t
by pain accompanying the spasms; the muscles are found to be hard and
there are frequent twitchings of the limb. A characteristic reflex is
present in the lower extremity, namely, extension of the foot and leg
when the sole is tickled.

_Cephalic Tetanus_ is another localised variety which follows injury in
the distribution of the facial nerve. It is characterised by the
occurrence on the same side as the injury, of facial spasm, rapidly
followed by more or less complete paralysis of the muscles of
expression, with unilateral trismus and difficulty in swallowing. Other
cranial nerves, particularly the oculomotor and the hypoglossal, may
also be implicated. A remarkable feature of this condition is that
although the muscles are irresponsive to ordinary physiological stimuli,
they are thrown into spasm by the abnormal impulses of tetanus.

_Trismus._--This term is used to denote a form of tetanic spasm limited
to the muscles of mastication. It is really a mild form of chronic
tetanus, and the prognosis is favourable. It must not be confused with
the fixation of the jaw sometimes associated with a wisdom-tooth
gumboil, with tonsillitis, or with affections of the temporo-mandibular
articulation.

_Tetanus neonatorum_ is a form of tetanus occurring in infants of about
a week old. Infection takes place through the umbilicus, and manifests
itself clinically by spasms of the muscles of mastication. It is almost
invariably fatal within a few days.

_Prophylaxis._--Experience in the European War has established the
fact that the routine injection of anti-tetanic serum to all patients
with lacerated and contaminated wounds greatly reduces the frequency of
tetanus. The sooner the serum is given after the injury, the more
certain is its effect; within twenty-four hours 1500 units injected
subcutaneously is sufficient for the initial dose; if a longer period
has elapsed, 2000 to 3000 units should be given intra-muscularly, as
this ensures more rapid absorption. A second injection is given a week
after the first.

The wound must be purified in the usual way, and all instruments and
appliances used for operations on tetanic patients must be immediately
sterilised by prolonged boiling.

_Treatment._--When tetanus has developed the main indications are to
prevent the further production of toxins in the wound, and to neutralise
those that have been absorbed into the nervous system. Thorough
purification with antiseptics, excisio