Other tomes: ElTh1908
Synonyms.—Lockjaw; Trismus; Opisthotonos.
Definition.—An acute infectious disease, recognized as caused by the bacillus tetanus, and characterized by painful spasmodic contraction of the voluntary muscles, most frequently those of the jaw, face, and neck; less frequently those of the trunk, the extensors of the spine and limbs. It has occurred as an epidemic during times of war. In the new-born it is known as Trismus Neonatorum.
Etiology.—The tetanus bacillus was first discovered by Nicolaier, though Roenbach first found it in man, and Kitasato made the first cultures. This bacillus gains entrance into the system through a wound of some character, the most favorable being a puncture or bruise.
The bacillus tetanus is a long, slender rod, terminating in a bulbar enlargement, the spore, and giving it the appearance of a pin or drumstick. As but few of the bacilli are found in the wound, and few or none in the blood, it is now generally believed that the infection is due to a chemical product, tetanin or tetano-toxin, isolated by Brieger. Tetanus then is purely toxic in character.
The spores are found in earth and manure, in stables or streets, near polluted streams, and also in the dust from hay or the cobwebs found so abundantly in ill-kept stables. The spores retain their activity and infectious character for years; thus Babes found the spores remain very virulent after being dried on wood, for two and a half years, without any especial protection.
Pathology.—The post-mortem lesions are neither positive nor constant. The nerves are sometimes found red, swollen, and inflamed, and in some cases granular degeneration of the nerve-cells takes place. The anterior horns of the spinal cord are usually injected, and sometimes softened.
Method of Invasion.—The infection usually enters by way of a wound, especially of the hands or feet, and a punctured wound rather than an incised one; a crushing injury, a fracture or dislocation, and in one case that came under my observation, from the cutting of a wisdom tooth.
Age, race, and climate may be mentioned as predisposing to lockjaw, from ten to twenty years being the most susceptible age, excepting tetanus neonatorum, which generally occurs during the first week of life.
The colored races are far more subject to the disease than the white, and it prevails more frequently in warm than in cold climates. The proportion of males who suffer compared to females is six to one, due no doubt to the greater frequency of injury in the male.
Symptoms.—The period of incubation is from seven to fourteen days, often less than ten. Of seventy-five cases reported by Faber, seventy-four per cent had a forming stage of from seven to eleven days.
The first symptom is a sensation of stiffness and soreness of the jaws and neck; this may rarely be preceded by chills or rigors. The soreness increases, mastication being painful and difficult; these increase, terminating in a spasm of the masseters, giving rise to trismus or lockjaw. There is also spasm of the muscles of the neck. The eyebrows are elevated, the corners of the mouth are everted, which gives rise to the condition known as sardonic grin—risus sardonicus. Gradually the convulsive action continues till nearly all the muscles of the body are involved save the hands and wrists.
The contractions, while continuous, are relieved at intervals by slight relaxation, only to be followed by contractions of increased intensity. During a paroyxism the head is drawn back, the powerful contraction of the muscles of the back produce a bending of the body, so that the weight of the person rests upon the head and heels—opisthotonos. In rare cases the body is arched forward—emprosthotonos; or it may be curved laterally—pleurothotonos. During an excessive spasm there may be a rupture of the muscles.
Any slight exertion will bring on a spasm, and, later, even a sudden noise will bring on a convulsion. During a severe paroxysm the chest is contracted, the diaphragm is restricted, and the respiration is greatly impaired. The spasms are attended with acute lancinating or excruciating pains, and though the patient's mind remains clear and he is conscious of his intense suffering, the viselike contractions render him unable to cry out.
A copious perspiration bathes the body; inability to eat or drink, coupled with the severe attacks, produces extreme exhaustion. The spasmodic contraction of the sphincters causes constipation and retention of the urine. The temperature may remain normal throughout, or, owing to disturbance of the heat centers, it may rise to 103°, 104°, 105°, or as high as 108° or no°.
Chronic Tetanus.—In this form, there is a longer period embraced in the forming stage. The same symptoms observed in the acute will in time be enacted in the chronic, with the exception that a paroyxism is followed by an interval of varying duration when there is relaxation of the muscles and freedom from pain, save a soreness of the muscles. During this interval the patient is enabled to take nourishment and stimulants, thus preventing the exhaustion seen in the acute attacks.
Where recovery takes place, which occurs far more frequently than in the acute form, the spasms occur at longer intervals and in lighter form, till they cease entirely. Relapses may occur, however, when least expected, and the case terminate fatally.
Diagnosis.—The history, showing injury in most cases, the period of incubation lasting four or more days, the locked jaws and stiffness of the neck, the muscular contractions spreading downwards, the hands and arms escaping, the continued rigidity during the intervals of the spasms, are symptoms so pronounced that the diagnosis is not difficult.
Strychnin poisoning, the disease most likely to produce confusion, is followed almost immediately upon its ingestion by muscular contraction; there is usually gastric disturbance, and during the absence of a spasm there is relaxation. The course of the latter is also much shorter, death or recovery occurring within twenty-four or forty-eight hours.
Prognosis.—The prognosis must be guarded; in infants, and when the result is due to deeply penetrating wounds, the termination is usually death. Every day the patient survives after the fourth day makes the prognosis more favorable. In chronic cases, a more hopeful prognosis may be given.
Treatment.—Prophylaxis.—In all traumatic cases, the wound should be carefully examined, and all foreign material removed, and the wound cauterized. The patient should then be placed in a darkened room, and kept free from all curious visitors, noises, and everything that would tend to cause irritation. Sometimes the slightest sound is sufficient to bring on a paroxysm.
To relieve the intense pain, morphia may be used hypodermically. The remedies, however, that will be most useful will be lobelia and gelsemium, together with the vapor bath. Dr. Waterhouse, of St. Louis, Mo., reports in the Eclectic Medical Journal, October, 1891, a severe case, cured by gelsemium when all other remedies had failed. He gave the remedy in thirty-drop doses every hour by mouth, and thirty drops hypodermically every six hours.
Dr. W. H. Huntly, of Australia, also reports in the same journal, November, 1893, a cure where the principal remedy used was lobelia. Dr. Wolgemuth, of Springfield, Ill., also gives a very interesting account of a cure where the use of lobelia per mouth and rectum were the chief means used. These are but a few cases of many that might be cited where these remedies turned the tide in favor of the patient. I would lay stress on the use of lobelia per rectum. Often the jaws are so firmly locked as to prevent swallowing; here thirty drops of gelsemium hypodermically, and one or two drams of lobelia per rectum, will produce the desired relaxation, when agents can not be given by mouth. The vapor bath will prove a great aid to the means already mentioned.
Where there is evidence of sepsis, the treatment will be antiseptic. It may be the sulphites, the chlorates, the mineral acids, or the well-known vegetable antiseptics, echinacea and baptisia.
As the disease is attended by great prostration, nourishment will be an important feature of the treatment. When locked jaws prevent feeding by mouth, rectal feeding should be practiced.