but when present it is a valuable aid to diagnosis. This man's eyes were turned to the extreme right, away from the paralyzed side, his head being rotated in the same direction; and any effort to move his head seemed to be painful to him even in his semi-comatose condition. The right side was in constant motion, a feature which made it less difficult to locate the paralysis. From the history we conclude that this, in all probability, is a case dependent upon cerebral hemorrhage secondary to syphilitic degeneration of the blood-vessels. I say "probably," because I do not think we should make a very positive diagnosis.

Pediatrics.

TETANUS NEONATORUM; BASILAR MENINGITIS, ETIOLOGY AND TREATMENT.

CLINICAL LECTURE DELIVERED AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL.

BY HENRY DWIGHT CHAPIN, M.D.,

Professor of the Diseases of Children at the New York Post-Graduate Medical
School and Hospital; Attending Physician to Demilt Dispensary,
New York City, New York.

GENTLEMEN,-On January 1 there was admitted to the babies' wards of the hospital an infant suffering from tetanus neonatorum, who died about four hours after admission. I was enabled to exhibit the child to a few before its death, and I will now give a more detailed history of this instructive case.

Simon F, ten days old, was born healthy, weighing nine pounds. The mother had been deserted by her husband, and was in poor circumstances. She seems to have been fairly healthy, and has never had any miscarriages, this being the first and only child. The condition at birth was normal. The first disturbance that was noted was on the sixth day, when the infant turned its head to one side as if in a slight spasm. This grew somewhat worse, and on the eighth day the child had clonic convulsions, which passed off in a few hours. There has been no history of vomiting. On the ninth day the infant refused the breast, and, as the mother was in a bad condition, it was brought to the hospital.

An examination showed the infant to be in a condition of poor nutrition; it seemed to be suffering from a general tonic spasm, the arms and legs were flexed and rigid, the fingers tightly clinched, the head thrown back, and the jaws somewhat rigid. Opisthotonos was fairly well marked; the infant could be raised with one hand under the head and the other under the legs, while it remained as stiff as a poker. During the few hours of life it had exacerbations of this condition; at times, however, there was considerable relaxation; the

pupils were contracted and reacted to light. An examination of the lungs gave a negative result. The child swallowed with much difficulty, although it managed to take part of a bottle of sterilized milk and lime-water. There was frothing at the mouth when the spasms increased in severity. An examination of the head showed that the occipital bone was much depressed, the parietal bones overriding upon both sides. This was reduced without any difficulty, but the reduction made no difference in the condition of the spasm. A rather untidy dressing was removed from the umbilicus, and the stump was seen to be suppurating and in an unhealthy condition. Swallowing grew more and more difficult, and the infant soon died of exhaustion.

Much trouble was encountered in procuring an autopsy. However, I refused a certificate, and finally, after a week's delay, secured the privilege of examining the body. During this interval it was packed in ice and frozen stiff. An examination showed no disease or lesion of the central nervous system, the brain and cord both being studied. The inflammation in the umbilicus could be recognized, and a phlebitis extended about half an inch back of the stump. There was no evidence, however, of peritonitis or pleurisy. The intestines were decomposed, and presented nothing worthy of note. It was evident that the cause of the tetanus was infection derived from the umbilicus.

It has long been recognized as a fact that although this disease is distributed through a very wide geographical area it is nearly always found in filthy surroundings. Among the negroes in the South it is exceedingly common, also in India and the West Indies, and in parts of Iceland. One of the physicians in the class, who has been practising in China, tells me it is exceedingly common among the poorest classes there. He mentioned one family in which four infants died of this fearful malady. The beginning of the affection is seen in most cases after the navel-string has separated. We are indebted for a better understanding of this disease to bacteriology. Something besides filth is necessary; there must be a specific cause. As early as 1884, Nicolaier observed that tetanus could be produced in guinea-pigs and rabbits by injecting various particles of earth. This earth contained a bacillus which, although not then separated, produced by its cultures the same disease. This bacillus was afterwards described as being of the pin-head and bristle-shaped form. It may exist in straw or dust from hay, which explains the fact that horses are subject to this disease, and that traumatic tetanus is often seen among laborers who are employed about farms and stables. Guelpe, in 1889, published a

