304 
PATHOLOGY. 
mufcles of the jaw, and of the root of the tongue, fo that 
both maftication and fwallowing become difficult and 
painful; and at length impoffible. The attempt at 
deglutition is attended with convulfive efforts; efpe- 
cially when liquids are endeavoured to be fwallowed. 
So great is the diftrefs which accompanies thefe convul- 
fions, that the patient becomes very reluctant to renew 
the trials, and refufes all nouriffiment; and it fometimes 
infpires him with even a dread of the fight of water. 
As the difeafe advances, another fet of fymptoms ap¬ 
pears, bringing with them a confiderable increafe to the 
fufferings of the patient. A fudden and violent pain is 
felt (hooting from the lower extremity of the fternum to 
the fpine, in the fituation of the diaphragm. Thefe fpafms 
recur from time to time, at ihort intervals ; and at each 
recurrence, give the fignal for an immediate aggravation 
of all the other fpafms. The mufcles of the neck and 
jaw are immediately called into violent action ; the head 
is pulled ftrongly backwards; and the jaw becomes firm¬ 
ly clenched. Thefe periodical acceffions of fpafm become 
more fevere, and their effects more durable; fo that the 
head continues to be in a (late of retradtion, and. the jaw 
is permanently clofed, the teeth being fo firmly fet toge¬ 
ther, as not to admit of the ftnalleft opening. Such con- 
ftitutes what may be regarded as the firft ftage of the dif¬ 
eafe; which fometimes takes up three or four days. At 
other times the difeafe eftablifhes itfelf, with its whole 
train of dreadful fymptoms, in a few hours; in which 
cafe the danger is imminent; as death generally takes 
place in from twenty-four to forty-eight hours, and the 
patient very rarely paffes over the third day. 
The continuance of the difeafe, if the patient furvive 
the immediate attack, is marked by the increafing fpafm 
of the diaphragm, which now returns every ten or fifteen 
minutes, and is inftantly fucceeded by a ftronger retrac¬ 
tion of the head, and rigidity of the mufcles extending 
down the back, along the fpine, and aft'edting even thofe 
of the lower extremities. Their .contradtions increafing 
in force, the body is frequently raifed in the form of a 
bow, relting upon the head and feet alone : a (late which 
is more particularly denominated opijlholomos. The 
countenance is pale and contradted ; the maftoid, cora- 
co-hyoid, and lterno-hyoid, mufcles, together with the 
others concerned in deglutition, and the deltoid and 
pedtoral mufcles, are mod violently contradfed, fo that 
the (houlders are ftrongly raifed forwards, and the arms 
are ftretched out, .or drawn acrofs the body; but the 
wrifts and fingers feem not to be affedted. In a few fe- 
conds a remiffion takes place; the (houlders and arms re¬ 
cline, and the inferior extremities relax; yet not fo en¬ 
tirely, but that generally fuch a degree of rigidity con¬ 
tinues as to prevent their being bent, even when this is 
attempted by another perfon. The mufcles on the (ides 
and fore part of the neck continue (fill contradted, al¬ 
though not fo ftrongly; but their adtion is overcome by 
the number and ftrength of the pofterior ones; fo that the 
contradlion 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 
irregular; but both become more calm and (low. The 
face is fometimes pale in the intervals, but oftenerfluffied; 
and the whole countenance expreffes ftrong appearances 
of the mod melancholy diftrefs; as well on account of 
the terror the patient feels at the approaching paroxyfm, 
as from the torture he has differed from the iaft, of which 
the painful contractions he (till feels perpetually remind 
him. He, for the inoft part, defires to lie (till as much as 
poffible, and to avoid all attempts at drinking, fpeaking, 
or any kind of motion ; all of which are apt to occafion a 
return of the fpafm in all its horrors. Some, indeed, are 
felicitous to try a change of pofition, in hopes of obtain¬ 
ing one of greater eafe; but the adt of turning the pa¬ 
tient never fails to bring on an attack of the convulfion, 
by which the head is drawn back to the fpine : and it is 
at length found, that the beft means of avoiding this is 
for him to lie perfedtly (till on the back. 
