nes.

As time goes on, the clonic exacerbations become more and more frequent,
and the slightest external stimulus, such as the feeling of the pulse, a
whisper in the room, a noise in the street, a draught of cold air, the
effort to swallow, a question addressed to the patient or his attempt to
answer, is sufficient to determine an attack. The movements are so
forcible and so continuous that the nurse has great difficulty in
keeping the bedclothes on the patient, or even in keeping him in bed.

The general condition of the patient is pitiful in the extreme. He is
fully conscious of the gravity of the disease, and his mind remains
clear to the end. The suffering induced by the cramp-like spasms of the
muscles keeps him in a constant state of fearful apprehension of the
next seizure, and he is unable to sleep until he becomes utterly
exhausted.

The temperature is moderately raised (100 to 102 F.), or may remain
normal throughout. Shortly before death very high temperatures (110 F.)
have been recorded, and it has been observed that the thermometer
sometimes continues to rise after death, and may reach as high as
112 F. or more.

The pulse corresponds with the febrile condition. It is accelerated
during the spasms, and may become exceedingly rapid and feeble before
death, probably from paralysis of the vagus. Sudden death from cardiac
paralysis or from cardiac spasm is not uncommon.

The respiration is affected in so far as the spasms of the respiratory
muscles produce dyspnoea, and a feeling of impending suffocation which
adds to the horrors of the disease.

One of the most constant symptoms is a copious perspiration, the patient
being literally bathed in sweat. The urine is diminished in quantity,
but as a rule is normal in composition; as in other acute infective
conditions, albumen and blood may be present. Retention of urine may
result from spasm of the urethral muscles, and necessitate the use of
the catheter.

The fits may cease some time before death, or, on the other hand, death
may occur during a paroxysm from fixation of the diaphragm and arrest of
respiration.

_Differential Diagnosis._--There is little difficulty, as a rule, in
diagnosing a case of fulminating tetanus, but there are several
conditions with which it may occasionally be confused. In _strychnin
poisoning_, for example, the spasms come on immediately after the
patient has taken a toxic dose of the drug; they are clonic in
character, but