TETANUS. 



hringiiie; with them a confiderablo iwiTeafc to the fufferings 

 ot the patient. A fiulden and violonl pain is Mt (hooting 



from tlie lower extremity of the ilernum to the fpine, in the 

 (iliiation of the diaphragm. Thefe fpafms recur from time 

 lo time, at fliort intervals ; and at each recurrence, give the 

 ligiial for an immediate aggravation of all the other fpafms. 



I'lie mufcles of the neck and jaw are immediately called into 

 violent adion ; the head is pulled llrongly backvrards ; and 

 the j.aw becomes firmly clenched. Thefe periodical accef- 

 fions of fpafm become more fevere, and their effefts more 

 ilurable ; fo that the head continues to be in a Hate of re- 

 traction, and the jaw is permanently clofed, the teeth being 

 to firmly fet together, as not to admit of the fmallelt open- 

 ing. Such conliitutes wiiat may be regarded as the tirft 

 :tage of the difeafe ; whicii fometimes takes up three or four 

 days. At other times the difeafe eftablifties itfelf, with its 

 whole train of dreadfu4 fymptoms, in a few hours ; in whicii 

 caie the danger is imminent ; as death generally takes place 

 in from twenty-four to forty-eight hoars, and tlie patient 

 very rarely paifes over the third day. 



The continuance of the difeafe, if the putier.t furvive tlie 

 immediate attack, is marked by the inereafing fpafm of the 

 diaphragm, which now returns every ten or fifteen minutes, 

 and is inftantly fucceeded by a ftronger retradlion of the 

 head, and rigidity of the mufcles extending down the back, 

 along the fpine, and afFetling even thofe of the lower extre- 

 mities. Their contraClions increafing in force, the body is 

 frequently raifcd in the form ef a bow, retting upon the 

 head and feet alone : a ilate which is more particularly de- 

 nominated op'tjlhotonos . The countenance, as is obferved by 

 Dr. Chalmers, is pale and contrafted ; the maftoid, coraco- 

 hyoid, and ftenw-hyoid mufcles, together with the others 

 concerned in deglutition, and the deltoid and peftoral 

 mufcles, are mod violently contrafted, fo that the fhoulders 

 are ftrongly railed forwards, and the arms are ftretched out, 

 or drawn acrofs the body ; but the wrifts and fingers feem 

 not to be affefted. In a few feconds, aremilTion takes place ; 

 the flioulders and arms recline, and the inferior extremities 

 relax ; yet not fo entirely, but that generally fuch a degree 

 of rigidity continues, as to prevent their being bent, even 

 whai this is attempted by another perfon. The mnfcles on 

 the fides and fore part of the neck continue ftill contrafted, 

 although not fo ttrongly ; but their aftion is overcome by 

 the number and ilrength of the pollerior ones ; fo that the 

 contraftion of the head conftantly remains. The patient 

 breathes quick for fome minutes, as if he had been excef- 

 fively exercifed, and the pulfe is fmall, fluttering, and irregu- 

 lar, but both become more calm and (low. The face is 

 fometimes pale in the intervals, but oftener fluflied ; and the 

 whole countenance expreffes ilrong appearances ot the moll 

 melancholy diftrefs ; as well on account of the terror the 

 patient feels at the approaching paroxyfm, as from the tor- 

 ture he has fuffered from the lad, of which the painful con- 

 Iraftions he lliLl feels perpetually remind him. He, for the 

 moft part, delires to lie ItiU as much as pofllble, and to 

 avoid all attempts at drinking, fpeaking, or any kind of mo- 

 tion ; all of which are apt to occafion a return of the fpafm in 

 all its horrors. Some, indeed, are folicitous to try a change 

 of pofition, in hopes of obtaining one of greater eafe ; but 

 the aft of turning the patient never fails to bring on an attack 

 of the convullion, by which the head is drawn back to the 

 fpine : and it is at length found, that the bcft means of avoid- 

 ing this is for him to lie perfeftly ftill on the back. 



