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 KLEINER
GARDNER’S

GARDNER’S
ART THROUGH
THE AGES
A Concise Global History
FOURTH EDITION
FRED S. KLEINER

ART THROUGH THE AGES

FOURTH EDITION
A Concise Global History
To register or access your online learning solution or purchase materials
for your course, visit www.cengagebrain.com.
 G a r d n e r’ s

Art
Thro u g h t h e
Ages
 G a r d n e r’ s

Art
Thro u g h t h e
Ages
A C onc ise Gl oba l H is tory

fourth edition

fred s. kleiner

Australia • Brazil • Mexico • Singapore • United Kingdom • United States

 Gardner’s Art through the Ages:
A Concise Global History, Fourth Edition
Fred S. Kleiner
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Cover Image: Summer Trees, Heritage Images,
© The British Museum
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About the Cover Art

Song Su-nam, Summer Trees, 1983. Ink on paper, 2' 1 58 " high. British Museum, London.

Song Su-nam (b. 1938), a Korean artist who was one of the founders of the Oriental Ink Movement of the
1980s, has very successfully combined native Asian and Western traditions in his paintings. Song’s Summer
Trees, painted in 1983, owes a great deal to the Post-Painterly Abstraction movement of mid-20th-century
America and to the work of painters such as Helen Frankenthaler (1928–2011) and especially Morris Louis
(1912–1962). But in place of those painters’ acrylic resin on canvas, Song used ink on paper, the centuries-old
preferred medium of East Asian literati (scholar-artists). He forsook, however, the traditional emphasis on
brushstrokes to explore the subtle tonal variations that broad stretches of ink wash make possible. Nonethe-
less, the painting’s name recalls the landscapes of earlier Korean and Chinese masters. This simultaneous
respect for tradition and innovation has been a hallmark of art from both China and Korea throughout their
long histories. The fruitful exchange between Western and non-Western artistic traditions is one of the chief
characteristics of the global art scene today.
Song’s distinctive personal approach to painting characterizes the art of the modern era in general,
but it is not typical of many periods of the history of art when artists toiled in anonymity to fulfill the
wishes of their patrons, whether Egyptian pharaohs, Roman emperors, or medieval monks. Art through the
Ages: A Concise Global History surveys the art of all periods from prehistory to the present, and worldwide,
and examines how artworks of all kinds have always reflected the historical contexts in which they were
created.
Brief Contents

Preface  xv Ch a pter 13
Impressionism, Post-Impressionism, and Symbolism,
I ntro duct io n
1870 to 1900   356
What Is Art History?   1
Ch a pter 14
Chapter 1
Modernism in Europe and America, 1900 to
Prehistory and the First Civilizations   14 1945  376
Chapter 2 Ch a pter 15
Ancient Greece  44 Modernism and Postmodernism in Europe and
Chapter 3 America, 1945 to 1980   410
The Roman Empire   82 Ch a pter 16
Chapter 4 Contemporary Art Worldwide   438
Early Christianity and Byzantium   116 Ch a pter 17
Chapter 5 South and Southeast Asia   460
The Islamic World   142 Ch a pter 18
Chapter 6 China and Korea   482
Early Medieval and Romanesque Europe   156 Ch a pter 19
Chapter 7 Japan  506
Gothic and Late Medieval Europe   186 Ch a pter 20
Chapter 8 Native Americas and Oceania   526
The Early Renaissance in Europe   216
Ch a pter 21
Chapter 9 Africa  554
High Renaissance and Mannerism in Europe   250
Notes  573
C hap t e r 10
Baroque Europe  284 Glossary  575
Bibliography  591
C hap t e r 11
Credits  603
Rococo to Neoclassicism in Europe and America   312
Index  607
C h a p t e r 12
Romanticism, Realism, and Photography, 1800
to 1870  330

vii
Contents

Preface  xv The Greeks and Their Gods   46

Prehistoric Aegean  47
Intro du ction
Greece  53
What Is Art History?  1 ■ R e l i g i o n a n d M y t h o l o g y: The Gods and Goddesses
Art History in the 21st Century   2 of Mount Olympus   47

■ A r c h i t e c t u r a l Ba s i c s : Doric and Ionic Temples   57

Different Ways of Seeing   13
■ Mat e r ia l s a n d T e c h n i q u e s : Hollow-Casting Life-
Size Bronze Statues   64

1 Prehistory and
■ P r o b l e m s a n d S o l u t i o n s : Polykleitos’s Prescription
for the Perfect Statue   65
the First Civilizations 14 ■ Mat e r ia l s a n d T e c h n i q u e s : White-Ground
Painting  72
F r a m i ng t h e E r a Pictorial Narration in Ancient
M a p 2 - 1 The Greek world   46
Sumer  15
Ti m e l i n e 16 THE BIG P ICTURE 81

Prehistory  16
Ancient Mesopotamia and Persia   22
3 The Roman Empire 82
Ancient Egypt  30
Framin g t h e Era Roman Art as Historical
■ P r o b l e m s a n d S o l u t i o n s : How to Represent
an Animal  17 ­Fiction  83
■ A r t a n d S o c i e t y: Why Is There Art in Paleolithic Ti m e l i n e 84
Caves?  18
Rome, Caput Mundi   84
■ P r o b l e m s a n d S o l u t i o n s : How Many Legs Does
a ­Lamassu Have?  27 Etruscan Art  85
■ A r t a n d S o c i e t y: Mummification and Immortality   32 Roman Art  88
■ P r o b l e m s a n d S o l u t i o n s : Building the Pyramids ■ A r t a n d S o c i e t y: Who’s Who in the Roman World   90
of Gizeh  34
■ A r c h i t e c t u r a l Ba s i c s : Roman Concrete
M a p 1 - 1 Stone Age sites in western Europe   16 Construction  92
M a p 1 - 2 Ancient Mesopotamia and Persia   22 ■ A r c h i t e c t u r a l Ba s i c s : The Roman House   93
M a p 1 - 3 Ancient Egypt  30 ■ P r o b l e m s a n d S o l u t i o n s : The Spiral Frieze of the
Column of Trajan   104
THE B IG PICTURE 43
■ P r o b l e m s a n d S o l u t i o n s : The Ancient World’s
Largest Dome  106

2 Ancient Greece 44
■ P r o b l e m s a n d S o l u t i o n s : Tetrarchic
Portraiture  112

F r a m i ng t h e E r a The Perfect Temple   45 M a p 3 - 1 The Roman Empire at the death of Trajan in 117 ce  84

Ti m e l i n e 46 THE BIG P ICTURE 115

ix
 ■ P r o b l e m s a n d S o l u t i o n s : Beautifying God’s
4 Early Christianity and Byzantium 116 Words  161

■ R e l i g i o n a n d M y t h o l o g y: Medieval Monasteries
F ram i ng t he E r a Romans, Jews, and Benedictine Rule   165
and Christians  117 ■ A r t a n d S o c i e t y: Pilgrimages and the Veneration of
Ti m e l i n e 118 Relics  170

■ A r c h i t e c t u r a l Ba s i c s : The Romanesque Church

Early Christianity  118 Portal  173
Byzantium  124 ■ T h e Pat r o n ’ s V o i c e : Terrifying the Faithful at Autun   175
■ R e l i g i o n a n d M y t h o l o g y: Jewish Subjects in M a p 6 - 1 Western Europe around 1100   158
­Christian Art  119
THE BIG P ICTURE 185
■ R e l i g i o n a n d M y t h o lo g y: The Life of Jesus in Art   120

■ Mat e r ia l s a n d T e c h n i q u e s : Mosaics  124

■ P r o b l e m s a n d S o l u t i o n s : Picturing the Spiritual

World  125
7 Gothic and Late Medieval ­Europe 186
■ P r o b l e m s a n d S o l u t i o n s : Placing a Dome over a Framin g t h e Era “Modern Architecture” in
Square  128 the Gothic Age   187
■ A r t a n d S o c i e t y: Icons and Iconoclasm   134 Ti m e l i n e 188
M a p 4 - 1 The Byzantine Empire at the death of Justinian “Gothic” Europe  188
in 565  118
France  189
THE BIG PICTURE 141
England  201
Holy Roman Empire   202
5 The Islamic World 142 Italy  205
F ram i ng t he E r a The Rise and Spread ■ A r c h i t e c t u r a l Ba s i c s : The Gothic Rib Vault   190
of Islam  143 ■ P r o b l e m s a n d S o l u t i o n s : Building a High Gothic
Ti m e l i n e 144 ­Cathedral  193

■ Mat e r ia l s a n d T e c h n i q u e s : Stained-Glass
Muhammad and Islam   144 ­Windows  195
Architecture  144 ■ A r t a n d S o c i e t y: Gothic Book Production   199

Luxury Arts  151 ■ Mat e r ia l s a n d T e c h n i q u e s : Fresco Painting  208

■ R e l i g i o n a n d M y t h o l o g y: Muhammad M a p 7- 1 Europe around 1200   188

and Islam  145
THE BIG P ICTURE 215
■ A r c h i t e c t u r a l Ba s i c s : The Mosque  147

M a p 5 - 1 The Islamic world around 1500   144

THE BIG PICTURE 155 8 The Early Renaissance in Europe 216

Framin g t h e Era Rogier van der Weyden

and Saint Luke   217
6 Early Medieval and Romanesque Ti m e l i n e 218

Europe 156 The Early Renaissance in Europe   218

F ram i ng t he E r a The Door to Salvation   157 Burgundy and Flanders   219
Ti m e l i n e 158 France  224
Early Medieval Europe   158 Holy Roman Empire   226
Romanesque Europe  169 Italy  229

x Contents
■ Mat e r ia l s a n d T e c h n i q u e s : Tempera and Oil ■ P r o b l e m s a n d S o l u t i o n s : Rethinking the Church
­Painting  220 ­Facade  291
■ Mat e r ia l s a n d T e c h n i q u e s : Woodcuts, Engravings, ■ A r t i s t s o n A r t: The Letters of Artemisia Gentileschi   294
and Etchings  228
■ P r o b l e m s a n d S o l u t i o n s : How to Make a Ceiling
■ P r o b l e m s a n d S o l u t i o n s : Linear and Atmospheric Disappear  295
Perspective  232
■ P r o b l e m s a n d S o l u t i o n s : Franz Hals’s Group
M a p 8 - 1 France, the duchy of Burgundy, and the Holy Roman Portraits  300
­Empire in 1477   218
■ A r t i s t s o n A r t: Poussin’s Notes for a Treatise on
M a p 8 - 2 Italy around 1400   229 Painting  307

THE B IG PICTURE 249 M a p 1 0 - 1 Europe in 1648 after the Treaty of Westphalia   286

