592 LEWELLYS F. BARKER 



M. splenius capitis et cervicis of each side. An attitude of torticollis ap- 

 pears whemthe contracture involves predominantly the M. sternocleido- 

 mastoideus and the obliquus capitis inferior of one side. 



In the face, trismus may appear, owing to spasm of the M. masseter 

 on each side. Sometimes all the muscles of the face are rigid and 

 immohile, yielding the so-called "ietany face." If the M. orbicularis 

 be especially involved, the lips may be pointed. A fish mouth attitude 

 (carp mouth) has been described by some observers, due probably to 

 drawing of the angles of the mouth downward by spasm in the Mm. 

 quadrat! labii inferioris. 



The characteristics of the tetany face are worthy of detailed descrip- 

 tion. Since carpopedal spasms, so characteristic of the manifest tetany 

 of adults, are often absent in the tetany of children, any criterion that will 

 help in the early recognition of infantile tetany must be gratefully wel- 

 comed. Uffenheimer (1005;, of Munich, drew attention to the fact that 

 a large number of children, suffering from tetany, exhibit a peculiai 

 facial expression, which deviates extraordinarily from that of normal 

 healthy children of the same age. The specific childlike features of the 

 face disappear and in their place one observes an expression of "reflec- 

 tion" or of "care" (Fig. 3). Uffenheimer, speaking of this to his 

 colleagues, described the facial expression as knifflichen verschlagenen. 

 This peculiar change in the facial expression depends on the fact that 

 the muscles of the face; ,are under a certain degree of tension. There 

 exists, in other words, the very slightest state of tonic spasm of the facial 

 muscles. It is the smallest expression of that tonic spasm that we have 

 learned to recognize in true tetanus as "risus sardonicus," due to perma- 

 nent spasm of the mimic musculature. Finkelstein (a) had earlier pointed 

 out, in his textbook on the diseases of sucklings, that participation of the 

 face in the rigidity of tetany produces a peculiar stiffness with permanent 

 contraction of the M. corrugator or of the M. orbicularis oris (carp mouth). 

 And Escherich (/>), in 1003, had observed an irritable frightened behavior 

 of the children, with an anxious expression and an increased tonus of the 

 musculature of the face. But Uffenheimei 1 emphasized the increased 

 tonus and a reflective, careworn look, rather than an anxious expression. 

 On analysis, the muscles concerned in the slight spasm that gives rise co 

 the tetany face are all innervated by the N. facialis. In the first place, 

 the M. nrbicularis oris (pointing the lips), the M. zygomaticus and 

 the M. (juadniti labii inferioris (drawing the angles of the mouth 

 to the side and downward) participate in the spasm. Their contractures 

 together give the reflective look to the face, and this is strengthened by 

 the wrinkling of the forehead transversely and the elevation of the eye- 

 brows (duo to slight spasm of the M. epicranius), and especially by 

 the slight frowning, or longitudinal wrinkling on both sides of the 

 root of the nose, due mainly to contraction of the M. corrugator on 



