in the genitals of lying-in women, producing puerperal fever. Erysipelas simplex is the ordinary cutaneous form. Erysipelas neonatorum begins in the unhealed navel of a newborn child and spreads from this point. Typhoid erysipelas occurs with profound adynamia. Universal erysipelas involves the entire body. Cellulitis is erysipelas of the subcutaneous layers. Phlegmonous erysipelas involves the skin and subcutaneous tissues, and causes suppuration, and often gangrene. Edematous erysipelas is a variety of phlegmonous erysipelas with enormous subcutaneous edema. Lymphatic erysipelas is characterized by rose-red lines of lymphangitis. Venous erysipelas is marked by the dark color of venous congestion. Mucous erysipelas involves a mucous membrane. Erysipelas may attack the fauces, producing a very grave condition.

Clinical Forms.-The clinical forms are cutaneous erysipelas, cellulocutaneous or phlegmonous, cellulitis, and mucous erysipelas.

Cutaneous erysipelas most frequently attacks the face. A fever suddenly appears, rises rapidly, reaches a considerable height, and at the time of febrile onset spots of redness appear on the skin. These spots run together, and a large extent of surface is found to be red and a little elevated. Any wound, ulcer, or abrasion which exists becomes dry and unhealthy, and its edges redden and swell. This combination of redness and swelling extends, and its area is sharply defined from the healthy skin. The color fades at once on pressure and returns at once when pressure is removed. In the hyperemic area vesicles or bullæ form, containing first serum and later it may be sero-pus. Edema affects the subcutaneous tissues, producing great swelling in regions where they are lax (as in the eyelids). The anatomically related lymphatic glands become large and tender, and between them and a wound are often seen the red lines of inflamed lymphatic vessels. In an ordinarily strong person the color is bright red or more rarely dark red. A dusky color precedes suppuration. A blue color precedes gangrene or indicates profound cardiac and pulmonary involvement. There is slight burning pain in erysipelas which is increased by pressure. Erysipelas spreads at its periphery and fades at its point of origin. It spreads now in one direction, now in another, influenced, according to Pfleger, by the furrows of the skin. When spreading stops the swelling and redness gradually abate, and after they disappear desquamation takes place, and the blebs become dry and

crusted. Cutaneous erysipelas rarely suppurates, but may do so. The fever is remittent, and usually terminates in four or five days by crisis.

In strong subjects the symptoms are usually slight. In the old or debilitated the symptoms are typhoid, delirium comes on, and death is usual. Possible complications are meningitis, pneumonia, septicemia, pleuritis, pyemia, endocarditis, and albuminuria. Erysipelas neonatorum is generally fatal. In some instances an attack of erysipelas will cure an old skin eruption, a new growth, an ulcer, or an area of lupus. This is the érysipèle salutaire of our French confrères (p. 230).

Treatment.-Isolate the patient, asepticize any wound, and give a purge. Cases of cutaneous erysipelas tend to get well without treatment. If a person is debilitated, stimulate freely. Tincture of chlorid of iron and quinin are usually administered. Nutritious food is important. For sleeplessness or delirium use chloral or the bromids; for high temperature, cold sponging and antipyretics. To prevent spreading some have advised injection of the healthy skin near the blush with a 2 per cent. carbolic solution or with gr. of corrosive sublimate. Locally, paint the inflamed area with equal parts of iodin and alcohol and apply lead-water and laudanum. If an extremity be involved, bandage it. Another good application is a 50 per cent. ichthyol ointment with lanolin. A very useful method is Von Nussbaum's. The author applies it somewhat modified, as follows: wash with ethereal soap, irrigate with a solution of corrosive sublimate (1: 1000), dry with a sterile towel, apply an ointment of ichthyol and lanolin (50 per cent.), and dress with antiseptic gauze. Some use iced-water cloths and some prefer hot fomentations. Others apply borated talc or salicylated starch. Ringer advised painting every three hours with a mixture composed of gr. xxx of tannic acid, gr. xxx of camphor, and giv of ether. J. M. Da Costa recommends pilocarpin internally in the beginning of a case. Antistreptococcic serum has been used in erysipelas, and great results have been claimed for it. Roger and Charrin's serum may be used. The dose is 30 c.cm. It is asserted that under its influence the temperature soon becomes normal. We have had no personal experience with the serum treatment.

Cellulocutaneous or phlegmonous erysipelas is characterized by high temperature (104°-106°), the rapid onset of grave prostration, irregular chills, sweats, and a strong tendency to delirium. The parts are not so red as in the pre

ceding form, but the tumefaction is vastly greater; it is brawny, comes on early and with exceeding rapidity, inducing a high degree of tension and frequently producing sloughing or even cutaneous gangrene. The lymphatic glands are swollen, but the inflamed lymphatic vessels are hidden by the tumefaction. In most cases suppuration occurs, and when this happens the parts become boggy. When the disease abates sloughs form, which leave ulcers upon being thrown off. In bad cases muscles, vessels, tendons, and fascia may slough away. The commonest complications are suppression of urine, bronchopneumonia, congestion and edema of the lungs, meningitis, congestion of the kidneys, and acute pleurisy. We see this form of erysipelas sometimes after extravasation of urine. It is not a pure streptococcus infection. There is a mixed infection with other pyogenic cocci, and often with organisms of putrefaction.