THE BIG P ICTURE 311

9 High Renaissance and

Mannerism in Europe 250 11 Rococo to Neoclassicism
in Europe and America 312
F r a m i ng t h e E r a Michelangelo in the Service
of Julius II  251 Framin g t h e Era The Enlightenment, Angelica
Ti m e l i n e 252 Kauffman, and Neoclassicism   313
Italy  252 Ti m e l i n e 314

Holy Roman Empire   272 A Century of Revolutions   314

France  277 Rococo  314

The Netherlands  277 The Enlightenment  316

Spain  281 Neoclassicism  323
■ P r o b l e m s a n d S o l u t i o n s : Rethinking the Basilican ■ A r t a n d S o c i e t y: Joseph Wright of Derby and the
Church  264 ­Industrial Revolution  317

M a p 9 - 1 Europe in the early 16th century   252 ■ P r o b l e m s a n d S o l u t i o n s : Grand Manner

­Portraiture  320
THE B IG PICTURE 283 ■ A r t a n d S o c i e t y: The Grand Tour and Veduta Painting   322

■ A r t i s t s o n A r t: Jacques-Louis David on Greek Style and

Public Art  324
10 Baroque Europe 284 THE BIG P ICTURE 329

F r a m i ng t h e E r a Baroque Art
and ­Spectacle  285
Ti m e l i n e 286
12 Romanticism, Realism,
and ­Photography, 1800 to 1870 330
Europe in the 17th Century   286
Italy  287 Framin g t h e Era The Horror—and Romance—
of Death at Sea   331
Spain  295
Ti m e l i n e 332
Flanders  298
Art under Napoleon   332
Dutch Republic  300
Romanticism  334
France  306
Realism  341
England  310
Architecture  348
■ P r o b l e m s a n d S o l u t i o n s : Completing Saint
­Peter’s  288 Photography  351

Contents xi
■ A r t a n d S o c i e t y: The Romantic Spirit in Art, Music, Ti m e l i n e 378
and Literature  335
Global Upheaval and Artistic Revolution   378
■ A r t i s t s o n A r t: Delacroix on David and
Neoclassicism  337 Europe, 1900 to 1920   378
■ P r o b l e m s a n d S o l u t i o n s : Unleashing the Emotive
United States, 1900 to 1930   390
Power of Color   340

■ A r t i s t s o n A r t: Gustave Courbet on Realism   342 Europe, 1920 to 1945   393

■ Mat e r ia l s a n d T e c h n i q u e s : Lithography  345
■ A r t a n d S o c i e t y: Edmonia Lewis, an African American
Sculptor in Rome   347
■ P r o b l e m s a n d S o l u t i o n s : Prefabricated
­Architecture  350
United States and Mexico, 1930 to 1945   399
Architecture  405
■ A r t i s t s o n A r t: Henri Matisse on Color   379
■ A r t i s t s o n A r t: Futurist Manifestos  387

■ Mat e r ia l s a n d T e c h n i q u e s : Daguerreotypes, ■ A r t a n d S o c i e t y: The Armory Show   391

­Calotypes, and Wet-Plate Photography   352
■ W r i t t e n S o u r c e s : André Breton’s First Surrealist
M a p 1 2 - 1 Europe around 1850   332 ­Manifesto  395

THE BIG PICTURE 355 ■ A r t a n d S o c i e t y: Jacob Lawrence’s Migration of

the ­Negro  402

M a p 1 4 - 1 Europe at the end of World War I   380

13 Impressionism, Post-Impressionism, THE BIG P ICTURE 409

and Symbolism, 1870 to 1900 356
F ram i ng t he E r a Modernism at the Folies-
Bergère  357
15 Modernism and Postmodernism
in Europe and America, 1945 to 1980 410
Ti m e l i n e 358
Framin g t h e Era After Modernism: Post­
Marxism, Darwinism, Modernism   358
modernist Architecture  411
Impressionism  360 Ti m e l i n e 412
Post-Impressionism  364 The Aftermath of World War II   412
Symbolism  370 Painting, Sculpture, and Photography   412
Sculpture  372 Architecture and Site-Specific Art   429
Architecture  373 Performance and Conceptual Art and New Media   434
■ P r o b l e m s a n d S o l u t i o n s : Painting Impressions ■ A r t i s t s o n A r t: Jackson Pollock on Action Painting   415
of Light and Color   359
■ A r t i s t s o n A r t: Helen Frankenthaler on Color-Field
■ A r t a n d S o c i e t y: Women Impressionists  363 ­Painting  417
■ A r t i s t s o n A r t: The Letters of Vincent van Gogh   366 ■ A r t a n d S o c i e t y: Pop Art and Consumer Culture   421
■ P r o b l e m s a n d S o l u t i o n s : Making Impressionism ■ A r t i s t s o n A r t: Judy Chicago on The Dinner Party   427
Solid and Enduring   369

M a p 1 3 - 1 France around 1870 with towns along the Seine   358 THE BIG P ICTURE 437

THE BIG PICTURE 375

16 Contemporary Art Worldwide 438

14 Modernism in Europe and America, Framin g t h e Era Art as Sociopolitical

1900 to 1945 376 ­Message  439
Ti m e l i n e 440
F ram i ng t he E r a Picasso Disrupts the Western
Pictorial Tradition  377 Art Today  440

xii Contents
Personal and Group Identity   440 ■ Mat e r ia l s a n d T e c h n i q u e s : Chinese Painting
­Materials and Formats   491
Political and Social Commentary   445
■ Mat e r ia l s a n d T e c h n i q u e s : Calligraphy and
Representation and Abstraction   448 ­Inscriptions on Chinese Paintings   493

■ A r c h i t e c t u r a l Ba s i c s : Chinese Wood
Architecture and Site-Specific Art   451 ­Construction  494
New Media  456 ■ Mat e r ia l s a n d T e c h n i q u e s : Chinese Porcelain  497
■ A r t a n d S o c i e t y: Public Funding of Controversial ■ P r o b l e m s a n d S o l u t i o n s : Planning an Unplanned
Art  443 Garden  498
■ P r o b l e m s a n d S o l u t i o n s : Rethinking the Shape of M a p 1 8 - 1 China during the Ming dynasty   484
Painting  450
THE BIG P ICTURE 505
■ A r t a n d S o c i e t y: Maya Lin’s Vietnam Veterans
­Memorial  454

A r t a n d S o c i e t y: Richard Serra’s Tilted Arc  455

19
■
Japan 506
THE B IG PICTURE 459
Framin g t h e Era The Floating World
of Edo  507
17 South and Southeast Asia 460 Ti m e l i n e 508

F r a m i ng t h e E r a The Great Stupa at Japan before Buddhism   508

­Sanchi  461 Buddhist Japan  509
Ti m e l i n e 462
Japan under the Shoguns   513
South Asia  462
Modern Japan  523
Southeast Asia  477 ■ R e l i g i o n a n d M y t h o l o g y: Zen Buddhism  515
■ A r c h i t e c t u r a l Ba s i c s : The Stupa  465 ■ A r t a n d S o c i e t y: The Japanese Tea Ceremony   518
■ R e l i g i o n a n d M y t h o l o g y: Buddhism and Buddhist ■ Mat e r ia l s a n d T e c h n i q u e s : Japanese Woodblock
Iconography  466 Prints  522
■ R e l i g i o n a n d M y t h o l o g y: Hinduism and Hindu M a p 1 9 - 1 Japan  508
­Iconography  469

■ A r c h i t e c t u r a l Ba s i c s : Hindu Temples  471 THE BIG P ICTURE 525

■ Mat e r ia l s a n d T e c h n i q u e s : Indian Miniature

­Painting  474

M a p 1 7- 1 South and Southeast Asia   462 20 Native Americas and Oceania 526

THE B IG PICTURE 481 Framin g t h e Era War and Human Sacrifice

in Ancient Mexico   527
Ti m e l i n e 528
18 China and Korea 482 Native Americas  528
F r a m i ng t h e E r a The Forbidden City   483 Oceania  546
Ti m e l i n e 484 ■ A r t a n d S o c i e t y: The Mesoamerican Ball Game   532

China  484 ■ P r o b l e m s a n d S o l u t i o n s : The Underworld, the Sun,

and Mesoamerican Pyramid Design   534
Korea  501
■ R e l i g i o n a n d M y t h o l o g y: Aztec Religion  537
■ A r t a n d S o c i e t y: The First Emperor’s Army in the
­Afterlife  486 ■ A r t a n d S o c i e t y: Nasca Lines  539

■ R e l i g i o n a n d M y t h o l o g y: Daoism and ■ A r t a n d S o c i e t y: Tattoo in Polynesia   549

­Confucianism  488 M a p 2 0 - 1 Mesoamerica  528

Contents xiii
M a p 2 0 - 2 Andean South America   538 20th Century  566
M a p 2 0 - 3 Native American sites in the United States and ■ A r t a n d S o c i e t y: Art and Leadership in Africa   559
southern Canada  542
■ A r t a n d S o c i e t y: African Artists and Apprentices   567
M a p 2 0 - 4 Oceania  547
■ A r t a n d S o c i e t y: African Masquerades  568
THE BIG PICTURE 553
M a p 2 1 - 1 Africa  556

