sible. The teeth are firmly clenched, so that the patient speaks through them, and on attempts to depress the lower jaw forcibly with the fingers a sense of unyielding resistance is encountered. On palpation the masseter muscles are found to be tense and as hard as a board, and if the face be emaciated the outlines of the muscles named stand out prominently beneath the skin. This constitutes the well-known symptom of lock-jaw or trismus. In the newborn tetanus is occasionally confined essentially to lockjaw, so that the condition has been designated also trismus of the newborn. The remaining muscles of the face also take part in the tonic contracture. The buccal orifice appears increased in width and slightly open, so that generally the teeth are visible between the lips. As a result the lower portion of the face acquires a laughing expression-the so-called sardonic grin (p. 453, Fig. 75). The nasolabial folds are deep, and the nasal ale appear drawn outward. The palpebral fissure is narrowed, and the upper portion of the face presents a tired and sleepy expression. The forehead is often thrown into deep transverse folds, as if the patient were taken by astonishment and surprise. The facial expression in a case of tetanus therefore portrays various emotions, which together constitute the characteristics of the tetanic facies. Occasionally strabismus occurs.

The patient often complains of spasm of the pharynx, which greatly interferes with the taking of food, and may render it wholly impossible. Tonic contracture of the muscles of the back gives rise to abnormal curvature of the vertebral column. Most commonly the spinal column forms an arch with its convexity forward-opisthotonos-so that the body rests upon the bed only with the occiput and the sacrum, and the fist can be readily introduced between the spine and the bed. Less commonly there is marked convex curvature posteriorly-emprosthotonos-or toward one side-pleurothotonos-or the body is stretched out straight— orthotonos. The whole body may be lifted from the occiput like a stiff rod.

Tonic spasm of the thoracic muscles will, in the first place, give rise to marked interference with the respiratory movements, and, besides, the contracted muscles not rarely can be felt with the hands to be as hard as a board, and their outlines may even be visible beneath the skin. Tonic contraction of the abdominal muscles would give rise to retraction and board-like hardness of the abdominal walls. The muscles of the extremities also are generally involved in tonic contracture, at times in extension, and at other times in flexion, and accordingly they may offer considerable resistance to passive movement.

From time to time the muscular contractures are intensified paroxysmally, and are temporarily converted into clonic spasm. This change apparently occurs spontaneously, but especially as a

muscular contracture, exhibit no peculiarity. The bodily temperature is often unchanged; occasionally, however, elevation of temperature to 43° C. (109.4° F.), and above-hyperpyrexia-has been observed, and this is in all probability scarcely dependent upon the muscular spasm, but rather upon innervational disturbances in the nerve-centers controlling the bodily temperature. The pulse remains regular, and is but temporarily less full, or not at all palpable, during the paroxysm of tetanus, because the strongly contracted muscles and the tense tendons interfere with its palpability. Occasionally derangement in micturition and priapism occur, in consequence of tetanus of the muscles of the penis. The urine not rarely contains albumin.

Tetanus may pursue an acute, a subacute, or a chronic course. Some cases terminate fatally within a few hours. Chronic cases are occasionally protracted over several weeks, and frequently exhibit remissions and exacerbations. Death generally occurs in a paroxysm of tetanus, in consequence of cerebral or cardiac paralysis.

Among the anomalies of tetanus is localized tetanus, in which the tetanic manifestations are confined to one or more members or to trismus, or occur in unilateral distribution. Cephalic or hydrophobic tetanus also is worthy of mention. This generally develops in connection with wounds of the face, and is attended with facial paralysis, frequently with simultaneous contracture of the facial muscles upon the same side and spasm of the pharynx on any attempt at swallowing.

Diagnosis. The diagnosis of tetanus is easy in view of the readily recognized symptoms. From meningitis, which also may be attended with contracture of the muscles of the nucha and rigidity of the neck, tetanus is distinguished, among other things, by the fact that it is unattended with headache and progressive loss of consciousness, while these are conspicuous in cases of meningitis.

Prognosis.-Tetanus is an exceedingly grave disease. The longer the affection is protracted the more likely, it is true, is recovery to take place. Elevation of temperature and delirium are indications of unfavorable significance.

Anatomic Alterations.-Distinctive anatomic alterations in cases of tetanus are as yet unknown. Not rarely hemorrhage takes place upon and into the meninges, as well as into the brain and the spinal cord, although these are insignificant secondary changes and results of the circulatory disturbances induced by the muscular spasm. Recently fine structural alterations in the ganglion-cells of the spinal cord have been described, although it has not been definitely demonstrated that these findings are peculiar.

