses through out the body. The toxin effects the motor neuron cells and the neuro-muscualr junctions where the nerve ending communicates with the voluntary muscle fibre causing the muscle to contract. Apparently, this young lady was not immunized and had no protection against Tetanus infection.

Based upon the suspicion, she was admitted to the Hospital after initiating treatment to prevent Tetanus. The homologous or Human Tetanus Immunoglobulin was not available in India at that time. She had received the equine Anti Tetanus Serum. In spite of this early diagnosis, she had lost her battle against Tetanus. An autopsy was conducted at the Hospital to discover the site of Tetanus infection in her body. The Hospital Pathologist, Major B K Sharma, AMC had found the bacteria in the inner lining membrane of her womb(Uterus) and it was determined that she was exposed to the deadly Tetanus spores during a surgical procedure known as 'Curettage' which involves the scraping of the inner lining of the uterus. The instrument used in the procedure was not sterile and was exposed to dust bearing the spores. Due to reasons of modesty and cultural sensitivity, she did not reveal this information and even if she had disclosed, she was caught in a situation with no easy escape. To our regret, the autopsy results had indicated that this 17 year old woman was exposed to surgical infection while undergoing a procedure for which we could find no medical justification.

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