Tetanus Nascentium. (By J. LEWIS SMITH, M.D., Physician to the Infant Asylum; Physician to the Prot. Epis. Orphan Asylum, New York.) (Concluded from March No.) * * * * Hence the theory of Dr. Sims cannot be accepted; and yet there are few cases on record in which tetanus seemed to be due to injury received at birth. Dr. Sims has related one such case, that of a negro infant. The mistress, an observing lady, gave to Dr. Sims the following account of it :-Its head 66 was mightily mashed. The bones seemed to be loose. I got it to take a little boiled milk on the first day; but it swallowed very little, and very badly, for its jaws seemed to be locked. On the next day it took spasms, and got stiff all over; its hands were shut up tight, and its arms were bent up so (she placed her forearms at right angles). Every time I touched it the spasms would get worse all over, screwing up its face till it was the ugliest thing in the world; and when the spasms went off, it looked as well in the face as any new-born baby. But then the stiffness never left it, and the spasms kept coming and going till it died." It lived two days. It is evident, from the description of the mistress, that this was a case of tetanus nascentium, commencing at, or so soon after birth, that it was really congenital. The apparent cause wag injury of the head, occurring in consequence of protracted birth; the infant was resuscitated with difficulty after several minutes. Dr. W. C. Sutton published a similar case in the Nashville Journal of Medicine and Surgery, April, 1843. The infant, at birth, was apparently dead, but was resuscitated so as to live eighteen hours in a state of tetanic rigidity. In these cases of congenital tetanus, doubtless, the cerebro-spinal axis is in some way affected; but, in the absence of post-mortem examinations, the exact nature of the injury is uncertain. It is evident, then, that tetanus nascentium cannot be ascribed, abstractly considered, to any one cause. On the other hand, in different cases, the causes may be essentially distinct; so that the disease, as regards causation, corresponds with eclampsia in older children. Dr. James Johnson, many years ago, expressed his belief in the multiplicity of causes, and he had been a careful and intelligent observer in the West Indies. The causes may be arranged in two groups, one external, the other internal. In the first group may be placed imperfect ventilation, personal and domiciliary uncleanliness, and atmospheric vicissitudes; in the second group, so far as ascertained, inflammation of the umbilicus and umbilical vessels, meningitis, and, rarely, injury of the cerebro-spinal axis during birth. It is highly probable that in a large proportion of cases an external and internal cause are both present, the external preceding and producing the internal, and the internal in turn producing the tetanus. Lesions resulting from Tetanus.-The lesions resulting from tetanus nascentium, most frequently observed in those who have died of this disease, are chiefly such as are produced by the arrest of circulation, which, will be seen, occurs especially in the paroxysms. In the cases examined by Prof. Cederschjold, of Stockholm, already alluded to, the vessels and sinuses of the brain, and the brain and spinal marrow, were gorged with blood; heart and large vessels filled with blood. Careful autopsies were made by Finckh in the Stuttgard hospital, in twenty cases, the bodies at death having been placed on their faces, in order to prevent any deceptive appearance from the gravitation of blood. In four there was no appreciable alteration in the spinal marrow or its membranes, In the remaining sixteen there was an effusion of blood, in considerable quantity, the whole length of the spinal canal, between the bony walls and the dura mater. It should be stated, however, that there was spinal meningeal inflammation in nine of the sixteen, though the effusion of blood did not probably result from the inflammation, but from the tetanus. The blood was very dark, sometimes fluid, at other times coagulated. In one case there was no change in the appearance of the brain or its membranes; in the remaining nineteen more or less extravasated blood was found on the surface of the brain or in its interior. The substance of the brain was healthy, and also its membranes, except the congestion. The only abnormal appearance observed in the thoracic and abdominal viscera was strong contraction of some portion of the intestinal tube in five cases. Dr. West says:— "The most frequent post-mortem appearance in these cases," refering to tetanus nascentium, "and that which I found in the bodies of all the four children whom I observed, consists of effusion of blood, either fluid or coagulated, into the cellular tissue surrounding the theca of the cord. Conjoined with this there is generally a congested state of the vessels of the spinal arachnoid, and sometimes an effusion of blood or serum into this cavity. The signs of congestion about the head are less constant, though much oftener present than absent, and sometimes existing in an extreme degree; while in one instance I found not merely a highly congested state of the cerebral vessels, but also an effusion of blood, in considerable quantity, between the skull and dura mater, and also a slighter effusion into the arachnoid cavity. Dr. Weber, of Keil, also placed infants who had died of tetanus on their faces, and, without exception, found injection of the capillaries of the cord and spinal meninges, and extravasation of blood. M. Matuzynski, according to Bouchut, "has observed effusions of blood, of variable quantity, in the cerebral pia mater, in the ventricles, and in the choroid plexuses, with considerable injection of the membranes of the brain. He has also seen serous infiltration beneath the arachnoid, and serous effusion into the ventricles, accompanied by a diminution of the consistency of the cerebral substance." In two cases examined by myself, there was intense injection of the cerebral meninges and of the meninges of the upper part of the spine, but no extravasation was noticed. The spinal canal was not opened. Dr. H. O Wooten (New Orleans Medical and Surgical Journal, May, 1846,) states that he has made several post-mortem examinations, and has found the pathological appearances as uniform as in any other disease, as follows:Engorgement of the substance of the brain, and of the meninges lining the |