It may, in general, be obferved, that the extender mud 
cles are affedted with fpafm before the flexors. In the 
lower extremities, indeed, both the flexor and extenfor 
mufcles are commonly at the fame time affedted, and keep 
the limbs rigidly extended. The flexors of the head, and 
the mufcles that pull down the lower jaw, become affedted 
in the progrefs of the difeafe, together with the abdomi¬ 
nal mufcles; fo that the belly is ftrongly retradted, and 
feels hard, like a piece of board. The fpafm of thefe and 
the other flexor mufcles, becoming fo powerful as to ba¬ 
lance the adtion of the extenfors, is a circumftance that 
marks the advance of the difeafe, and may be regarded as 
conftituting the commencement of a third jlage. In this 
fituation the body and limbs are perfedtly ftraight and 
rigid, and incapable of being moved in any way ; and it 
is to this condition that the term tetanus has been more 
efpecially applied. It is a (fate of the mod exquifite ftif- 
fering : the patient is on the rack from the continual 
recurrence of the fpafm, which has fcarcely any remiffion. 
The redti mufcles of the abdomen often contradt un¬ 
equally, producing the appearance of hard balls in parti¬ 
cular parts. The whole belly is drawn inwards, and does 
not yield in the leaft to the defeent of the diaphragm in 
infpiration. Although the lower extremities are always 
rigid at this period, yet their adtion is fo violent during 
the height of the paroxyfms, that, were it not for the 
ftanders-by, the patient would be projedted feet-foremoft 
off' the bed ; or would, at other times, be puffied upwards 
with fuch an impetus as to ftrike the head with great 
force againft whatever might happen to be in the why. 
Occafionally, the flexor mufcles acquire the preponder¬ 
ance 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 emprojlhotonos, and occurs only in 
the mod violent, and of courfe the leaft frequent, form 
of the difeafe. It would appear from fome cafes reported 
by Sauvages, that thefe oppofite dates are difpofed to al- 
ternate with one another. 
In extreme cafes, there are hardly any of the voluntary 
mufcles that remain in their natural (late. The face and 
eyes are diftorted ; the tongue is fuddenly darted out 
between the teeth, and often miferably lacerated from 
their doling at the fame moment. Even the fmall muf¬ 
cles of the ear partake of the fpafmodic adtion, which fo 
univerfally prevails in the fyftem. While the tongue is 
thruft out, the mufcular (left, which is fituated between 
the arch of the lower jaw and the upper part of the tra¬ 
chea, is drawn upwards within the throat. The counte¬ 
nance is much contradted ; a general fweat breaks out; 
the eyes are watery and languid; and a pale or bloody 
froth bubbles out from between the lips. Tetanus, in 
thefe violent forms, is perhaps the moft painful difeafe 
that can affedt the human frame. So exquifite a degree 
of pain would fcarcely be compatible with life, were it 
not occafionally afl'uaged by the fliort and imperfedt re- 
miffions of fpafm which occur. A more continued and 
fevere fpafm, or a general convulfion, generally finifhes 
the tragedy, and releafes the unhappy vidtim from all his 
mifery : or, if already too exhaufted by the feverity of 
pain to admit of this mode of termination, delirium of¬ 
ten enfues, protects the patient by a happy infenfibility 
to further fuffering, and fmooths the avenue to death, 
which is then preceded by a general relaxation of the 
fpafms. 
Such are the fymptoms which peculiarly belong to te¬ 
tanus : and it is, perhaps, the moft remarkable circum¬ 
ftance attending the difeafe, that hardly any fundtion is 
primarily affedted, except that of mufcular adtion. The 
fenfes and appetites are perfedt and entire; the intellec¬ 
tual fundtions are undifturbed; and the natural fundtions 
proceed in their ulual courfe. Fever is neither an ef- 
fential nor a common attendant on the difeafe. In the 
firft ftage, when the fpafm is confined to a few mufcles, 
the pulfe is not affedted : it becomes accelerated only 
when the fpafmodic adtions are general; and this merely 
in confequence, as it would appear, of the mechanical 
eftedt 
