The muscles have been found healthy in appearance and constitution; discolored, softened, and the seat of blood-extravasations large and small; undergoing the vitreous degeneration; and ruptured, the laceration affecting a few fibres or the entire thickness of one or more muscles, as the rectus abdominis, the muscles of the neck, those in the vertebral gutter, and even the heart. The rigor mortis appears at once or very soon, thus confirming Brown-Séquard's observation, that cadaveric rigidity is “quick in coming on and quick in passing off in direct proportion to the amount of long-continued violent action which preceded death.” The visceral congestions that have been observed cannot be regarded as in any way peculiar, but as due simply to the muscular spasms and the mode of dying.
It is probably by chemical and microscopical examinations of the blood, and, much more, the solids and fluids of the damaged part or the secretions of the skin in the non-traumatic cases, that the cause of this obscure affection is to be discovered, and not from study of the nerves, the cord, and the brain; which study up to the present time has only shown that “tetanus has no morbid anatomy, except perhaps its traumatic cause and the asphyxial congestions resulting from it.”
SYMPTOMS.—Following the receipt of a wound, tetanus may be developed quickly or only after many days, cases of more or less credibility being on record of immediate appearance, and of an elapsed interval of one, two, three, even seven months (in a case occurring during our late war). Doubt, however, may very properly be entertained as to the true tetanic character of some at least of these very long-delayed cases, or of their dependence upon the previous traumatism. The very common belief that after the lapse of three weeks no fear of the disease need be entertained is unquestionably an erroneous one, but the danger certainly is slight when the wounded person has escaped for twenty-two entire days. In by far the larger proportion of cases the outbreak occurs between the fifth and fifteenth days after injury—in about two-thirds, according to Yandell's, or about four-fifths, according to Joseph Jones's and Otis's statistics.
Not infrequently for a day or two before any distinct evidences of the disease are manifested there is prodromal malaise, associated at times, but by no means constantly, with unusual sensitiveness, or even positive pain, in the wound and slight muscular twitching in its vicinity. In the larger number of cases the first symptoms noticed are stiffness about the jaw, more or less difficulty in opening the mouth, and perhaps slight interference with deglutition, the patient feeling as if he had taken cold; such symptoms often appearing early in the morning after waking from the night's sleep. With more or less rapidity well-marked trismus comes on, the jaws being locked, the corners of the mouth retracted, and the lips either firmly closed or separated so as to uncover the teeth, producing the peculiar grin long known as the risus sardonicus.
In rare cases it is the depressors, and not the elevators, of the lower jaw that are in a state of contraction, the mouth consequently being kept wide open. The forehead is wrinkled, the eyes staring, the nose pinched, and not seldom there is the facial expression of old age. The voice is altered and swallowing is difficult. Occasionally the spasms of the muscles of deglutition are so intense as to be the principal tetanic symptom, such dysphagic or hydrophobic (Rose) tetanus very generally proving fatal. In a few cases, after wounds of the face and head, these violent spasms have been found associated with facial paralysis, almost always, if not always, on the injured side; such paralysis having been present in at least one case (Bond's) in which throat-spasm was wanting, the wound being in the temporo-parietal region. Often there is early felt in greater or less intensity pain, as from pressure, in the epigastrium, piercing through to the back—a symptom by some regarded as pathognomonic, and due without doubt to contraction of the diaphragm.
From the region of the jaw the disease passes on to successively attack the muscles of the neck, the back, the abdomen, the chest, the lower, and, last of all, the upper, extremities, those of the forearm long after those of the arms. The muscles of the fingers, of the tongue, and those of the eyeball are very late if at all affected, the tongue probably never being tonically contracted. The anterior abdominal wall is broadened, depressed, and hard. In the fully-developed acute cases the whole body is rigid, remaining perfectly straight (orthotonos), arched backward (opisthotonos), forward (emprosthotonos), or laterally (pleurosthotonos), according as the muscular tension is balanced or greater on one side than another. The action of the extensors being usually the more powerful, backward bending (opisthotonos) to a greater or less extent is the ordinary condition; but only in rare and extreme cases is the contraction such as to curve the body like a bow and keep it supported upon the occiput and heels. Frequently the bending is not specially noticeable except in the neck. Emprosthotonos is rare, and pleurosthotonos has been so seldom observed that its very existence has been denied. Occasionally, in well-marked cases of opisthotonos, there is some associated lateral arching, due rather to voluntary efforts on the part of the patient (for the purpose of obtaining relief) than to tetanic contraction. Larrey's opinion that the location of the wound (behind, in front, or on the side) determined the direction of the curving has been proved to be incorrect. Except in a small proportion of cases to the persistent tonic spasm8 there is added convulsive seizures of the affected muscles, developed upon any, even the slightest, peripheral excitation of the reflex irritability, as by a movement, a touch, a draft of air, a bright light, a sudden noise, an attempt at swallowing, etc. The frequency of these clonic exacerbations and their intensity vary much, being severer and coming on closer together in the grave acute cases and in the later stages of those terminating fatally. They may occur only once in several hours or four, five, or more times in a single hour, each spasm lasting from but a few seconds to a minute or two. During its continuance the suffering is intense, both from the pain of the contraction and the experienced sense of suffocation. Between the paroxysms there is usually but little pain, the sensation being rather one of tension or pressure. Occasionally cessation of spasms and complete relaxation of all muscular contraction suddenly take place six, eight, or twelve hours before death, the patient quickly passing into a state of collapse.
8 This is not, in reality, a state of uninterrupted spasm, but one of very numerous, quickly-repeated muscular contractions, as many even as six hundred and sixty per minute (Richelot).
Throughout the whole course of the disease the mind remains clear,9 except in the later stages of a few cases; and then the existing delirium or coma is often, it is probable, an effect of the treatment that has been employed. Except in the more chronic cases the patient is generally unable to sleep, and even when fortunate enough to do so the tonic spasm may not relax. In other than the mildest attacks there is usually noticed a marked increase, local or general, of the perspiration; such sweating being a much more prominent symptom of the disease as met with in tropical than in temperate regions.
9 “The brain alone in this general invasion has appeared to us to constantly preserve the integrity of its functions down to the very last moment of existence, so that the unfortunate subject of this disease is, as it were, an eye-witness of his own death” (Larrey).