THE BIG P ICTURE 571

21 Africa 554

F ram i ng t he E r a The Royal Arts of Benin   555

Notes  573
Ti m e l i n e 556
Glossary  575
African Peoples and Art Forms   556
Bibliography  591
Prehistory and Early Cultures   557
Credits  603
11th to 18th Centuries   558
Index  607
19th Century  562

xiv Contents
Preface
I take great pleasure in introducing the extensively revised and
expanded 4th edition of Gardner’s Art through the Ages: A Concise
Global History, which for the first time is, like the unabridged 15th
edition published last year, a hybrid textbook—the only introductory
survey of the history of art and architecture of its kind. This innova-
tive new type of “Gardner” retains all of the best features of traditional
books on paper while harnessing 21st-century technology to increase
the number of works and themes discussed without enlarging the size
of the printed book—and at negligible additional cost to the reader.
When Helen Gardner published the first edition of Art through
the Ages in 1926, she could not have imagined that nearly a cen-
tury later instructors all over the world would still be using her
textbook in their classrooms. (The book has even been translated
into Mandarin Chinese.) Nor could Professor Gardner have fore-
seen that a new publisher would make her text available in special
editions corresponding to a wide variety of introductory art history
courses ranging from yearlong global surveys to Western- and non-
Western-only surveys to the one-semester course for which this
concise edition was designed. Indeed, if Helen Gardner were alive
today, she would not recognize the book that long ago became—and
remains—the world’s most widely read introduction to the history
of art and architecture. I hope that instructors and students alike
will agree that this new edition lives up to that venerable tradition
and, in fact, exceeds their high expectations.
key features of the 4th edition
For the 4th concise edition of Art through the Ages, in addition to
updating the text of every chapter to incorporate the latest research, I
have added several important new features while retaining the basic
format and scope of the previous edition. The new edition boasts
more photographs, plans, and drawings than the previous three ver-
sions of the book, nearly all in color and reproduced according to
the highest standards of clarity and color fidelity. The illustrations
include a new set of maps and scores of new images, among them
a series of superb photographs taken by Jonathan Poore exclusively
for Art through the Ages in Germany and Italy (following similar
forays into France and Italy in 2009–2011). The online MindTap®
component also includes custom videos made by Sharon Adams
Poore during those five photo campaigns. This extraordinary new
archive of visual material ranges from ancient temples in Rome; to
medieval, Renaissance, and Baroque churches in France, Germany,
and Italy; to such modern masterpieces as Notre-Dame-du-Haut in
Ronchamp, France, and the Bauhaus in Dessau, Germany. The 4th
edition also features an expanded number of the highly acclaimed
architectural drawings of John Burge. Together, these exclusive pho-
tographs, videos, maps, and drawings provide readers with a visual
feast unavailable anywhere else.
Once again, scales accompany the photograph of every paint-
ing, statue, or other artwork discussed—another distinctive feature
of the Gardner text. The scales provide students with a quick and
effective way to visualize how big or small a given artwork is and its
relative size compared with other objects in the same chapter and
throughout the book—especially important given that the illus-
trated works vary in size from tiny to colossal.
Also retained in this edition are the Quick-Review Captions
(brief synopses of the most significant aspects of each artwork or
building illustrated) that students have found invaluable when pre-
paring for examinations. These extended captions accompany not
only every image in the printed book but also all the digital images
in the MindTap version of the text. Each chapter also again ends with
the highly popular full-page feature called The Big Picture, which
sets forth in bullet-point format the most important characteristics
of each period or artistic movement discussed in the chapter. Also
retained from the third edition are the timelines summarizing the
major artistic and architectural developments during the era treated
(again in bullet-point format for easy review) and the chapter-opening
essays called Framing the Era discussing a characteristic painting,
sculpture, or building and illustrated by four photographs.
Boxed essays on special topics again appear throughout the
book as well. These essays fall under eight broad categories, three of
which are new to the fourth edition:
Architectural Basics boxes provide students with a sound foun-
dation for the understanding of architecture. These discussions are
concise explanations, with drawings and diagrams, of the major
aspects of design and construction. The information included is essen-
tial to an understanding of architectural technology and terminology.
Materials and Techniques essays explain the various media
that artists have employed from prehistoric to modern times. Since
materials and techniques often influence the character of artworks,
these discussions contain important information on why many
monuments appear as they do.
Religion and Mythology boxes introduce students to the princi-
pal elements of the world’s great religions, past and present, and to
the representation of religious and mythological themes in painting
and sculpture of all periods and places. These discussions of belief
systems and iconography give readers a richer understanding of
some of the greatest artworks ever created.
Art and Society essays treat the historical, social, political, cul-
tural, and religious context of art and architecture. In some instances,
specific monuments are the basis for a discussion of broader themes.
In the Artists on Art boxes, artists and architects throughout
history discuss both their theories and individual works.
New to the 4th edition are three new categories of boxed essays:
Written Sources, The Patron’s Voice, and Problems and Solutions.
The first category presents and discusses key historical documents
illuminating major monuments of art and architecture throughout
the world. The passages quoted permit voices from the past to speak
directly to the reader, providing vivid insights into the creation of art-
works in all media. The Patron’s Voice essays underscore the important
xv
roles that individuals and groups played in determining the character
of the artworks and buildings that they commissioned and paid for.
The new Problems and Solutions boxes are designed to make students
think critically about the decisions that went into the making of every
painting, sculpture, and building from the Old Stone Age to the pres-
ent. These essays address questions of how and why various forms
developed, the problems that painters, sculptors, and architects con-
fronted, and the solutions that they devised to resolve them.
Other noteworthy features retained from the 3rd edition are
the (updated) bibliography of books in English; a glossary contain-
ing definitions of all italicized terms introduced in both the printed
text and MindTap essays; and a complete museum index, now
housed online only, listing all illustrated artworks by their present
location. The host of state-of-the-art MindTap online resources are
enumerated on page xxi.
acknowledgments
A work as extensive as a global history of art could not be undertaken
or completed without the counsel of experts in all areas of world
art. As with previous editions, Cengage Learning has enlisted more
than a hundred art historians to review every chapter of Art through
the Ages in order to ensure that the text lives up to the Gardner
reputation for accuracy as well as readability. I take great pleasure
in acknowledging here those individuals who made important con-
tributions to the 4th concise edition and to the unabridged 15th
edition on which the shorter version is based: Patricia Albers, San
Jose State University; Kirk Ambrose, University of Colorado Boul-
der; Jenny Kirsten Ataoguz, Indiana University–Purdue University
Fort Wayne; Paul Bahn, Hull; Denise Amy Baxter, University of
North Texas; Nicole Bensoussan, University of Michigan–­Dearborn;
Amy R. Bloch, University at Albany, State University of New York;
Susan H. Caldwell, The University of Oklahoma; David C. Cateforis,
The University of Kansas; Gina Cestaro, University of West Flor-
ida; Thomas B. F. Cummins, Harvard University; Joyce De Vries,
Auburn University; Scott Douglass, Chattanooga State Community
College; Verena Drake, Hotchkiss School; Jerome Feldman, Hawai’i
Pacific University; Maria Gindhart, Georgia State University; Tracie
Glazer, Nazareth College of Rochester; Annabeth Headrick, Uni-
versity of Denver; Shannen Hill, University of Maryland; Angela K.
Ho, George Mason University; Julie Hochstrasser, The University
of Iowa; Hiroko Johnson, San Diego State University; Julie John-
son, The University of Texas at San Antonio; Molly Johnson, Ocean
County College; Paul H.D. Kaplan, Purchase College, State Univer-
sity of New York; Nancy Lee-Jones, Endicott College; Rob Leith,
Buckingham Browne & Nichols School; Brenda Longfellow, The
University of Iowa; Susan McCombs, Michigan State University;
Jennifer Ann McLerran, Northern Arizona University; Patrick R.
McNaughton, Indiana University Bloomington; Mary Miller, Yale
University; Erin Morris, Estrella Mountain Community College;
Nicolas Morrissey, The University of Georgia; Basil Moutsatsos, St.
Petersburg College–Seminole; Johanna D. Movassat, San Jose State
University; Micheline Nilsen, Indiana University South Bend; Cath-
erine Pagani, The University of Alabama; Anna Pagnucci, Ashford
University; Allison Lee Palmer, The University of Oklahoma; Wil-
liam H. Peck, University of Michigan–Dearborn; Lauren Peterson,
University of Delaware; Holly Pittman, University of Pennsylvania;
Romita Ray, Syracuse University; Wendy Wassyng Roworth, The
University of Rhode Island; Andrea Rusnock, Indiana University
South Bend; Bridget Sandhoff, University of Nebraska at Omaha;
James M. Saslow, Queens College, City University of New York;
xvi Preface
James Slauson, Carroll University; Anne Rudolph Stanton, Uni-
versity of Missouri; Suzanne Thomas, Rose State College; Achim
Timmermann, University of Michigan; David Turley, Weber State
University; Lee Ann Turner, Boise State University; Marjorie S.
Venit, University of Maryland; Shirley Tokash Verrico, Genesee
Community College; Louis A. Waldman, The University of Texas at
Austin; Ying Wang, University of Wisconsin–Milwaukee; Lindsey
Waugh, University of Tennessee; Gregory H. Williams, Boston Uni-
versity; and Benjamin C. Withers, University of Kentucky.
I am especially indebted to the following for creating the
instructor and student materials for the 4th edition: Ivy Coo-
per, Southern Illinois University Edwardsville; Patricia D. Cosper
(retired), The University of Alabama at Birmingham; Anne McCla-
nan, Portland State University; Amy M. Morris, The University of
Nebraska Omaha; Erika Schneider, Framingham State University;
and Camille Serchuk, Southern Connecticut State University. I also
thank the more than 150 instructors and students who participated
in surveys, focus groups, design sprints, and advisory boards to help
us better understand your needs in our print and digital products.
I am also happy to have this opportunity to express my gratitude
to the extraordinary group of people at Cengage Learning involved
with the editing, production, and distribution of Art through the Ages.
Some of them I have now worked with on various projects for nearly
two decades and feel privileged to count among my friends. The suc-
cess of the Gardner series in all of its various permutations depends in
no small part on the expertise and unflagging commitment of these
dedicated professionals, especially Sharon Adams Poore, product
manager (as well as videographer extraordinaire); Lianne Ames, senior
content project manager; Rachael Bailey, senior product assistant;
Cate Barr, senior art director and cover designer of this edition; J­ illian
Borden, marketing manager; Rachel Harbour, content developer;
­
Erika Hayden, associate content developer; Chad Kirchner, content
developer; and the entire team of professionals, too numerous to list
fully here, who had a hand in the design, creation, and implementa-
tion of the new e-reader featured in this edition’s MindTap. Finally,
I owe my gratitude to the incomparable group of learning consultants
nationwide who have passed on to me the welcome advice offered by
the hundreds of instructors they speak to daily.
I am also deeply grateful to the following out-of-house contrib-
utors to the 4th concise edition: the incomparable quarterback of the
entire production process, Joan Keyes, Dovetail Publishing Services;
Michele Jones, copy editor; Susan Gall, proofreader; Pat Rimmer,
Indexer; PreMediaGlobal, photo researchers; Cenveo Publisher Ser-
vices; Jay and John Crowley, Jay’s Publishing Services; Mary Ann
Lidrbauch, art log preparer; and, of course, Jonathan Poore and John
Burge, for their superb photos and architectural drawings.
I also owe thanks to two individuals not currently associated
with this book but who loomed large in my life for many years: Clark
Baxter, who retired from Cengage in 2013 at the end of a long and
distinguished career, from whom I learned much about textbook
publishing and whose continuing friendship I value highly, and my
former co-author and longtime friend and colleague, Christin J.
Mamiya of the University of Nebraska–Lincoln, with whom I have
had innumerable conversations not only about Art through the Ages
but the history of art in general. Her thinking continues to influence
my own, especially with regard to the later chapters on the history
of Western art. I conclude this long (but no doubt incomplete) list of
acknowledgments with an expression of gratitude to my colleagues
at Boston University and to the thousands of students and the scores
of teaching fellows in my art history courses since I began teaching
in 1975, especially my research assistant, Angelica Bradley. From
them I have learned much that has helped determine the form and
content of Art through the Ages and made it a much better book than
it otherwise might have been.
Fred S. Kleiner
chapter-by-chapter changes
in the FOURTH edition
All chapters include changes in the text reflecting new research and
discoveries, new maps, revised timelines and The Big Picture, and
online bonus images, essays, videos, and other features included
within the MindTap version of the text, an integral part of the com-
plete learning package for this 4th edition of Art through the Ages: A
Concise Global History.
A chapter-by-chapter enumeration of the most important revi-
sions follows.
Introduction: What Is Art History?: New chapter-opening illus-
