NATORUM.
Varieties. — The infection usually takes place through an open, though often inconspicuous, wound: traumatic tetanus. When it occurs spontaneously or after exposure to cold, no wound being discoverable, it is called idiopathic tetanus.
Symptoms. — Following some injury, slight or severe, and usually ten days after—although longer periods of in cubation have been noted — the first symptoms of tetanus appear. There are slight stiffness of the neck, and some rigidity of the muscles of mastication with interference with the movements of the tongue. In a small proportion of cases chilly feelings may be complained of, and the wound, if unhealed, is apt to become tender and painful.
Yawning has often been noticed to be a forerunning symptom of tetanus. Henry Gray Croly (Brit. Med. Jour., Jan. 8, '98).
There is often some muscular twitch ing in the vicinity of the wound, and, as the disease gradually develops, the mus cles of the jaw begin to exhibit marked tonic spasms, resulting in the typical "locked jaw." The facial muscles are also often attacked, producing distor tions of facial expression. The head is often drawn backward and the dorsal muscles become involved, causing back ward bending of the vertebral column. As the spasm extends to other trunk muscles, the body may be bent forward, backward, or to one or other side ac cording to the relative severity of the contractions in different muscle groups. The muscles of the hands, arms, and legs are comparatively little affected. In ad dition to the tonic muscular spasm, the least source of irritation, such as a light touch of hands or bedclothes, moving the limbs, a breath of air, a loud sudden noise, will cause, so soon as the attack is well established, a severe clonic ex acerbation of spasm. The muscles of the whole body are thrown into violent con traction, with distortion, and often with great interference with respiration and phonation, or with spasm of the glottis causing partial asphyxia. This clonic exacerbation subsides after a few min utes or sooner, to be repeated under the slightest provocation. In the intervals
some tonic spasm of the muscles per sists. During the paroxysms there is usually profuse sweating; the pulse rate runs up to 130 to 150; and in some cases there is hyperpyrexia, 110° to 115° F. being seen in fatal cases just before death. There may be retention of urine from spasm, and in any case the secre tion is apt to be scanty. At first the tonic spasm causes comparatively little pain, but, after the attack reaches its height, the pain during the paroxysms is most excruciatingly intense. The mental faculties remain unimpaired throughout the attack. Death may oc cur from asphyxia or cardiac dilatation during a paroxysm, or at later stages of the disease from exhaustion. The attack endures from a few days to several weeks.
Diagnosis.—In typical cases following injury no difficulty in diagnosis could arise. The muscular spasms in STRYCH NINE POISONING simulate those of teta nus to some extent, but in strychnine poisoning the muscles of the jaw are not first, if at all, affected; in the intervals between the paroxysms there is no stiff ness nor tonic spasm; the symptoms develop rapidly, not gradually, as in tetanus; and the histoty of the case is different.
The HEAD TETANUS of Rose, with its well-pronounced trismus, clysphagia, and facial paralysis, might be mistaken for rabies or hydrophobia, but in hydro phobia the trismus and involvement of neck- and hack- muscles is wanting.
The most constant and striking feature of cephalic tetanus is the facial paralysis. It mostly affects all the branches of the facial nerve, sometimes the lower part of the face ba.4 alone been involved. This facial paralysis practically always occurs on the same side as the injury, but it has been seen on the opposite side. The spasm on swallowing is less constant, and therefore less characteristic, than the paralysis of the seventh. Paralysis of some of the other ocular nerves has been noted in some few cases. E. E. Tre velyan (Brit. Med. Jour., Feb. 8, '96).