It may, in general, be obferved, that theextenfor mufcles 

 are affefted willi fpafm before the flexors. In the lower 

 extremities, indeed, both the flexor and extenfor mufcles are 

 commonly at the fame time affc6ted, and keep the limbs 



rigidly extended. The flexors of the head, and the mulclcs 

 tiiat pull down the lower jaw, become affefted in the progrefs 

 of the difeafe, together with the abdominal mufcles ; fo tliat 

 the belly is ftrongly retrafted, and feels hard, like a piece of 

 board. The fpafm of thefe and the other flexor mufcles, 

 becoming fo powerful as to balance the aftion of the exten- 

 fors, is a circumftance that marks the advance of the dif- 

 eafe, and may be regarded as conftituting the commence- 

 ment of a third ftage. In this iituation the body and limbs 

 are perfeftly ftraight and rigid, and incapable of being moved 

 in any way ; and it is to this condition that the term tdamis 

 has been more cl'peeially applied. It is a ftate of the moft ex- 

 quifite fufienng : the patient is on the rack from the continual 

 recurrence of the fpafm, which has fcarccly any remiflion. 

 The refti mufcles of the abdomen often contraft unequally, 

 producing the appearance of hard balls in particular parts. 

 The whole belly is drawn inwards, and does not yield in the 

 leaft to the defcent of the diaphragm in infpiration. Although 

 the lower extremities are alw.nys rigid at this period, yet 

 their aftion is lo violent during the height of the paroxyfms, 

 that were it not for the ftandera-by, the patient would be pro- 

 jeftcd feet foremoft off the bed ; or would, at other times, 

 be puflied upwards with fuch an impetus, as to flrike the 

 head with great force againfl whatever might happen to be 

 in tiie way. Occafionally, the flexor mufcles acquire the 

 preponderance over the extenfors, and the trunk of the body 

 is bent forwards, the chin being fixed to the breaft. This 

 is what has been called emprojlbotouos, and occurs only in 

 the moft violent, and of courfe the leaft frequent form of the 

 difeafe. It would appear fnmi fome cafes reported by 

 Sauvages, that thefe qppofite ftates are difpofed to alternate 

 with one another. ■ . 



In extreme cafes, there are hardly any of the voluntary 

 mufcles that remain in their natural ftate. The face and 

 eyes are dittorted ; the tongue is fuddcnly darted out be- 

 tween the teetJi, and often miferably lacerated from their 

 clofing at the fame moment. Even the fmall mufcles of the 

 ear partake of the fpafmodic aftion, which fo univerfally 

 prevails in the fyftem. While the tongue is thruft out, the 

 mufcular flefli, which is (ituated between the arch of the 

 lower jaw, and the upper part of the trachea, is drawn up- 

 wards within the throat. Tiie countenance is much con- 

 trafted ; a general fweat breaks out ; t!ie eyes are watery 

 and languid ; and a pale or bloody froth bubbles out from 

 between the lips. Tetanus, in thefe violent forms, is, per- 

 haps, the moft painful difeafe that can affeft the human 

 frame. So exquifite a degree of pain would fcarcely be com- 

 patible with life, were it not occafionally affuagedby the fhort 

 and imperfeft remilTions of fpafm which occur. A more 

 continued and fevere fpalm, or a general .convulfion, gene- 

 rally finiflies the tragedy, and rcleafes the unhappy victim 

 from all his mifery : or, if already too exhaulled by the 

 feverity of pain to admit of this mode of termination, deli- 

 rium often enfues, protefts the patient by a happy infen- 

 fibility to further fuffering, and fmooths the avenue to 

 death, wliich is then preceded by a general relaxation of the 

 fpafms. 



Such arc the fymptoms which peculiarly belong to teta- 

 nus : and it is, perhaps, the moil remarkable circumftance 

 attending the difeafe, that hardly any funftion is primarily 

 affefted, except that of mufcular aftion. The fenfes and appe- 

 tites are perfeft and entire ; the intellectual funftions are 

 undifturbed ; and the natural funftions proceed in their 

 ufual courfe. Fever is neither an eflcntial nor a common 

 attendant on the difeafe. In the iirft flagc, when the fpafm 

 is confined to a few mufcles, the pulfe is not affefted : it 

 becomes accelerated only when the fpafmodic aftions arc 



gcneriJ, 