tration of Claude Lorrain’s Embarkation of the Queen of Sheba with
new details. Added 18th-century Benin altar to the hand.
1: Prehistory and the First Civilizations: New Framing the Era
essay “Pictorial Narration in Ancient Sumer.” New Problems and
Solutions boxes “How to Represent an Animal” and “How Many
Legs Does a Lamassu Have?” Added the Apollo 11 Cave in Namibia,
the head of Inanna from Uruk, the seated scribe from Saqqara, and
the Judgment of Hunefer. New photographs of the Warka Vase,
Stonehenge, the lamassu from the citadel of Sargon II, a model of
the Gizeh pyramids, the Great Sphinx and pyramid of Khafre, and
the temple of Amen-Re at Karnak.
2: Ancient Greece: New Art and Society box “Archaeology, Art
History, and the Art Market.” New Problems and Solutions box
“Polykleitos’s Prescription for the Perfect Statue.” New Materials
and Techniques box “White-Ground Painting.” New Architectural
Basics box “The Corinthian Capital.” Added the calf bearer from
the Athenian Acropolis, the Charioteer of Delphi, the Massacre of
the Niobids by the Niobid Painter, the tholos at Delphi, and the
Hellenistic bronze boxer. New photographs of the Parthenon (gen-
eral view, Doric columns, and the cavalcade and seated gods of the
frieze), the Lion Gate and exterior and interior of the Treasury of
Atreus at Mycenae, the Erechtheion and Temple of Athena Nike on
the Athenian Acropolis, the theater at Epidauros, and the Barberini
Faun. New reconstruction drawing of the palace at Knossos.
3: The Roman Empire: New Framing the Era essay “Roman Art
as Historical Fiction.” New Art and Society boxes “The ‘Audac-
ity’ of Etruscan Women” and “Spectacles in the Colosseum.” New
Written Sources box “Vitruvius’s Ten Books on Architecture.” New
Problems and Solutions boxes “The Spiral Frieze of the Column
of Trajan,” “The Ancient World’s Largest Dome,” and “Tetrarchic
Portraiture.” Added Apotheosis of Antoninus Pius, Banditaccia
necropolis tumuli, the Maison Carrée at Nîmes, and third-century
sarcophagus of a philosopher. New photographs of the Tomb of
the Leopards at Tarquinia, the Tomb of the Reliefs at Cerveteri, the
brawl in the Pompeii amphitheater, the Third Style cubiculum from
Boscotrecase, and, in Rome, the Ara Pacis Augustae, the facade of
the Colosseum, the Arch of Titus (general view and two reliefs),
the Column of Trajan (general view and three details), the interior
of the Markets of Trajan, the exterior of the Pantheon, the colossal
portrait head of Constantine, the Basilica Nova, and the Arch of
Constantine (general view and Constantinian frieze).
4: Early Christianity and Byzantium: New Religion and Mythol-
ogy box “Jewish Subjects in Christian Art.” New Art and Society box
“Medieval Books.” New Problems and Solutions boxes “Picturing
the Spiritual World” and “Placing a Dome over a Square.” Added an
Early Christian statuette of the Good Shepherd, and images of Santa
Sabina in Rome and of the Rabbula Gospels. New photographs of
Santa Costanza in Rome, of Hagia Sophia in Constantinople, and of
the Katholikon at Hosios Loukas.
5: The Islamic World: New Art and Society box “Major Muslim
Dynasties.” Added the ivory pyxis of al-Mughira, the Baptistère de
Saint Louis, and Sultan-Muhammad’s Court of Gayumars. New pho-
tographs of the exterior and interior of the Dome of the Rock in
Jerusalem and the Great Mosque at Kairouan.
6: Early Medieval and Romanesque Europe: New Framing the Era
essay “The Door to Salvation.” New Problems and Solutions box
“Beautifying God’s Words.” New The Patron’s Voice box “Terrifying
the Faithful at Autun.” New Written Sources boxes “The Burning
of Canterbury Cathedral” and “Bernard of Clairvaux on Clois-
ter Sculpture.” New Religion and Mythology box “The Crusades.”
Added two Merovingian looped fibulae, the abbey church at Cor-
vey, the Gospel Book of Otto III, and the Morgan Madonna. New
photographs of the Palatine Chapel at Aachen and the south portal
and cloister of Saint-Pierre at Moissac, and a new restored cutaway
view of the Aachen chapel.
7: Gothic and Late Medieval Europe: New Framing the Era essay
“‘Modern Architecture’ in the Gothic Age.” New Art and Society
boxes “Paris, the New Center of Medieval Learning” and “Gothic
Book Production.” New The Patron’s Voice boxes “Abbot Suger and
the Rebuilding of Saint-Denis” and “Artists’ Guilds, Artistic Com-
missions, and Artists’ Contracts.” Added Nicholas of Verdun’s Shrine
of the Three Kings, Pietro Cavallini’s Last Jugdment, and the Doge’s
Palace, Venice. New photographs or drawings of Gothic rib vaults,
the facade and rose window of Reims Cathedral, plan and elevation
of Chartres Cathedral, elevation of Amiens Cathedral, aerial view
and interior of Salisbury Cathedral, Death of the Virgin tympanum
of Strasbourg Cathedral, the Naumburg Master’s Ekkehard and Uta,
and the Pisa baptistery pulpit by Nicola Pisano.
8: The Early Renaissance in Europe: New Framing the Era essay
“Rogier van der Weyden and Saint Luke.” New Art and Society
box “The Artist’s Profession during the Renaissance.” New Written
Sources box “The Commentarii of Lorenzo Ghiberti.” New Artists
on Art box “Leon Battista Alberti’s On the Art of Building.” Added
Memling’s diptych of Martin van Nieuwenhove, the Buxheim Saint
Christopher, Brunelleschi’s San Lorenzo and Pazzi Chapel, and
Alberti’s Palazzo Rucellai. New photographs of Riemenschneider’s
Creglingen Altarpiece and Donatello’s Gattamelata.
9: High Renaissance and Mannerism in Europe: New Framing the
Era essay “Michelangelo in the Service of Julius II.” New Artists on
Art box “Leonardo and Michelangelo on Painting versus Sculpture.”
New Written Sources box “Giorgio Vasari’s Lives.” New The Patron’s
Voice box “The Council of Trent.” New Problems and Solutions box
“Rethinking the Basilican Church.” New Religion and Mythology
box “Catholic versus Protestant Views of Salvation.” Added Michel-
angelo’s Fall of Man, the facade and plan of Il Gesú in Rome, Giulio
Romano’s Fall of the Giants from Mount Olympus, and Lucas Cra-
nach the Elder’s Law and Gospel. New photographs of the Sistine
Chapel and Bramante’s Tempietto in Rome.
10: Baroque Europe: New Problems and Solutions boxes “Com-
pleting Saint Peter’s,” “Rethinking the Church Facade,” “How to
Preface  xvii
Make a Ceiling Disappear,” and “Frans Hals’s Group Portraits.”
Added Bernini’s Apollo and Daphne, Gentileschi’s Judith Slaying
Holofernes, Gaulli’s Triumph of the Name of Jesus, Vermeer’s Woman
Holding a Balance, and Girardon and Regnaudin’s Apollo Attended
by the Nymphs of Thetis. New photographs of Saint Peter’s, Bernini’s
Ecstasy of Saint Teresa, Borromini’s San Carlo alle Quattro Fontane
(exterior and dome), and Rembrandt’s Night Watch.
11: Rococo to Neoclassicism in Europe and America: New Fram-
ing the Era essay “The Enlightenment, Angelica Kauffman, and
Neoclassicism.” New Written Sources box “Femmes Savantes and
Rococo Salon Culture.” New Art and Society boxes “Joseph Wright
of Derby and the Industrial Revolution” and “Vigée-Lebrun,
Labille-Guiard, and the French Royal Academy.” New Problems and
Solutions box “Grand Manner Portraiture.” New The Patron’s Voice
box “Thomas Jefferson, Patron and Practitioner.” Added Labille-
Guiard’s Self-Portrait with Two Pupils, Batoni’s Charles John Crowle,
Boyle and Kent’s Chiswick House, and Jefferson’s Monticello.
12: Romanticism, Realism, and Photography, 1800 to 1870: New
Framing the Era essay “The Horror—and Romance—of Death at
Sea.” New Problems and Solutions boxes “Unleashing the Emo-
tive Power of Color” and “Prefabricated Architecture.” New Artists
on Art box “Thomas Cole on the American Landscape.” New Art
and Society box “Edmonia Lewis, an African American Sculptor
in Rome.” Added Vignon’s La Madeleine in Paris, Daumier’s Nadar
Raising Photography to the Height of Art, and Muybridge’s Horse
Galloping. New photographs of Daumier’s Rue Transnonain and the
Houses of Parliament, London.
13: Impressionism, Post-Impressionism, and Symbolism, 1870
to 1900: New Framing the Era essay “Modernism at the Folies-
Bergère.” New Problems and Solutions boxes “Painting Impressions
of Light and Color” and “Making Impressionism Solid and Endur-
ing.” New Art and Society box “Women Impressionists.” Added
Manet’s A Bar at the Folies-Bergère and Claude Monet in His Studio
Boat, Monet’s Saint-Lazare Train Station, Morisot’s Summer’s Day,
Rodin’s Burghers of Calais, Gaudi’s Casa Milà in Barcelona, and Sul-
livan’s Carson, Pirie, Scott Building in Chicago. New photographs of
the Eiffel Tower and a detail of Seurat’s A Sunday on La Grande Jatte.
14: Modernism in Europe and America, 1900 to 1945: New Fram-
ing the Era essay “Picasso Disrupts the Western Pictorial Tradition.”
New Art and Society boxes “The Armory Show” and “Jacob Law-
rence’s Migration of the Negro.” New Written Sources box “André
Breton’s First Surrealist Manifesto.” Added Derain’s The Dance,
Léger’s The City, Dove’s Nature Symbolized No. 2, Lam’s The Jungle,
Moore’s Reclining Figure, and Orozco’s Hispano-America 16. New
photograph of the Bauhaus, Dessau.
15: Modernism and Postmodernism in Europe and America,
1945 to 1980: New Framing the Era essay “After Modernism: Post-
modernist Architecture.” New Artists on Art boxes “David Smith
on Outdoor Sculpture,” “Roy Lichtenstein on Pop Art and Comic
Books,” and “Chuck Close on Photorealist Portrait Painting.” Added
Moore’s Piazza d’Italia, Krasner’s The Seasons, Noguchi’s Shodo
Shima Stone Study, Warhol’s Marilyn Diptych, Freud’s Naked Portrait,
and White’s Moencopi Strata. New photographs of the interior of Le
Corbusier’s Notre-Dame-du-Haut and of Graves’s Portland Building.
16: Contemporary Art Worldwide: Major reorganization and
expansion of the text with the addition of many new artists, archi-
tects, artworks, and buildings: Burtynsky’s Densified Scrap Metal
#3A, Rosler’s Gladiators, Botero’s Abu Ghraib 46, Zhang’s Big Family
xviii Preface
No. 2, Schnabel’s The Walk Home, Song’s Summer Trees, Murray’s
Can You Hear Me?, Anatsui’s Bleeding Takari II, Behnisch’s Hyso-
lar Institute in Stuttgart, Hadid’s Signature Towers project in Dubai,
Serra’s Tilted Arc, Kapoor’s Cloud Gate, and Suh’s Bridging Home.
New Artists on Art box “Shirin Neshat on Iran after the Revolu-
tion.” New Problems and Solutions box “Rethinking the Shape of
Painting.” New Art and Society box “Richard Serra’s Tilted Arc.” New
photographs of Christo and Jeanne-Claude’s Surrounded Islands and
Gehry’s Guggenheim Museo in Bilbao.
17: South and Southeast Asia: New Framing the Era essay “The Great
Stupa at Sanchi.” New The Patron’s Voice box “Ashoka’s Sponsorship
of Buddhism.” New Materials and Techniques box “Indian Miniature
Painting.” New Written Sources box “Abd al-Hamid Lahori on the Taj
Mahal.” Added meditating Buddha statue from Gandhara, Mamalla-
puram relief of Durga slaying Mahisha, Shiva as Nataraja from Tamil
Nadu, and the Bayon temple and towers at Angkor. New photographs
of the Great Stupa at Sanchi and its east torana; Bodhisattva Padma-
pani in Ajanta cave 1; the Vishnu Temple at Deogarh and its Ananta
panel; the Vishvanatha Temple at Khajuraho and its mithuna reliefs;
and the pietra dura stonework of the Taj Mahal.
18: China and Korea: New Materials and Techniques boxes “Chi-
nese Jade,” “Silk and the Silk Road,” and “Chinese Porcelain.” New
Art and Society box “The First Emperor’s Army in the Afterlife.” New
Artists on Art box “Xie He’s Six Canons.” New Problems and Solu-
tions box “Planning an Unplanned Garden.” Added Eastern Zhou
bi disk; Lingering Garden, Suzhou; Shang Xi’s Guan Yu Captures
General Pang De; Ming lacquered table with drawers; Shitao’s Riding
the Clouds; and Jeong Seon’s Geumgangsan Mountains. New photo-
graphs of the throne room in Beijing’s Forbidden City; Fan Kuan’s
Travelers among Mountains and Streams; the Yuan David Vases; the
Garden of the Master of the Fishing Nets, Suzhou; Ye Yushan’s Rent
Collection Courtyard; and the Buddhist cave temple at Seokguram.
19: Japan: New Framing the Era essay “The Floating World of Edo.”
New Religion and Mythology box “Shinto.” New Written Sources
box “Woman Writers and Calligraphers at the Heian Imperial
Court.” New Art and Society box “The Japanese Tea Ceremony.”
Added the honden of the Ise Jingu in Ise, the Daibutsuden and
Unkei’s Agyo of Todaiji in Nara, the karesansui garden of Ryoanji in
Kyoto, and the White Heron Castle of Himeji. New photographs of
the Phoenix Hall at Uji, a tea ceremony Kogan in Cleveland, and a
large plate by Hamada Shoji.
20: Native Americas and Oceania: New Framing the Era essay “War
and Human Sacrifice in Ancient Mexico.” New Problems and Solu-
tions box “The Underworld, the Sun, and Mesoamerican Pyramid
Design.” New Art and Society box “Nasca Lines.” New general view
and details of the watercolor copy of the Lord Chan Muwan mural
at Bonampak. Added the Raimondi Stele and a Mandan buffalo-hide
robe as well as a new section on Oceania, including the Ambum
Stone, the moai of Rapa Nui, a Chuuk prow ornament, the Hawaiian
feather cloak of Kamehameha III, an engraving of a tattooed Mar-
quesan warrior, the Maori Mataatua meeting house, a Rarotonga
staff god, an Australian Dreaming bark painting, a New Ireland
malanggan mask, and an Art and Society box “Tattoo in Polynesia.”
21: Africa: New Framing the Era essay “The Royal Arts of Benin.”
New Art and Society box “African Artists and Apprentices.” Added
the Tassili n’Ajjer rock painting of a running woman, a 16th-century
brass plaque portraying a Benin king on horseback, a Fang bieri
reliquary figure, the Kuba ndop portrait of King Shyaam aMbul
aNgoong, and a Baga d’mba mask.
a bo ut the author
Fred S. Kleiner
Fred S. Kleiner (Ph.D., Columbia University) has been the author or coauthor of Gardner’s Art through the
Ages beginning with the 10th edition in 1995. He has also published more than a hundred books, articles,
and reviews on Greek and Roman art and architecture, including A History of Roman Art, also published by
Cengage Learning. Both Art through the Ages and the book on Roman art have been awarded Texty prizes
as the outstanding college textbook of the year in the humanities and social sciences, in 2001 and 2007,
respectively. Professor Kleiner has taught the art history survey course since 1975, first at the University of
Virginia and, since 1978, at Boston University, where he is currently professor of the history of art and archi-
tecture and classical archaeology and has served as department chair for five terms, most recently from
2005 to 2014. From 1985 to 1998, he was editor-in-chief of the American Journal of Archaeology.
Long acclaimed for his inspiring lectures and devotion to students, Professor Kleiner won Boston Uni-
versity’s Metcalf Award for Excellence in Teaching as well as the College Prize for Undergraduate Advising
in the Humanities in 2002, and he is a two-time winner of the Distinguished Teaching Prize in the College of
Arts & Sciences Honors Program. In 2007, he was elected a Fellow of the Society of Antiquaries of London,
and, in 2009, in recognition of lifetime achievement in publication and teaching, a Fellow of the Text and
Academic Authors Association.

