(LOCK-JAW)
=Definition.=—An infectious disease, caused by Nicolaier’s tetanus
bacillus, characterized by persistent, tonic spasms of the muscles with
violent exacerbations.
=Etiology= and =Pathology=.—The exciting cause of tetanus is a specific
bacillus which usually gains access to the system through some wound.
The site of infection is the only place the germs are found.
The disease is much more prevalent in some localities than in others.
It is found in hot countries, as in India and the West Indies, far more
commonly than in temperate regions. Exposure to damp cold is one of the
recognized causes, also those localities where there are rapid changes
from cold. Such regions seem to produce conditions favorable to the
existence and growth of the bacilli.
Earth mould, particularly where putrefaction is taking place, as in
soil that has been manured, is especially favorable to the existence
of the bacillus. It is frequently found in the intestinal tract of the
horse, so that the soil about stables is apt to contain the germs. The
highly fertilized soil of France and Belgium rendered it a special
menace to the wounded of the Great War. Antitetanic serum, according to
all reports, was particularly efficacious.
Wounds and abrasions of various kinds, particularly contused and
punctured wounds of the hands and feet, favor the excitation of
tetanus. When an open wound is present, the term =traumatic tetanus=
is given to the disease; =idiopathic tetanus= when no wound is
discoverable; =tetanus neonatorum= when it attacks infants—this form
is usually due to insanitary conditions, especially the improper care
of the umbilical cord; =lock-jaw= or trismus when the jaw alone is
affected; =cephalic tetanus= when the throat and face is involved.
Characteristic lesions have not been found in the cord or the brain.
The bacilli develop at the site of the wound where the toxin is
manufactured. The bacilli do not invade the blood and organs. The
toxalbumin is one of the most virulent poisons known.
Congestion occurs in various organs, due to obstruction of the movement
of the blood during a spasm. The brain, cord, lungs and muscles are
congested. The nerves are often found swollen.
=Symptoms.=—The period of incubation is from one to twenty days. This
is time required for the poison “to be absorbed by the end plates in
the muscles and to pass up the motor nerves to the spinal cord.” In
most cases the incubation is from five to ten days. A chill precedes
other symptoms in a few cases. The onset is quite sudden, with
stiffness in the neck, jaw and tongue. There are headache, stomach
disturbance and languor. Opening the mouth is difficult, but is not
painful. Deglutition is difficult. The stiffness increases and extends
to the spinal muscles, abdomen and legs which are held in a firm spasm.
Thus, the trunk and legs are inflexible.
These symptoms vary in degree of severity, dependent upon the extent
of involvement. The jaws may be firmly locked or they may yield to
forced extension—“lock-jaw.” The muscles of the face may be involved,
the angle of the mouth drawn out, and the eyebrows raised—“risus
sardonicus.” The neck and trunk muscles affected produce opisthotonos.
Spasms of the pharynx and esophagus may occur, especially when there
are injuries to the fifth nerve.
Associated with these tonic convulsions is intense pain. The distress
of the patient is extreme when the chest muscles are affected. All
symptoms are increased during the paroxysm. A foot fall, the slamming
of a door, a draught of air or any slight sensory impression may excite
a paroxysm. The paroxysm may relax and during the interval the patient
may walk about. The spasms vary in frequency from a few minutes to
one in several hours. During spontaneous or induced sleep the spasm
usually ceases. The febrile reaction is generally slight and apparently
of nervous origin; in many cases 102 degrees F. In severe cases the
temperature may be considerably higher. Perspiration is excessive. The
urine is scanty and high colored. The bowels are usually constipated.
The mind remains clear throughout. Death is generally caused by
exhaustion. =Chronic tetanus= presents similar symptoms, but less
marked, and it develops slowly.
=Diagnosis.=—The history of a wound followed by the characteristic
symptoms would rarely occasion an error. =Strychnine poisoning=
differs from tetanus in the history, in the more rapid development of
the symptoms, no trismus at the beginning, marked involvement of the
extremities, and absence of rigidity between the paroxysms. In =tetany=
the extremities are chiefly affected by the spasms, the muscles are
relaxed during intervals, and trismus is a late or very rare condition.
In =hydrophobia= trismus does not occur and the respiratory spasm is
caused by attempts at swallowing. The mental symptoms increase.
=Prognosis.=—The prognosis is unfavorable. Eighty per cent of traumatic
and fifty per cent of the idiopathic cases prove fatal. Cases that
are fatal usually die within six days. Cases where there is slight
elevation of temperature, and where the spasm is localized to the
muscles of the face, neck and jaw, or where muscle stiffness is late in
appearing, are more likely to recover.
=Treatment.=—Free incision and thorough disinfection with hydrogen
peroxide and cauterization with pure carbolic acid, of the wound are
necessary. The patient should be put in a dark room and there remain as
quietly as possible. Avoid all sources of peripheral irritation. Liquid
food is to be given, and if the jaws are firmly set, rectal feeding may
be employed or food may be passed through the nose with a catheter.
For the spasms, strong inhibition of the nerve centers controlling the
affected muscles may be of use. Probably the most effectual treatment
for the paroxysms would be strong, thorough treatment of the upper
cervical region. Hot baths give relief to the spasms. All the excretory
organs should be greatly stimulated, particularly the kidneys, lungs
and bowels. Other symptoms are to be treated as they arise. Tetanus
antitoxin is highly commended by surgeons who used it during the Great
War. As death is at a two to one ratio any method of treatment is
justified. A few cases have been treated osteopathically with fair
success, following antiseptic measures.