arms are involved. Between the spasms the muscles are relaxed, and not rigid as in tetanus. The course is shorter than that of tetanus.

2. Hydrophobia.-Here there are the history of the case, involvement chiefly of the muscles of deglutition, and absence of trismus.

3. Hysteria. The convulsions are not limited to any special group of muscles; there is no trismus; between the spasms there is muscular relaxation; there is no change in temperature or pulse; other hysterical symptoms are present; the spasms are irregular and more spontaneous than reflex.

Prognosis. The disease is fatal in 80 per cent. of traumatic cases and in 50 per cent. of idiopathic cases. It is almost always fatal in infants. Most of the cases of hydrophobic tetanus recover. When the incubation period is less than ten days, the mortality is 96.6 per cent.

Treatment. The patient should be kept in a darkened room from which all sounds and other causes of irritation are to be excluded absolutely. No talking or unnecessary movements are to be permitted. If the trismus prevents the patient from taking even fluid food, he may be fed through a tube or by the rectum. To relieve the spasms morphine hypodermically is the most satisfactory drug. In milder cases chloral combined with sodium bromide may be employed. In very severe cases inhalations of chloroform may be necessary. In mild cases the use of hot baths may be of service. Woorara, which has been employed frequently, is not recommended, because of its depressing effect on the heart. In all cases the infected wound must be disinfected to prevent further absorption. Scars may be excised and foreign bodies be removed. Nerve-stretching and nerve-section have proved disappointing.

The hope of successful treatment lies in the use of anti

toxines derived from the blood-serum of animals rendered immune. Immunity is procured by the injection of germ cultures treated with trichloride of iodine. The injection of the blood-serum of such immune animals into persons suffering from tetanus has frequently been followed by a prompt recovery, while in almost all cases the severity of the disease has been modified greatly.

LEPROSY.

Definition.-Leprosy is a chronic infectious disease due to the bacillus lepræ and characterized by tubercular nodules of the skin and the mucous membranes and by changes in the nerves.

Etiology. At present the principal centres of leprosy are India, China, and the Sandwich Islands. Other important foci are Norway, the Baltic provinces of Russia, Mexico, certain parts of Central and South America, and the West India Islands. In North America it occurs in certain of the Gulf cities, especially New Orleans, in the province of New Brunswick, and along the Pacific coast, where it occurs chiefly among the Chinese. Isolated cases occur from time to time in all large cities.

The disease may be called "contagious," but only in the sense that direct inoculations are necessary, as is the case with syphilis. It may be congenital or hereditary, and it may be acquired through sexual congress. The majority of cases occur from the fifteenth to the thirtieth year. The specific cause is the bacillus lepræ, discovered in 1874 by Hansen. This bacillus, which closely resembles the tubercle bacillus but may be distinguished from it, can be cultivated; but while inoculations of the leprous nodules can reproduce the disease, inoculations of the pure bacillus cultures have produced only negative results.

Pathology. The leprous nodules consist of aggregated

lymphoid, epithelioid, and giant cells in and among which are found numerous bacilli. The nodules may in rare cases become organized and encapsulated, but they have a tendency to break down, discharge puriform matter, and result in ulcers which may heal in one direction while spreading in another. In the nerves the bacilli cause neuritis. In the last stages of the disease leprous nodules may be found in internal organs, especially the spleen and the liver.

Symptoms. Two forms are described, which may occur separately or be combined in the same patient:

1. Tubercular Leprosy.-There appear on the skin hyperæsthetic patches of sharply-defined erythema that become gradually darker from pigmentation. These patches which precede the nodules are designated as "macular leprosy." In some cases they subsequently become anæsthetic and lose their pigment, white spots being left, the "white leprosy." Nodules then develop in the skin of any part of the body excepting the scalp, and in the mucous membranes, especially of the mouth, throat, larynx, and conjunctiva. The nodules vary in size from a pea to a walnut, and coalesce. This is especially marked in the face, the term leontiasis being applied to the thickened and distorted features so caused.

The skin over the nodules is tense and glistening and may become red and painful. The hairs of the affected areas drop out, the loss of the eyebrows being a suggestive symptom. From the softening and breaking down of the nodules there are caused extensive ulcerations frequently covered with crusts. The ulceration may extend to the bones, causing falling of the bridge of the nose or loss of the fingers or toes, or there may be total destruction of the eyeball.

2. Anesthetic leprosy occurs when the nerve-trunks are involved. There are at first areas of hyperæsthesia and

neuralgic pains, followed by anæsthesia over more or less extensive surfaces. The anesthetic spots following the macules have already been alluded to. If the larger nervetrunks are involved, they may be felt as nodular cords. Suppression of sweating occurs in the affected areas.

There are trophic changes. Bullæ may form at any time, and after discharging their contents may either heal or be converted to extensive ulcers. There may be perforating ulcer of the foot or loss of the phalanges of the fingers or the toes. Paralyses, contractures, and atrophy of muscles. are commonly observed.

The prognosis is bad, but not absolutely hopeless. The average duration of the tubercular cases is from eight to ten years; of the anæsthetic cases, fifteen to twenty years.

Treatment.-Patients should live in isolated communities and under the best hygiene. Their general health and nutrition must be superintended carefully.

There is no specific medication. Iodide of potassium in full doses (falling short, however, of iodism) and arsenic have been recommended. Of late gurjun oil in 10-minim doses and chaulmoogra oil in 2-dram doses have been favorably regarded. The former may be given by the mouth or by inunction.

GLANDERS.

Definition and Synonym.-Glanders is an infectious disease of the horse, ass, and mule, communicable to man. Synonym: Farcy.

Etiology. The disease is due to a specific bacillus, the bacillus mallei, which is short and non-motile, closely resembling the tubercle bacillus. The bacillus can be cultivated, and causes the disease by inoculation. The disease is acquired in man by contact of the nasal discharges of the horse with an abraded mucous or cutaneous