Also by Fred Kleiner: A History of Roman Art, Enhanced Edition (Wadsworth/Cengage Learning 2010; ISBN
9780495909873), winner of the 2007 Texty Prize for a new college textbook in the humanities and social sciences. In
this authoritative and lavishly illustrated volume, Professor Kleiner traces the development of Roman art and architec-
ture from Romulus’s foundation of Rome in the eighth century bce to the death of Constantine in the fourth century ce,
with special chapters devoted to Pompeii and Herculaneum, Ostia, funerary and provincial art and architecture, and
the earliest Christian art. The enhanced edition also includes a new introductory chapter on the art and architecture
of the Etruscans and of the Greeks of South Italy and Sicily.

xix
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 As the lungs fill with the first crop of infected emboli, and the first
series of metastatic abscesses form there, there is more or less
dyspnea and sense of oppression; there may be also pulmonary
complications—pleurisy, bronchitis, etc., even pulmonary edema.
Frequently there is expectoration of frothy and discolored sputum;
occasionally there is blood in the sputum. A peculiar sweetish odor
of the breath has been noted by many observers in this disease, and
is supposed to be idiopathic and characteristic. (See acetonemia in
previous chapter.) With the dispersion of the second crop of emboli
from the lungs there is apt to be icterus, with evidence of metastatic
abscess in the liver, and collection of pus as the result of
coalescence of small abscesses. The sensorium is not so affected in
pyemia as in septicemia, and in the former disease patients are
more likely to be alert and active in mind. General hyperesthesia and
restlessness are common. Colliquative sweats are also a feature of
pyemia. There is the same liability to eruptions, etc., which may
mislead or complicate the diagnosis. A dermatitis is seen sometimes
in pyemia, the lesions assuming a papular or pustular form, due to
local infections of the skin. Purpuric spots are also seen, and
vesication is not infrequent. Within the mouth sordes collect upon the
teeth or gums; the tongue becomes dry and brown and heavily
coated. Diarrhea is less common in pyemia. The urine is usually
scanty and high colored, containing solids in excess; albumin is
sometimes found therein, as well as peptone. The presence of
peptone in the urine is probably an indication of the breaking down of
pus corpuscles in various parts of the tissues.
A significant objective evidence of pyemia is met with in the
metastatic collections of pus within the joints, which occur relatively
early, and which, if multiple, may lead to a correct diagnosis. One of
the earliest joints to be involved is the sternoclavicular, although
none of the joints are free from the possibility of invasion. The
articular serous membranes seem to have the property of carrying
and holding the infective thrombi better than any other tissue in the
body. The pyarthrosis of pyemia is for the most part painless, yet
implies loss of function of the affected joints. The distention of these
is usually evident to the eye, the fluctuation pronounced, tenderness
not extreme, but the swollen part merges into tissues which are
edematous and reddened. When pain in the limb is extreme, it is
usually because of metastatic abscess within the bone-marrow
cavity. In other words, we now have a metastatic osteomyelitis.
In all cases of pyemia prostration is marked, yet the pulse is
seldom weak, at least until toward the close of life. As cases
progress from bad to worse subsultus tendinum is often noted.
The appearance of the wound or site of operation does not differ
essentially from that already described under Septicemia. There is
usually, however, less discharge, granulations are smoother and
dryer, and if tissues are gangrenous they are not as wet and
nauseous as in the other case. Evidences of thrombophlebitis and
lymphangitis will proceed from the wound toward the body, as in
other instances of septic infection.
Prognosis.—Prognosis is usually bad. While recovery may follow
where metastatic infiltration has not been too general,
the ordinary case of pyemia will die within twelve to fourteen days
after diagnosis. Sometimes the entire process is much slower, and
isolated cases occur which can be designated as so-called chronic
pyemia, which differs but little from the acute form. A case of pyemia
should not fail of recognition because there is no evidence of
infection from without. A fatal case of pyemia has been known to
occur from a suppurating soft corn which was not discovered during
life; also from peridental abscess, etc., which had been overlooked.
Death is the result of tissue destruction and septic intoxication.
Postmortem Appearances.—In the vessels these consist
essentially of thrombosis, examples
of which may be seen, for instance, in the cranial sinuses and in the
large veins. Aside from these, with the enlargement and softening of
the spleen, the liver, and lymphatic structures, already described
under Septicemia, the principal objective evidences consist in the
discovery of metastatic abscesses in many or all parts of the body.
As stated above, there is no tissue or organ in which they may not
be found. The mechanism of their production has been already
described. Infarcts may also be met with, in the kidneys especially,
the liver and spleen as well, and indicate areas already cut off from
blood supply by thrombo-arteritis, in which abscess formation would
have occurred had time been given. In the liver large abscesses may
be found; joint cavities may be filled with pus; the lungs are usually
the site of innumerable small abscesses. The other postmortem
changes commonly noted are not difficult of explanation, but are not
so characteristic or pathognomonic as to call for further mention. In a
joint which has become filled with pus there usually has been
loosening of the cartilage and more or less disorganization of all the
joint structures, which appear to have undergone rapid ulcerative
destruction and putrefaction.
Treatment.—Treatment of pyemia is in large degree
unsatisfactory. That which used to be the terror of
surgeons in the pre-antiseptic era is now, thanks to Lister and others,
almost abolished. Pyemia is a rare disease in modern surgical
practice. Its possibility should be borne constantly in mind, however,
and the necessity for careful antiseptic or for a rigid aseptic
technique is in large degree based upon fear of pyemic
consequences.
When once established, the disease is to be treated on lines
nearly similar to those laid down for septicemia, including resort to
the ichthyol or silver ointments, and to intravenous infusion of silver
solution. (See p. 89.) Amputation or extirpation of the part from which
infection has first proceeded may be of avail. Among the most
successful measures for surgical treatment of this disease is to
expose the infected area, open the involved veins, and either excise
them or scrape them out and disinfect them. This treatment has
been successful in cases of cranial infection following middle-ear
disease, etc. (See chapter on Cranial Surgery.)
Disinfection of the infected area and immersion in hot water should
be practised. Metastatic abscesses should be opened and drained,
and every accessible collection of pus evacuated, either by the knife
or aspirator needle—e. g., in the liver.
The medicinal treatment is practically the same as in septicemia,
while the surgeon’s mainstays are alcohol and strychnine. These,
with cathartics and intestinal antiseptics, will practically sum up the
drug treatment, the surgeon meantime not neglecting the matter of
nutrition, crowding it in every assimilable form.

