When the muscles of the back become spasmodically contracted, the body is raised from the bed, sometimes to such an extent that the patient rests only on his heels and occiput—­the position of opisthotonos.  Lateral arching of the body from excessive action of the muscles on one side—­pleurosthotonos—­is not uncommon, the arching usually taking place towards the side on which the wound of infection exists.  Less frequently the body is bent forward so that the knees and chin almost meet (emprosthotonos).  Sometimes all the muscles simultaneously become rigid, so that the body assumes a statuesque attitude (orthotonos).  When the thoracic muscles, including the diaphragm, are thrown into spasm, the patient experiences a distressing sensation as if he were gripped in a vice, and has extreme difficulty in getting breath.  Between the attacks the limbs are kept rigidly extended.  The clonic spasms may be so severe as to rupture muscles or even to fracture one of the long bones.

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.