<unk>  often begins with mild spasms in the jaw muscles—also known as lockjaw. Similar spasms can also be a feature of trismus. The spasms can also affect the facial muscles resulting in an appearance called risus sardonicus. Chest, neck, back, abdominal muscles and buttocks may be affected. Back muscle spasms often cause arching, called opisthotonus. Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems. Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups, called<unk> any. These episodes can cause fractures and muscle tears. Other symptoms include fever, headache, restlessness, irritability, feeding difficulties, breathing problems, burning sensation during urination, urinary retention and loss of stool control. Even with treatment, about 10% of people who contract<unk>  die. The mortality rate is higher in unvaccinated people and people over 60 years of age. Incubation period The incubation period of<unk>  may be up to several months, but is usually about ten days. In general, the farther the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the more severe the symptoms. In trismus nascentium (i.e. neonatal<unk> , symptoms usually appear from 4 to 14 days after birth, averaging about 7 days. On the basis of clinical findings, four different forms of<unk>  have been described. Generalized<unk>  Generalized<unk>  is the most common type of<unk> , representing about 80% of cases. The generalized form usually presents with a descending pattern. The first sign is trismus or lockjaw, and the facial spasms are called risus sardonicus, followed by stiffness of the neck, difficulty in swallowing, and rigidity of pectoral and calf muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms may occur frequently and last for several minutes with the body shaped into a characteristic form called opisthotonos. Spasms continue for up to four weeks, and complete recovery may take months. Neonatal<unk>  Neonatal<unk>  (trismus nascentium) is a form of generalized<unk>  that occurs in newborns, usually those born to mothers who themselves have not been vaccinated. If the mother has been vaccinated against<unk> , the infants acquire passive immunity and are thus protected. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. As of 1998 neonatal<unk>  was common in many developing countries and was responsible for about 14% (215,000) of all neonatal deaths. In 2010 the worldwide death toll was 58,000 newborns. As the result of a public health campaign, the death toll from neonatal<unk>  was reduced by 90% between 1990 and 2010, and by 2013 the disease had been largely eliminated from all but 25 countries. Neonatal<unk>  is rare in developed countries. Local<unk>  Local<unk>  is an uncommon form of the disease, in which people have persistent contraction of muscles in the same anatomic area as the injury. The contractions may persist for many weeks before gradually subsiding. Local<unk>  is generally milder; only about 1% of cases are fatal, but it may precede the onset of generalized<unk> . Cephalic<unk>  Cephalic<unk>  is the rarest form of the disease (0.9–3% of cases) and is limited to muscles and nerves in the head. It usually occurs after trauma to the head area, including skull fracture, laceration, eye injury, dental extraction, and otitis media, but it has been observed from injuries to other parts of the body. Paralysis of the facial nerve is most frequently implicated, which may cause lockjaw, facial palsy, or ptosis, but other cranial nerves can also be affected. Cephalic<unk>  may progress to a more generalized form of the disease. Due to its rarity, clinicians may be unfamiliar with the clinical presentation and may not suspect<unk>  as the illness. Treatment can be complicated as symptoms may be concurrent with the initial injury that caused the infection. Cephalic<unk>  is more likely than other forms of<unk>  to be fatal, with the progression to generalized<unk>  carrying a 15–30% case fatality rate.
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