ERYSIPELAS.
 Erysipelas is an acute infectious disease characterized by its
tendency to involve the skin and cellular structures, to extend along
the lymphatic vessels, to involve wounds and injuries under certain
conditions, accompanied by more or less fever of septic type,
leading frequently to septic disturbances of profoundest character,
yet tending in the majority of instances to spontaneous recovery. It
has been observed probably from prehistoric times, but has not
found a proper description nor appreciation until perhaps within the
past century. It occurs in so-called traumatic and idiopathic form—
which latter means that the site of infection is not discovered—and
also in a virulent and contagious type, which leads to the
appearance of a number of cases over a large territory; it often
appears in the epidemic form. On account of the reddening of the
skin it goes by the name of the rose among the German laity. It may
assume the type of an infectious dermatitis, subsiding without
suppuration, or a similar lesion of exposed mucous membrane may
be noted, or, occasionally, its virulence seeming greater, its lesions
are met with in more deeply seated parts, accompanied by
suppuration or even gangrene, and it is then called phlegmonous. In
a small proportion of cases the infectious organism appears to be
transported from one part of the body to another, and thus we have
metastatic expressions of this disease. The most common examples
of this are seen in erysipelatous meningitis after erysipelas of the
face or scalp, and erysipelatous peritonitis after the disease has
manifested itself on the truncal surface. It is of a type which makes
itself almost interchangeable with puerperal fever; and when
epidemics of erysipelas have involved certain states or areas, it has
been noted also that nearly every obstetrical case developed
puerperal septicemia.
Etiology.—There is more than passing interest connected with
this last statement. It is now definitely established that
the infectious organism is a streptococcus which is allied to, if not
identical with, the streptococcus pyogenes, the ordinary pyogenic
organism of this form. This specific organism has been separated,
studied, and its role assigned by Fehleisen, and the organism is
frequently called Fehleisen’s coccus. Preserving always its
morphological characteristics, it acts, as do many other pathogenic
organisms, within wide limits in virulence. Cultivated from some
cases, it scarcely seems infectious, while from others it is fatal.
Pathology.—The disease manifests a tendency to travel via
lymphatic routes. As long as it is confined to the skin
and superficial tissues it has the appearance of an acute dermatitis.
When it migrates deeper it generally leads to suppuration, another
reason for believing that the streptococci of erysipelas and of pus
production are the same. In the affected and infected area the
minute lymphatics will be found crowded with the cocci, which are
seen much less often in the small bloodvessels; also in the tissues
beyond the apparently infected area they may be found dispersed
less freely. The bacterial activity seems most active along the
advancing border of the superficial lesion. Here the phenomena of
hyperemia and phagocytosis are most active. Even in the vesicles
that are characteristic of the disease the organisms may be found.
The discharges from this region are infectious, and caution should
be observed in dressing such cases. A finger pricked by a pin from a
dressing may subject the individual to loss of life. The dressings
containing the discharges should be burned immediately.
The path of infection is usually through a wound, and as soon as
discovered a case of erysipelas should be separated from all
surgical cases, or if the erysipelatous patient cannot be isolated, he
should be removed from proximity of other wounded individuals.
Erysipelas which follows injury, however slight, is termed
traumatic. The terms “idiopathic” or “spontaneous” should be
restricted to those cases in which the path of infection is not
discovered.
Symptoms.—With the exception of the local appearances, they
are essentially the same in both of the above-
mentioned forms. The characteristic feature of the disease is a
dermatitis with its peculiar roseate hue, which it is impossible to
describe in words. In tint it differs slightly from that noted in certain
cases of erythema. It is, however, accompanied by an infiltration of
the structures of the skin, so that the area which is reddened is at the
same time elevated above the surrounding surface. Its edges are
often irregular. As exudate takes the place of blood in the tissues,
the red tint merges into a yellow. At this time there is more induration
of the skin and tendency to pit on pressure. Vesication of this
involved area is now frequent, the vesicles often coalescing and
forming large blebs and bullæ, which fill with serum that may
become discolored or purulent. When exposed to the air, unless the
tissues become gangrenous, this serum usually evaporates and
forms scabs. This disturbance of the skin is always followed after a
number of days by desquamation. This infectious dermatitis shows a
constant tendency to spread in all directions. Its most characteristic
appearances are limited to the margin of the enlarging zone, while in
its centre there may be evidences of recession of the disease. If it
commences in the vicinity of a wound it will probably spread in all
directions from it. Beginning in the face, it usually spreads upward; in
the trunk, in all directions; if on the extremities it tends to migrate
toward the trunk. Wandering erysipelas is a term often applied to
these phenomena. The metastatic expressions of the disease have
been described.
When this affection attacks a recent wound the local appearances
are not essentially distinct from those mentioned under Septicemia.
The wound margins separate to a greater or less extent, the
surfaces slough, and a characteristic seropurulent discharge occurs.
Granulating surfaces usually become glazed—often covered with a
membrane resembling that of diphtheria; deep sloughs may occur,
undermining of wound edges, even hemorrhages from destruction of
vessel walls. In rare instances, however, under the influence of the
microbic stimulation granulations proceed faster than normal.
Whether the disease proceeds from an injury or not, the
constitutional symptoms vary but little. There is usually a period of
malaise with nausea, followed by alimentary disturbance, coating of
the tongue, elevation of temperature, sometimes with occurrence of
chill. Complaint of pain or unpleasant sensation will lead to
examination of the area involved, when the above symptoms will be
noted, with evidences of lymphangitis and enlargement of lymph
nodes. When chill occurs it is followed by pyrexia. Temperature
fluctuates, with a tendency to assume the remittent type. When the
disease subsides spontaneously it is by a gradual process of
betterment and subsidence of temperature. In other instances the
constitutional symptoms assume more or less of the septicemic or
typhoid type, and it is seen that the patient’s condition is practically
one of mild septicemia, which often proves fatal.
When the disease assumes the phlegmonous type the
constitutional symptoms become more and more typhoidal and the
septicemia becomes most pronounced. Locally exudation goes on to
the point of threatening, even of actual, gangrene, unless tension is
relieved by incisions. Pain is usually intense, partly because of
confined exudates beneath resisting structures. More or less rapidly
the local and constitutional signs of pus formation are noted, and
unless these are observed and acted upon early there will not only
be suppuration, but more or less actual gangrene, so that not only
pus, but sloughs of tissue will be discharged through the incision, or
will, when this is delayed, make their escape by death of overlying
textures.
In all phlegmonous cases there is practically coincidence of
septicemia, already described, and of the local appearances above
noted. In proportion to the extent of the lesion in these phlegmonous
cases, and failure to afford relief, will be the opportunity for septic
intoxication.
The mucous membrane does not always escape, and even in the
nose, the pharynx, the vagina, and the rectum a distinctive
erysipelatous lesion may be found. The disease may travel from the
pharynx through the nose and involve the face, or through the
Eustachian tube to the ear and thence to the scalp, or vice versa.
Erysipelatous laryngitis is to be feared on account of edema of the
glottis, which would soon be fatal unless overcome by intubation or
tracheotomy. An infectious exudation into the lungs is also known to
follow erysipelas, and has been considered an erysipelatous
pneumonia. The cellular tissue of the orbits may also be involved,
when abscesses will occur, which should be opened early; the
parotid and other salivary glands may become involved, usually in
suppuration.
Many cases are accompanied by much gastric irritation, which it is
difficult to explain. Ulcers are sometimes found in the intestines, as
after burns. These usually give rise to bloody diarrhea. The cerebral
symptoms may be simply those of delirium from irritation or of
meningitis from infection. Strange phenomena have followed the
disease in certain instances—cessation of neuralgic and of vague,
unexplainable pain, improvement in deranged mental condition,
spontaneous disappearance of tumors, etc. Advantage has been
taken of this last in the treatment of these cases. (See Cancer.)
It is quite likely that some of the worst forms of phlegmonous
erysipelas are due to mixed infection. To inject the bacillus
prodigiosus together with the streptococcus of erysipelas will greatly
enhance the virulence of the latter, so that reaction may proceed
even to gangrene.
Postmortem Appearances.—These are not distinctive, but are a
combination of local evidences of
suppuration and gangrene, with the deterioration of the blood, the
softening of the spleen, etc., which are characteristic of septic
poisoning. Only in the skin, and then under microscopic examination,
can any pathognomonic appearance be discovered. This will consist
in the crowding of the lymphatic vessels and connective-tissue
spaces with cocci, in the evidences of rapid cell proliferation, in the
quantity of exudate, in vesication, sloughs, etc.
Diagnosis.—Diagnosis of erysipelas should be made mainly from
various forms of erythema, from certain drug eruptions,
and from other forms of septic infection which do not assume the
clinical type of erysipelas. The gastric symptoms of this disease are
sometimes produced by certain poisonous foods or the distress
which is produced by medicines, such as quinine, antipyrine, etc.
Prognosis.—The majority of instances of idiopathic erysipelas run
a certain limited course, although the eruption may
spread to almost any distance upon the body. When the disease
attacks surgical cases, and especially when it involves wound areas,
the prognosis is not so good. When the disease assumes an
epidemic type and involves cases of all kinds, it will be found to have
a virulence that may make it a most serious affair. In proportion to
the extent to which it assumes the phlegmonous type it will be found
locally, if not generally, destructive. The ordinary case of facial
erysipelas will recover with almost any treatment. Nevertheless
meningitis may develop, and even a mild case is to be treated with
care and caution.
Treatment.
—Danger comes from two sources—septic intoxication and local
phlegmons or gangrenous destruction. Each is therefore to be
combated. Treatment should consist of isolation. There is no specific
internal treatment for this disease. Tincture of iron, which was long
vaunted as such, has proved unsatisfactory, and is of benefit only as
a supporting measure in a limited class of cases. Constitutional
measures should be employed: First, for the purpose of maintaining
free excretion by bowels and kidneys; second, for the purpose of
supporting and maintaining strength; third, for tonic and stimulant
measures in prostrated and debilitated patients; and, fourth, for the
purpose of combating intestinal sepsis or intoxication from any other
source. The robust patients with this disease need no particular
tonic. The aged, the enfeebled, the dissipated, the prostrated
individuals, and the confirmed alcoholics are those who need
vigorous stimulation, partly by alcohol and quinine, and partly by
strychnine, preferably given hypodermically, and by the other
diffusible stimulants by which they may be kept alive. Pilocarpine,
given subcutaneously and pushed to the physiological limit, has
been praised by some. If along with prostration there occur
restlessness and delirium, then anodynes and hypnotics are
serviceable, and should be administered to meet the indication—
morphine hypodermically and any of the agents which produce sleep
are now most beneficial. Finally, if there is any drug which can be
administered in doses sufficient to saturate the system with an
antiseptic which shall at the same time not prove fatal because of
toxicity, this is the ideal medicament for constitutional use only. Such
a drug is not known, but it will be well to give some near approach to
it internally, as by administering corrosive sublimate, salol,
naphthalin, or something else of this character in doses as large as
can be tolerated.
Should patients become violent it may be necessary to resort to
mechanical restraint—a strait-jacket, a restraining sheet, a camisole,
etc.
Nourishment must be kept up by the administration of the easily
assimilable and predigested foods.
Locally the number of remedies that have been resorted to is
legion. In a mild case of spontaneous erysipelas—i. e., where no
infection can be traced—it will sometimes be sufficient to put on a
soothing application, like a lead-and-opium wash. It often gives relief
to have the part protected from air contact, which may be done by a
soothing ointment or by dusting the part with a powder, such as
bismuth oleate or subnitrate, zinc oxide, etc., these being rubbed up
with powdered starch; or by a film of rubber tissue or of oiled silk.
Brewers’ yeast applied on compresses and covered with oiled silk is
efficacious.
Even before the bacterial origin of the disease was accepted it had
been suggested to use antiseptic applications, either in watery
solution or combined with oil or some unguent; this is now the ideal
method of local treatment, the difficulty being only to find that which
shall be efficacious as an antiseptic, yet not injurious in other ways.
Compresses wrung in solutions of various antiseptics are often
serviceable. The following preparation has given satisfaction:
Resorcin (or naphthalin) 5, ichthyol 5, mercurial ointment 40, lanolin
50. The proportions of these ingredients may be varied, and the
amount of ichthyol sometimes increased, especially when the skin is
not too tender. The affected parts are anointed with this, and then
covered with oiled silk or other impermeable material, simply to
prevent its absorption by the dressings; the parts are then enveloped
in a light dressing and bandaged. Credé’s silver ointment has also
proved useful. As the disease becomes mitigated the ointment may
be reduced with simple lard, and discontinued when local signs have
disappeared. Absorption of any of these preparations may be
hastened by scratches over the affected area with the sharp point of
a knife.
Treatment of threatening phlegmon, or phlegmonous erysipelas,
must be more radical, and consists of free incision down to the depth
of the deepest tissues involved. In treating dissecting and other
septic wounds of the fingers incision should be made to the tendon
sheaths, even to the bone. It is only by such radical measures that
worse disaster may be avoided. Some aggravated local cases are
treated by a series of deep incisions with the use of the curette, the
surface after careful clearing being kept buried under an antiseptic
solution (silver lactate 1 to 500) or ointment.
RELATION OF LYMPH NODES AND GRANULATION TISSUE TO
INFECTION.
In connection with erysipelas and the role of the lymphatics, it is
advisable to consider the relation and behavior of the lymph nodes
and granulation tissue to infecting agents. Depending on the
virulence of the infectious material, the site of infection, and the
variety of the microbe will be its arrival in these protective filters.
Then follows a series of cycles of maximum and minimum activity in
the nodes, during the former the bacteria almost disappearing. The
more pathogenic the microörganism the more certain the destruction
of the lymph node, or perhaps of the individual. The well-known
enlargement of the nodes is due almost solely to an increase in their
lymphoid elements. Halban, who demonstrated these cyclic
variations in the contents of the lymph nodes, is inclined to insist on
an intimate relation between them and the temperature variations
noted in cases of septic infection.
When granulations are present the lymph sacs are closed, as by a
sanitary cordon. Unless this tissue is broken they are proof against
ordinary infection. It is well known that erysipelas will appear about
an old wound or sinus that has been rudely probed. Even virulent
organisms spread upon healthy granulating surfaces fail to infect.
Strong carbolic and other toxic agents can be used in and about
such granulating cavities with an exemption from poisoning that
otherwise would produce dangerous effects.
 CHAPTER VIII.
SURGICAL DISEASES COMMON TO MAN AND
DOMESTIC ANIMALS.