Treatment-At once asepticize and drain any existing wound; apply iodin to the inflamed area and cover it with lint wet with lead-water and laudanum, and if a limb is involved use a roller-bandage and a sling. Instead of iodin and lead water, ichthyol may be applied. Open the bowels. with calomel and salines; order quinin, iron, stimulants, and nourishing diet. If suppuration occurs, make many incisions near together, each cut being 2 or 3 inches long. Spray out by means of hydrogen peroxid in an atomizer, and then wash with corrosive-sublimate solution (1:1000). Drain by means of iodoform gauze in strips. Excise spots of grene. Dress with many layers of gauze wet with a hot solution of corrosive sublimate and covered with a rubberdam; a hot-water bag being laid upon the dressing. If sloughs form, cut them partly away and employ antiseptic poultices. Change dressings often. Antistreptococcic serum. is employed by some. In severe cases employ hypodermoclysis or saline transfusion. When granulations begin to form, treat as a healing wound.

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Cellulitis. In cellulitis redness of the skin is not very pronounced and is late in appearing, following swelling, and not preceding it. It is essentially the same condition as phlegmonous erysipelas, but is often mild in degree. Its spread is heralded by red lines of lymphangitis ascending from an infected wound, swelling of glands, and fever. In slight cases the lymphatics may dispose of the poison and suppuration fail to occur. In severe cases septicemia arises. Cellulitis is usually a result of infection not only with streptococci, but also with other pyogenic cocci.

Treatment-Incise and curet the wound and sear it with pure carbolic acid. Treatment is the same as for the phlegmonous form.

XII. TETANUS, OR LOCKJAW.

Tetanus is an infectious spasmodic disease invariably preceded by some injury. The wound may have been severe, it may have been so slight as to have attracted no attention, or it may have been inflicted upon the alimentary canal by a fish-bone or other foreign body, or may have been situated in the nose, urethra, vagina, or ear. Idiopathic tetanus is either not tetanus at all, or is a term expressive of the fact that we have not found an injury which did exist. This disease is commonest after punctured or lacerated wounds of the hands or feet, and before it appears a wound is apt to suppurate or slough; but in some instances the wound is found soundly healed. Tetanus may appear twenty-four hours after an accident, but it may not arise until several weeks have elapsed. It prevails more in certain localities than in others. Colored people are very susceptible, and it may exist epidemically. Tetanus is due to infection by a bacillus (first described by Nicolaier and first cultivated by Kitasato), the toxic products of which, absorbed from the infected area, poison the nervous system precisely as would dosing with strychnin. This bacillus is found particularly in garden-soil, in the dust of walls, walks, and cellars, in street-dirt, and in the refuse of stables.

Symptoms.-Acute tetanus begins within nine days of an accident. The usual period of incubation is from three to five days. First, the neck feels stiff, and there is difficulty in deglutition, the patient thinking he has taken cold, and next the jaws also become stiff. The neck becomes like an iron bar, and the jaws as rigid as steel. The muscles of deglutition become rigid on attempts at swallowing. The muscles of the back, legs, and abdomen are thrown into tonic spasm, but the arms rarely suffer. If the infected injury is on the hand or foot, that extremity usually is found to be rigid. Spasm of the face-muscles causes the risus sardonicus, or sardonic smile (contraction particularly of the musculus sardonicus of Santorini). The contraction of the muscles of the back is often so powerful as to bend the patient back like a bow and allow him to rest only on his occiput and heels. This condition is known as "opisthotonos." If he is bent forward, so that the face is drawn to the legs, it

is called "emprosthotonos." If his body is curved sideways, it is designated "pleurosthotonos." An upright position is "orthotonos." The spasm may be so violent as to cause muscular rupture.

The state is one of widely diffused tonic spasm, aggravated frequently by clonic spasms arising from peripheral irritations. These irritations may be draughts, sounds, lights, shaking of the bed, attempts at swallowing, contact of the bed-clothing, the presence of urine in the bladder or of feces in the rectum, or various visceral actions. The agonizing "girdle-pain" so often met with is from spasm of the diaphragm. Each clonic spasm causes a hideous scream by the constriction of the chest forcing air through a contracted glottis. Constipation is persistent; retention of urine is the rule (because of sphincter spasm). The mind is entirely clear until near the end-one of the worst elements of the disease. Swallowing in many cases is impossible. Talking is very difficult and it is impossible to project the tongue. The muscles throughout the body feel very sore. The temperature may be normal, but it is usually a little elevated, and always rises just before death. Hyperpyrexia sometimes occurs (1080-110°), and the temperature may even ascend for a time after death. Insomnia is obstinate. Death almost invariably occurs in acute tetanus in two or three days. It may be due to exhaustion or to carbonic-acid narcosis from spasm of the glottis or fixation of the respiratory muscles.

Chronic tetanus comes on late after a wound (from ten days to several weeks). The symptoms are not so severe; the muscular spasm is widespread, but it may not be persistent, intervals of relaxation permitting sleep and the taking of food. It may last some weeks, and not infrequently the disease can be cured. Trismus is a mild form of tetanus, the contractions being limited to the face and jaw. Trismus neonatorum or trismus nascentium, which is lockjaw in the newborn, is due to infection of the stump of the umbilical cord, and is invariably fatal. Hydrophobic tetanus, head tetanus, or cephalic tetanus, is a condition in which the spasms are confined chiefly to the face, pharynx, and neck, although the abdominal muscles are usually also rigid. It follows head-injuries, and gives a better prognosis than does general tetanus.

Diagnosis.-Tetanus may be confounded with strychninpoisoning or with hysteria. Wood's table makes the diagnosis clear:1

1 Nervous Diseases, by Prof. H. C. Wood.