most complete monograph upon this disease. He arrived at the following conclusions: "(1) Tetanus is an infectious disease; traumatic tetanus in the true sense of the word does not exist. (2) Although the horse is one of the animals most apt to contract this disease, tetanus is not of equine origin. It would be more correct to attribute it to a telluric origin, but this would be too restricted. We believe it preferable to affirm simply that it is of microbic origin. (3) The symptoms of tetanus are not the direct effects of the microbes, but occur in consequence of the toxic substances generated by them. (4) During the first manifestations of tetanus, at least, the multiplication of the microbe is limited to the seat of infection; it is only later, and quite rarely, that the bacillus becomes generally diffused through the organism. (5) Although opposing the nervous theory of tetanus, we must admit that the nervous system possesses an excessive susceptibility altogether peculiar to the action of the micro-organisms or products generated by them.”

While the bacillus of tetanus does not necessarily exist in any one place, the umbilical sore is undoubtedly the source of its entrance in the vast majority of cases of tetanus neonatorum: hence the utmost cleanliness must be observed in cutting the cord and in dressing it. Dirty scissors are often employed, or string that has not been in a clean place. Scissors can be rendered antiseptic by drawing them through the flame of a spirit-lamp. The excess of the gelatinous matter may be stripped off the cord, and a dry antiseptic dressing applied. Speedy mummification of the stump will be the best safeguard against the entrance of microbes. There may be no evidences, however, of marked inflammation at the umbilicus.

Special care must be exercised in the umbilical dressings when the infant's parents work in stables, or where the dwelling is easy of access to stable-yards containing horse-manure or loose earth.

It is interesting, in connection with the case here cited, to observe the condition of the occipital bone. The late Dr. J. Marion Sims considered depression of the occipital bone to be the most common cause of tetanus neonatorum, and thought that relief could be frequently procured by putting the infant upon the face, and thus removing pressure from the back of the head. In this case the occipital bone was markedly depressed, but it was immediately reduced, and the reduction resulted in no change in the symptoms.

Prophylactic treatment is the most satisfactory. When the disease has become thoroughly established it is almost invariably fatal; however, means should be taken to discover, if possible, the seat of infection.

In cases of suppuration about the umbilicus, frequent washings with a solution of mercuric bichloride of suitable strength should be employed. Guelpe states that the bacillus exists to a great extent in the deeper portions of the wound, and hence curetting or free incision may be employed. This could hardly be done in the case of the umbilicus. Free antiseptic washing, however, is certainly indicated. With reference to drugs, the two most valuable are potassium bromide, in large doses, and chloral hydrate. At the same time these are administered, the infant must be given nourishment frequently, and stimulants freely employed. The difficulty of swallowing, however, handicaps us in satisfactorily carrying out these measures.

The next case I shall present to you is an infant, thirteen months old, who was admitted to the babies' wards December 29, 1890. His mother has always been healthy, has had no miscarriages, and has two other children, aged three and seven years respectively, and both are healthy. This infant was on the breast for a year. Dentition began two months ago, when the two lower incisors were cut. The infant seems to have been perfectly healthy until six weeks ago, when the present trouble began. The child then fell from a sofa, striking the back of the head. The parents are Polish Jews and very stupid, and it is difficult to obtain an accurate history from this time, but one week afterwards the infant was seized with convulsions, each lasting several hours. It had two attacks of these convulsions daily for about two weeks. A few days ago he apparently lost his sight, and the bowels were costive, acting only by injections. The infant is very dull and stupid, sleeps most of the time, vomits, and has some cough; the pupils are dilated and do not react to light, and there is internal strabismus in both eyes. An ophthalmoscopic examination has shown the fundus of the eye to be healthy. The reflexes are somewhat exaggerated. The child's weight on admission was nineteen pounds two ounces; temperature, 99°; respiration, 24; pulse, 118.

Since admission it has been unconscious all the time, lying with the head thrown back in the position in which you see it. It seldom cries except when disturbed; the limbs are held in the flexed position, but are not stiff. Examination of the lungs is negative. The pulse is irregular at times. On the second day of its stay in the hospital its temperature went up to 100°, but since then it has remained between 98° and 99°. The pulse has varied from 110 to 130, and is becoming more rapid and irregular. The respirations have ranged from 22 to 36. The skin is somewhat hyperemic and apparently hyperæsthetic, as the infant will cry if handled much. Both sight and hearing are largely