TETANUS.
Synonyms: Trismus, Lockjaw.
Tetanus is an acute infectious disease, of relatively infrequent
occurrence, invariably of microbic origin, characterized by more or
less tonic muscle spasm with clonic exacerbations, which, for the
most part, occurs first in the muscles of the jaw and neck, involving
progressively, in fatal cases, nearly the entire musculature of the
body. Certain races of people seem predisposed, and in certain
climates and geographical areas the disease is exceedingly
prevalent. Negroes, Hindoos, and many of the South Sea Islanders
show a peculiar racial predisposition, and, in a general way,
inhabitants of warm countries are less resistant. This is shown partly
by the fact that in various European wars the Italians and French
have suffered more than the soldiers of more northern climes.
Tetanus is by no means confined to adult life, since infants are far
from exempt, and in the tropics the trismus of the newborn is the
cause of a high mortality rate. In Jamaica one-fourth of the newborn
negroes succumb within eight days after birth, and in various other
hot countries the proportion is at times equally great. One plantation
owner states that fully three-fourths of the colored children born upon
his plantation succumbed to the disease. The peculiar reason for this
infection will appear later when speaking of tetanus neonatorum.
Men seem more commonly affected than women, probably because
of their occupations, by which they are more exposed. Military
surgeons have had to contend with the disease in its most virulent
form, and it has been noted that soldiers when worn out by fatigue or
suffering from the disaster of defeat seemed more liable to the
disease. In 1813 the English soldiers in Spain suffered from tetanus
in the proportion of 1 case to 80 wounded men. In the East Indies, in
1782, this proportion was doubled. Quick variations of heat and cold,
such as warm days and cold nights, coupled with the other
exposures incidental to military life, seem to exert a great effect.
Curiously enough, the wounded in many campaigns who have been
cared for in churches have suffered more from the disease than
those cared for in any other way. Tetanus, however, is by no means
necessarily confined to any one clime or race, but may be met with
anywhere, at any time, providing only that infection has occurred. A
celebrated Belgian surgeon lost by tetanus ten cases of major
operations before he discovered that the source of the infection was
his hemostatic forceps. As soon as these were thoroughly sterilized
by heat he had no further undesirable complications. If the disease
can be conveyed by the instruments of a careful surgeon, how much
more so by the dirty scissors of a careless midwife, etc.
It is true, also, that the popular notions of the laity concerning the
liability to tetanus after certain forms of injury are not ill-founded.
Small, ragged wounds of the hands and feet are those which
ordinarily receive little or no attention, and are among those most
likely to be followed by this disease. The toy pistol, which, a few
years ago, was such a prevalent and widely sold children’s toy, was
the cause of many a small laceration of the hand, due to careless
handling and the peculiar injury produced by the explosion of a small
charge of fulminating powder in a paper or other cap. It was not the
character of the laceration or injury thereby produced, but the fact
that such injuries occurred in the dirty hands of dirty children, which
were most likely to become infected, that has caused the so-called
toy-pistol tetanus to be raised almost to the dignity of a special form
of this disease. During the month of July, 1881, in Chicago alone,
there were over 60 deaths from tetanus among children who had
been injured in this way by these little toys. This led to their sale
being suppressed by law.
Etiology.—Two theories have had strong advocates, one being
that which would account for the disease by irritation of
nerves; while the second, the humoral, would explain the disease by
alterations in the blood. Each has had its most ardent defenders, but
both have now completely yielded to the investigations of a few
observers, among whom Kitasato and Nicolaier are the most
prominent. These ardent workers were, in 1885, able to clearly
establish the parasitic nature of this disease, and to isolate and
investigate the organisms by which it is produced.
Fig. 17
The bacillus of
tetanus is a
somewhat slender,
rod-shaped organism,
with a peculiar
tendency to spore
formation at one end,
which gives it a
drumstick
appearance. It is
essentially an
anaërobic organism,
and can never be
cultivated in contact
with the air. In
laboratory
experiments it is
grown in the depths
of a solid culture
medium or else in
Tetanus bacilli, showing spore formation. (Kitasato.) fluids and on surfaces
in an atmosphere of
hydrogen gas. It is one of the apparent contradictions of bacteriology
that this organism, which can only be grown as an anaërobe,
nevertheless abounds in earth, particularly the rich, black loam which
best supports luxuriant vegetable life, and that it practically inhabits
the upper layers of the soil, which accounts for the fact that so many
contaminations and infections have occurred from stepping upon
planks or boards with nails projecting, or from introduction of
splinters, or from lacerations of the hands and feet which are so
often followed by contact with such materials. There is nothing about
a rusty nail wound which, by itself, predisposes to tetanus, but the
rusty nail upon which a person steps is either itself infected or leaves
a rent or wound which may become infected within the next few
moments, and which is not likely to receive the careful attention
which it should. Verneuil has of late laid stress upon the fact that in
localities where horses are kept tetanus is more prevalent, and that
the infectious organism abounds in and upon stable floors, about
barn-yards, and wherever the excretions of a horse may be found.
Bacteriologists are aware that in the intestines of herbivorous
animals the bacilli (anaërobic) of tetanus and malignant edema are
often found. Verneuil has further shown that almost the only
instances of tetanus which occur on shipboard are upon those ships
which are used for transportation of horses and cattle. His
statements are at least interesting, if not absolutely well-founded. At
all events, tetanus is certainly of telluric origin.
A French veterinary surgeon of twenty-five years’ experience had
not seen a single case of tetanus until 1884, when he “removed a
tumefied testicle from a horse, with the ecraseur, and it died of
tetanus; in the following six months he castrated five, and all died;
another castrated fifteen in one day, and all died but one; another in
ten days castrated six bulls and operated on three fillies for umbilical
hernia, when five of the bulls and one of the fillies died.” This will
illustrate how the infectious agent may be conveyed by instruments,
etc.
The tetanus bacillus manifests other peculiar properties, for some
of which it is most difficult to account. Upon susceptible animals it is
violently infectious, but is rarely found at any distance from the
tissues in which it has first lodged. In laboratory investigations the
period of incubation is seldom longer than forty-eight hours. Another
peculiarity of the organism is that it generates certain poisons of
active properties which may be separated from pure cultures, by
whose injection the peculiar spasms of the disease itself may be
reproduced. These have been isolated, especially by Brieger, who
has given to them the names of tetanin, tetanotoxin, spasmotoxin,
etc. It has been estimated that about ¹⁄₃₀₀ Gm. of the pure toxin of
tetanus would be a fatal dose for a man. This toxin seems to have a
specific affinity for the ganglion cells of the anterior horn of the spinal
cord, with which it unites with great force. Herein lies the secret of its
disturbing power.
 It is peculiar that some time may elapse after its injection before
the appearance of the first symptoms. Diphtheria toxins appear to be
prompt in their action, and thus display quite opposite
characteristics. Experiment would seem to show, moreover, that the
tetanus toxins do not reach the cord through the blood stream, but
appear to slowly pass along the axis cylinders. Sensory nerves do
not transport the toxins to the cord. The toxin enters the nerve
termination, first of all, at the site of the infection, where it is most
concentrated, which will explain why the spasms most frequently
begin in the vicinity of the infection, or are the most marked there.
Most of the toxin is taken up by the blood and lymph and distributed
all over the body, and then passing along the motor fibers it enters
the cord and leads to general convulsion. When the toxin is injected
directly into the cord the symptoms begin at once. Therefore, for
protective purposes, much may be expected from the administration
of the antitoxin in cases of suspicious injury or those where
experiment has shown there is reason to fear the development of
tetanus. There does not appear to be on record a single instance in
which a person who had been given antitoxin soon after receiving
such a wound has developed tetanus, nor does the antitoxin by itself
seem to have done any harm. Obviously, then, the earlier antitoxin is
used in the case the better. It may be recalled that there are no
diagnostic symptoms of tetanus until the first spasm develops,
usually after the expiration of from five to twelve days. By this time
the nerve cells are thoroughly saturated with the poison and
considerable time may elapse before the antitoxin can reach these
cells by a more indirect route.
Tetanus Neonatorum.—Tetanus neonatorum, or tetanus of the
newborn, a condition already alluded to, is
a remarkably fatal affection, very prevalent among the negro race,
especially in hot climates. It nowise differs from traumatic tetanus,
but is such in effect, since the infection in these instances always
follows the division of the umbilical cord, which is usually effected
with dirty scissors in the hands of a dirty midwife, while the thread
with which the cord is tied is itself a possible source of infection, as
well as the rags which are used to cover the umbilicus in the first
dressing. It is generally fatal, because of the weakness and lack of
resistance of these little patients. It occurs usually within a week after
birth, if at all.
Tetanus Cephalicus.—Tetanus cephalicus, called also tetanus
hydrophobicus and head tetanus, is only a
peculiar manifestation of this same affection, confined mainly to the
head and usually following injuries to this region. The muscle
spasms are mostly confined to the facial, pharyngeal, and cervical
muscles, sometimes extending to the abdominal. These
manifestations may be reproduced in animals by inoculating them on
the head rather than upon the extremities. It is the least fatal form of
the disease.
Symptoms.—There is always a period of incubation, usually three
or four days, occasionally a week in length, but rarely
longer.
It is generally held that the longer the period of incubation the
more hopeful the prognosis. While for the great part the disease
assumes an acute type, a chronic tetanus is described and
occasionally seen. The first warning of the disease usually comes as
more or less stiffness of the cervical and maxillary muscles, which is
likely to be referred to by the patient as a “sore throat,” because of
the consequent difficulty in deglutition. A complaint to this effect
should be regarded as a warning, especially if on inspection no
visible reason for it can be detected in the pharynx. This complaint is
usually made in the morning after an ordinary night’s rest. This
muscle stiffness will be followed by increasing tonic spasm in the
muscles of the jaw, making it difficult to open the mouth, while the
head and neck gradually become stiffened and fixed by spasm of the
cervical muscles. These muscles may now be felt more or less
rigidly contracted, as if by voluntary effort, and the condition, which is
at first not painful, becomes after some hours a source of discomfort,
perhaps of actual pain, to the patient. If the disease pursues the
usual course, the other muscles of the body become gradually
affected, usually in the order of their proximity, but not necessarily
so. The abdominal muscles are firm and board-like, and the dorsal
muscles more or less contracted, sometimes to an extent which
causes arching of the spine. Should the original wound or port of
entry for infectious germs have been in the hand or foot, the muscles
of this limb become contracted, more or less rigidly, holding it in a
position which is not easily changed, even by efforts of the attendant.
Sensation is also often more or less perverted. In this condition of
tonic rigidity the muscles remain, to relax usually only with death.
The most characteristic features of the disease, however, are the
peculiar clonic exacerbations, which convert spastic rigidity into
violent and convulsive muscle activity, so that the limbs and even the
frame of the patient are more or less contorted, the muscle exertion
being sometimes painful to witness. Notable effects are thus
produced; the mouth is peculiarly puckered, and its corners drawn
upward and backward by the risorius muscles, giving to the face that
peculiar expression known as the “sardonic grin.” When the
abdominal and flexor muscles of the thighs are involved, and the
body is more or less curved forward, this condition is known as
emprosthotonos; when the muscles of the back especially are
involved, with the extensor muscles of the thighs, as opisthotonos;
and when the body is bent to one side or to the other it is called
pleurosthotonos. It is said that opisthotonic convulsions occur to
such an extent in some instances that the heels touch the head. At
all events, the patient’s body is frequently raised from the bed, so
that he rests upon the head and feet.
Another characteristic feature of the disease is the reflex irritability,
or hyperesthesia, by which these convulsive attacks apparently are
produced. Into this condition the patient falls more or less rapidly
within the first day after the inception of the disease, and to such a
height may it be augmented that the slightest movement in the room,
jarring of the bed, or displacement of clothing, even noise or a flash
of light, may immediately bring on a convulsion. Rupture of muscles
has been reported during some of these violent convulsions.
 Fig. 18

