The boy was admitted into the hospital on November 12th, two weeks after his complaint of chilliness. It was noted that he bad no marks of external injury. His face was drawn from contraction of the muscles, and there was risus sardonicus. Occasionally his body became quite stiff, his arms and legs rigid and extended, the abdominal muscles hard and the muscles of the nucha contracted. There was no opisthotonos. These at tacks generally came on at night. On the night of November 14th he had nine of the spasms, on the 15th, ten. He often bit his tongue. During the first few days his pulse was 80 ; temperature, 99-101° ; respiration, 20-24. The lungs and heart were healthy.
On the 16th, at 6 P.M., he began to take calabar bean extract, one-sixth of a grain every half hour. This reduced his pulse in a few hours to 54. On the 17th it was noticed : " Abdominal muscles feel hard, and there is much rigidity of the back of the neck. No stiffness of joints of arms or legs. Can only partially open mouth, when he does so the muscles under the chin become very stiff, but are painless. Keeps his eyes closed although light is not distressing to them. Cheeks and eyelids rather red. His face has a peculiar drawn expression ; nostrils widely open. Tongue sore from biting. Has no difficulty in swallowing. When asleep, the muscles are much less rigid than when he is awake, unless during the actual spasm. Temperature at 9 A.m., 98.2° ; pulse, 72, small and compressible, regular in force but not in rhythm ; respiration, 22." During the whole of the 17th the boy had only one paroxysm. In the course of the following night he had three attacks. At 10 P.M, on this night (the 17th), his pulse being only 48, the medicine was ordered to be given every hour instead of half hour. After this the spasms became fewer and less severe and the rigidity of the muscles gradually relaxed. The spasms still continued to occur at times during sleep, but they usu ally subsided at once when the child was roused. The bean extract was stopped on the 25th. His improvement continued and the patient was pronounced convalescent on December 12th. The last muscles to become completely relaxed were those of the abdominal wall.
Diagnosis.—Infantile tetanus is a disease which it is not easy to mistake. Violent paroxysms of tonic rigidity in which the jaws are set, the chest is fixed, the muscles generally are stiff and hard, and the face becomes dusky and drawn—these seizures occurring without twitching or sign of clonic spasm, and followed by intervals of only partial relaxation, are very char acteristic.
In older children it is important to distinguish between tetanus and the symptoms of strychnia poisoning. According to Sir Robert Christison, tetanus does not kill so quickly as a poisonous dose of strychnia. Moreover, in tetanus the symptoms become developed gradually ; in strychnia poi soning the convulsions very rapidly become general, and a perfect fit is de veloped in an hour, or even more quickly still. If strychnia have been given in carefully graduated doses, the distinction is less easy, but even in these cases there are very decided differences. Tetanus begins gradu ally and always runs a continuous course. Sir B. Brodie declared that he had never known a case of tetanus to begin, then subside, and then begin again in-twenty-four hours. This continuity of symptoms would be diffi cult to simulate even by the most carefully graduated doses of the poison. Again, in strychnia poisoning the upper extremities are affected early ; in tetanus they are implicated late, and the fingers last of all. The facies, too, of tetanus is very peculiar. The forehead is wrinkled perpendicularly and transversely, the eyebrows being drawn towards one another in a very remarkable manner. The eyes are not fully opened ; there is a "peering look " which is very characteristic, and after a time the eyeball becomes painfully sunken from tetanic contraction of its muscles. In strychnia poisoning the eyelids are widely opened and the eyeballs protrude.
Prognosis.—So few children recover from this disease that the prog nosis is always very unfavourable. Dr. Lewis Smith has collected forty cases, of which thirty-two died and eight recovered. This is a large pro portion of recoveries, but statistics gathered from published cases alone probably represent but feebly the fatal nature of the illness ; for in so mortal a disease it is likely that matey more successes than failures would be placed upon record. Early occurrence of the symptoms after birth, great violence of the spasms, shortness of the period of remission, and a very high temperature should excite the gravest apprehensions. The most favourable cases are those in which the disease appears after the first week has passed. The symptoms are then as a rule less severe, and sometimes deglutition is unaffected. The ability or inability of the child to swallow is an important element in the case. If he still continue capa ble of swallowing milk from a spoon, we are justified in entertaining some hope of ultimate recovery.