The pulse, which is normal in the earlier stages, may later be but little increased in frequency (except during the exacerbations, when, small and compressible, its beats may run up to 140, 160, or even 180 per minute), or it may become progressively feebler and more rapid as the case advances toward the fatal termination. The irregularity often noticed during the convulsive seizures is doubtless owing to the muscular contractions so compressing the vessels as to hinder the passage of the blood through them. That the heart itself is not tetanically contracted would seem to be proved by its regular quiet action during anæsthesia.
The body-heat varies greatly in different cases, the temperature being oftentimes normal, or even subnormal, until toward the very last. Not infrequently, even in severe and fatal cases, it is not increased more than two or three degrees, and quite rarely, except just before death, does it rise much above 103° F. Exceptionally, very high temperatures have been observed; I have myself seen one of 108° F. an hour before death. Prévost had a patient whose axillary temperature was 110¾° F. Lehmann reports a heat of 111.9° F. just before death, and in one of Wunderlich's cases the temperature (that three hours earlier was 103.5° F.) fifteen minutes before death was 110.1° F., and at death 112.5° F., with a further post-mortem rise of more than a degree (113⅔° F.)—a phenomenon that has been observed in a number of cases. This increased temperature of tetanus is not of inflammatory origin (except as a part of it, at times, may be due to intercurrent affections, especially a broncho-pneumonia), but depends doubtless upon a combination of causes, among them the violent muscular spasms, and, more particularly, the disturbance of the regulating heat-centre or centres from the alterations of their blood-supply in quantity and quality.
The bowels are usually constipated, because of the little food taken, the profuse sweating, the tonic spasms of the abdominal muscles, and the contraction of the external sphincter and the levator ani, the muscular coat of the bowel, like all the other involuntary muscles, remaining unaffected.
Micturition, generally infrequent because of scanty secretion, may or may not be disturbed. In many cases it is true, as written by Aretæus, "the urine is retained so as to induce strong dysuria, or passes spontaneously from contraction of the bladder,” though it is the external muscles, and not the bladder itself, the contraction of which produces the retention or the discharge; which latter is of rare occurrence.
DIAGNOSIS.—When fully developed, with all its characteristic symptoms present, tetanus cannot, or at least ought not to, be mistaken for anything else; yet a study of reported cases will show that errors of diagnosis have been made, and because of such errors various methods of treatment have been given undue credit as curative measures. Wound-spasms, clonic in character, of different degrees of severity, beginning in and confined to the muscles of the injured part or limb (even of the lower segment of the upper extremity), have not seldom been regarded as tetanic, which they certainly are not; and recovery having taken place, it has been attributed to the adopted treatment, operative or therapeutic. The comparatively few cases in which, primarily located in the vicinity of the wound, these traumatic spasms have become generalized in strict accordance with Pflüger's laws, or, much more rarely, passing over the intervening parts of the body, have seized upon the muscles of the jaw and neck, may perhaps, for want of accurate knowledge of the essential nature of tetanus, be regarded as a variety of the disease; but it is much to be regretted that observers and reporters have not clearly separated them from the cases of true tetanus (or the commonly met-with variety of tetanus) in which the first or first important symptoms are always in connection with the muscles whose nerves take origin in the medulla oblongata, no matter where the wound may be located or whether there is any wound at all. Not a few of the idiopathic cases may justly be regarded as of tetany, that “little tetanus” in which the spasms always proceed from the periphery toward the centre; are especially likely to affect the forearms and the fingers, forming in their contractions the obstetrical hand; are followed by periods of complete relaxation; can be brought on by compression of the main artery or nerve of the limb, or by light tapping of the affected area; may cause a rigid state of the trunkal muscles or even well-marked opisthotonos; are associated with impairment or paralysis of sensation; may last for a few minutes or for hours; and sooner or later spontaneously cease, a fatal termination of the affection being exceedingly rare.
Hysterical spasms may strongly simulate those of tetanus, and such attacks have without doubt been wrongly diagnosticated, the cases going to swell the number of those successfully treated by one remedy or another. They ought, however, to be readily recognized if due consideration be had of the age and character of the patients, the history of the attack, and the order and nature of the symptoms themselves, especially their frequent limitation to one member (preferably a leg), the absence of consciousness during the attacks, the long and uninterrupted rest at night, their more or less often and prolonged complete intermissions.
Cerebro-spinal meningitis, because of the developed stiffness of the neck and retraction of the head, the orthotonos, or even well-marked opisthotonos, the epigastric pressure-pain, the occasional trismus, and rigidity with reflex convulsive movements of the muscles of the extremities, may, and doubtless has been, mistaken for tetanus; but its generally epidemic prevalence, the headache, the cutaneous hyperæsthesia, the temperature, and the other well-known symptoms of the disease ought to suffice for its ready determination.
Strychnia-poisoning has many symptoms in common with tetanus, but there is an absence of the wound which is generally associated with the latter affection, a much more rapid development of severe convulsions, and a quickly-appearing opisthotonos. The spasms from the commencement affect the extremities, producing early contractions of the muscles of the hands and feet, and only later those of the jaw. Complete intermissions of greater or less length usually occur, and either death or marked amelioration of pain and spasm follows in a comparatively short time.
Hydrophobia, the dysphagic symptoms of which are like those at times observed in tetanus, has its peculiar wound of origin and protracted period of incubation, its absence of trismus or general tonic muscular contractions, its usual dread of water and inability to swallow fluids, its attendant restlessness, and its frequently-observed delirium, the entire aggregation of symptoms being characteristic of itself and nothing else except the simulating nervous affections occasionally developed in individuals bitten by rabid or supposed rabid animals.
PROGNOSIS.—As declared by Hippocrates, “the spasm that comes on after the receipt of a wound is a frequent cause of death.” Violent acute cases, developing early, are excessively dangerous; and there is much truth in Poland's declaration that “there is scarcely a well-authenticated instance of recovery on record.” Taking all the traumatic cases together as met with in military and civil hospitals, the death-rate may safely be placed at not less than 80 per cent. Of 1332 cases reported from the wars of the last thirty years, and occurring in six large hospitals during the last twenty years, 1060 proved fatal—i.e. 79.6 per cent.10