Characteristic tetanic spasm in a rabbit twenty-six hours after inoculation with pure
culture of tetanus bacilli. (Tizzoni and Cattani.)

During the course of this disease the jaws are so fixed that
patients speak with extreme difficulty and the tongue cannot be
protruded. The mind is clear until the end. The pain is rather the
acute soreness due to intense muscle strain. There is spasm of the
sphincters, by which urine and feces are often retained. There is
nothing characteristic about the temperature, which is seldom much
augmented. Attempts to swallow give pain, and are resisted because
of the renewed muscle spasm which is likely to follow the irritation
inseparable from the act itself. As the result of spasm of the glottis
peculiar respiratory sounds may be noted.
Until the last only the voluntary muscles are involved. Finally,
however, there are spasms of the accessory respiratory muscles and
of the diaphragm. Death is usually produced by involvement of these
muscles analogous to those of the others, and results usually from
apnea or suffocation. During the last hour or two perspiration may be
copious and the temperature may rise.
Chronic tetanus is characterized throughout by a milder and much
more prolonged series of symptoms. The period of incubation is
much longer, and, while the general program of the acute form is
adhered to, it is of less severe degree and is spread over a longer
time; in fact, cases covering two months or more are reported. In
chronic tetanus the prognosis is much more hopeful than in the
acute form.
 The wound is but slightly, if at all, affected. In some cases it will be
found to have healed before the onset of the disease. If suppurating
or open, its evidences of repair will be found unsatisfactory and
some indications of septic infection may be noted. Pricking or needle
sensations may be subjective phenomena.
Prognosis.—Prognosis is almost invariably bad; if patients live
more than five or six days it is thereby improved.
Postmortem Appearances.—These are rarely distinctive. In most
instances there are evidences at least
of hyperemia, if not of more active changes, in the upper portions of
the cord. Less often slight changes have been noted in the brain,
consisting, in some measure, of disintegration and softening.
Evidences of ascending neuritis in the nerve trunks leading to the
injured area have been claimed in some instances. Few if any
distinctive postmortem changes can be described as due to this
disease.
Diagnosis.—The diagnosis should be made as between
strychnine poisoning, hysteria, hydrophobia, tetany,
and, in the beginning, from pharyngitis, tonsillitis, etc. When the
disease is fully developed it is not likely to be mistaken for anything
else.
Tetanus may be simulated by hysteria, but in this event the
phenomena will be so uncertain, and the evidences of organic
disease so essentially lacking, that it is not likely that mistake can
occur.
Treatment.—If any case can be imagined in which efficient
treatment is most urgently demanded it is one of
tetanus. In scarcely any disease, however, is drug treatment so
unsatisfactory. In the rare instances in which patients have
recovered it is questionable whether it is not due to individual
resistance rather than to medication. Treatment may be subdivided
into local, constitutional, and specific. If there is still an open
suppurating or discharging wound, it is, of course, essential to
cleanse this out, basing this advice in some measure upon general
principles—largely upon the fact, already stated, that ordinarily only
the immediate surroundings of such a wound are found infected by
the bacilli themselves. Consequently thorough scraping, excising,