Re differential diagnosis of tetanic conditions, see Courtois-Suffit and Giroux in the Collection Horizon. The cases as a rule appear in subjects that have had serum treatment, and may occur in subjects in whom no trismus ever develops (the above case showed slight trismus).
The recognition of localized tetanic contracture is based upon (a) the intensity of the contracture, which causes the limb to feel wooden (in one case the foot, leg, and thigh were welded to the pelvis like an iron bar); (b) paroxysmal contractions resembling those of tetanus, confined to one limb, and started by a variety of external causes, forming the principal symptom in the disease; (c) contracture of comparatively brief duration (hardly ever over two or three weeks). A slight fever may help in the differential diagnosis.
Wound of left leg: Local spasms, later contracture, and painful crises (these associated with suppuration), the whole treated as tetanic.
Case 392. (Mériel, 1916.)
An infantryman was wounded by shell fragments September 28, 1915, at Virginy and was given a first dressing an hour later and a second at the ambulance, where antitetanic injection was also made. October 3, the patient arrived at Foix, showing a superficial wound of the left frontal region, a penetrating wound of the upper third of the left thigh, and another in the lower third of the left lower leg.
The evening of October 8, the man began to feel pain in the left leg, though the wounds looked well and there was no fever. October 9, sudden involuntary contractions of the left leg developed, and these increased in amplitude if the limb was touched. The other extremities were normal. Temperature 38.2; pulse 102. Restlessness at night.
Next day 10 c.c. of antitetanic serum was administered and more on the 11th, with chloral and isolation; but on the evening of the 11th, with the contractions still completely localized to the left lower extremity, came an extremely painful crisis interfering with sleep and at last requiring morphine. Up to the 15th the antitetanic injections, chloral and morphine were continued, but on the 15th the contractions were replaced in part by a contracture affecting the muscles of the posterior aspect of the thigh. In the meantime, the patient howled with pain, especially in the night. Chloral and morphine were given.
During the next five days the contractures and pains became still more violent, and on the 21st the antitetanic injections were begun once more and kept up through the 26th in 5 c.c. doses.
The patient began to urinate in bed and to be delirious. The contractions now disappeared, but the contracture persisted. Antitetanic serum was given every other day from October 28 to November 2; every third day from November 4 to November 19; every fourth day from November 22 to December 3; and every fifth day from December 3 to December 17. The chloral was diminished from 15 to 5 grams per diem and by the 20th of December all administration of chloral had ceased. The morphine was given up December 25.