Treatment.-Patients suffering from tetanus in surgical clinics must be isolated, because conveyance of the disenthrongh

bandages and articles of linen, through instruments and unclean nurses' hands, is not impossible. The sick-room should be as quiet as possible, and be capable of being rendered dark. Milk is to be recommended as the diet, and under some circumstances it may be administered at regular intervals by means of a tube introduced through the nares into the stomach. Wounds should be carefully inspected for the presence of foreign bodies, and should be enlarged if secretion has collected within them. The wounds should then be disinfected and bandaged. Occasionally resort has been had to amputation of members. Recently specific treatment of tetanus with tetanus-serum has been attempted by Behring, but the results have as yet been neither convincing nor brilliant, because generally the treatment was begun too late. The serum is prepared in the dye-works of Meister Lucius at Höchst, and can be obtained from that source. The results of treatment with a powdered tetanus-antitoxin prepared by Tizzoni, which can be preserved more conveniently, and for a longer time than the serum, and which is dissolved in water before being used, have not been more brilliant. Both preparations possess antitoxic, but not bactericidal, properties; that is, they do not destroy tetanus-bacilli that may be present, but only neutralize the toxins generated by them. Injections of cerebrospinal tissue also have been employed recently, this tissue combining with the tetanus-toxin and rendering it innocuous.2

Many clinicians confine themselves to symptomatic treatment, directing their efforts principally to reducing the abnormally increased reflex irritability of the spinal cord. For this purpose bromids and chloral hydrate especially are to be recommended, as, for instance:

R Solution of sodium bromid,
Potassium bromid,

Ammonium bromid,

30.0: 200 (1 ounce: 6 fluid ounces);

15.0
5.0

Dose: 15 c.c. (1 tablespoonful) thrice daily.

R Solution of chloral hydrate,

5.0: 200 (75 grains : 63 fluidounces). Dose: One-half to be used as an enema morning and evening.

Occasionally delirium occurs after the use of chloral hydrate, but it is without especial significance. The employment of opium and morphin is less to be recommended than that of chloral hydrate, because these agents rather increase the reflex irritability of the spinal cord, and in frogs even induce tetanic muscular spasm. Curare also is not a serviceable remedy, as it has no influence upon the central nervous system, and only inhibits the motility of the muscles without in any way influencing the tetanic state of the spinal cord. Some clinicians have observed good results from application of the galvanic current to the spinal column.

1 Antitetanic serum has been marketed by a number of reliable manufacturers. -A. A. E.

Preventive measures-prophylaxis-are of great importance, as with all traumatic infectious diseases. Every wound, however slight, should be disinfected with 5 per cent. solution of carbolic acid, or 0.1 per cent. solution of mercuric chlorid, and then be protected from subsequent contamination by a bandage. Cobwebs, an old hemostatic in domestic use, should not be applied to open wounds. Special consideration should be given to contused wounds and to impacted splinters of wood, as infection with tetanus-bacilli may readily take place under such circumstances.

INFECTIOUS DISEASES OF VARYING
LOCALIZATION.

I. DIPHTHERIA.

PHARYNGEAL DIPHTHERIA.

Etiology. The exciting agent of all diphtheric diseases, as also of pharyngeal diphtheria, consists in the diphtheria-bacilli, first thoroughly studied by Löffler in 1884.

Diphtheria-bacilli are small rods with rounded extremities, frequently with a bulbous enlargement at one end, for the staining of which Löffler's methylene-blue especially is to be recommended. They can be stained also by the method of Gram. In stained preparations it will be seen that especially the two poles of the diphtheria-bacilli are colored deeply, while the central portion of the body is stained irregularly, and therefore appears filled with colorless granules (Fig. 76). Diphtheria-bacilli can be readily cultivated upon solidified blood-serum from the calf or the sheep. Toxins have been separated from them, which in part contain albumin, and are therefore so-called to.ralbumins.

Although infection with diphtheria-bacilli is the principal requirement for the development of pharyngeal diphtheria, the condition is generally not one of pure infection with diphtheria-bacilli, but is a mixed infection with other bacteria, particularly with the Streptococcus pyogenes, and it is not without reason assumed that the principal dangers of pharyngeal diphtheria are attributable to the streptococcic infection.

Pharyngeal diphtheria is preeminently a disease of childhood, but cases appear by no means rarely in adults. The disease occurs at times sporadically, at other times epidemically. Infection takes place occasionally through immediate contact with the sick, as, for instance, in nursing, and especially through kissing, or the disease

be conveyed through a third person or inanimate objects