diarrhoea. At the end of twenty-four or thirty-six hours, trismus 2 shows itself, at first intermittent, then continuous; the jaws and tongue are stiff, suction is impossible, and soon the rigidity invades the attack muscles of the neck, body, and limbs. The hands become closed, the fingers contracted, and the toes firmly flexed on the soles of the feet. Opisthotonos, more or less marked, follows, so as to allow the child to be raised like a log by holding it by one of its extremities. Opisthotonos sometimes exists alone without the tetanic spasms, and the child, pale and depressed, utters some isolated cries, and remains fixed. Sometimes this rigidity of the body is interrupted by tonic convulsive attacks of greater force, which appear at more or less distant intervals. At each spasm the child stiffens, and is drawn up from the level of the bed; it utters cries, its face reddens and swells, the eyes are injected, the tongue is bruised, and a white foam escapes from the mouth. The least noise, the slightest touch, the sudden appearance of light, the splashing of water, bring on fresh and very painful attacks. Jaundice nearly always accompanies tetanus in new-born infants; audi others have observed sclerema, tania, &c., as complications. The disease lasts from three to four days, but after twelve or twenty-four hours the convulsions cease, and the child falls into a state of collapse. The body is emaciated, the face altered, bluish, and cold, like the extremities of the feet and hands. Respiration is difficult, interrupted, stertorous, the pulse imperceptible, and the beatings of the heart scarcely to be detected by the ear; the weakness is extreme, and death nearly always terminates the scene. With some children, towards the termination of the disease, a sort of febrile reaction is estab- usini: lished about the head, which becomes burning, while the extremities remain cold, but the result is the same and is not retarded. In a case which Underwood cites as very rare and unique, the tetanus continued beyond the third day, and lasted six weeks before death Which ensued. Amongst the children who die, autopsy reveals certain lesions of the nervous centres, which would be of great weight if they were constantly present, and which have been observed by M. Matuszynski in a tolerably large number of subjects. These lesions do not absolutely reveal the cause of the tetanus. They are probably only an effect of it, caused by the hyperemia which accompanies tetanic rigidity; but such as these researches are they merit a serious consideration. M. Matuszynski has enumerated the dirty yellow colour of the skin, numerous ecchymoses on the trunk and extremities, a large, bluish green areola around the umbilicus, and sometimes vesicles on the neck, thorax, Appala and abdomen. He 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 170 SPECIAL PATHOLOGY OF INFANCY. [Part III. also seen serous infiltration beneath the arachnoid, and serous effusion into the ventricles, accompanied by a diminution of the consistence of the cerebral substance. Sometimes the brain has appeared to him to habe indurated at the same time that there was a complete softening of the cerebellum. This observer has also pointed out the very frequent presence of an effusion of blood in the vertebral canal, external to the investing dura blood in mater, the effusion being more marked in the cervical region, accompanied with congestion of the pia mater of the cord, congestion of the spinal cord, and sometimes softening of this organ. Other observers, as MM. Lévy and Thore, have also several times remarked the presence of effusions of blood external to the dura mater, and injection of all the tissues comprised in the nervous centres. One would, consequently, imagine that compression of the spine and of the brain by hæmorrhage is the most frequent cause of tetanus infantum ; but unfortunately this lesion is not constant, and in several instances cited by MM. Matuszynski, Lévy, and Thore, this post mortem appearance has not been met with. It is not, then, the anatomical cause of tetanus; and when we reflect that this hæmorrhage, when it exists, is not confined to the nervous centres, but that it is also observed in the other tissues, in the intermuscular spaces and in the skin, under the form of ecchymoses, there is reason for supposing that it is consecutive, or, in other words, that it is the result of tetanus. This is very probable, and the obstructions to the functions of respiration and circulation, occasioned by the tetanic contractions and spasms, would then be a very natural explanation of the effusions of blood observed in the midst of the tissues, and external to the spinal dura mater. This way of considering the question appears to me at present the most justified by observation. However this may be, the prognosis of tetanus infantum is very unfavourable. It is a fatal disease, which carries off the greater part of the children it attacks. Several cases of cure can, with difficulty, be cited from a vast number of seizures. Cejerchsjoeld states that out of forty-four children labouring under this disease at Stockholm, forty-two died and the same is the case everywhere. Yet, as several physicians have been more successful in tetanus of the adult, and as O'Shaughnessy, O'Brien, and Miller pretend to have cured this disease by a particular mode of treatment, there is reason to hope that the same result may one day be obtained for the subjects of tetanus infantum-new facts must be waited for. When the children are attacked, death usually supervenes in two or three days-a longer respite is the exception. Once Underwood has seen it delayed to the end of the sixth week. [Dr. West (Lectures on Diseases of Infancy and Childhood, p. 125) mentions that three cases occurred under his notice in the Dublin Lying-in Hospital, but that no instance has come before him at the Infirmary for Children. He believes that few infantile diseases run so fearfully a rapid course as this; its fatal termination almost always taking place within thirty-six, often within twenty-four hours, from the appearance of the first symptoms. But Dr. Sims, whose experience in this disease is much more considerable, having lately stated that no less than fifty negro children in one plantation have died within the last ten years, says the disease may present different degrees of severity, some cases terminating fatally in a few hours, and others lasting several weeks. Mauthner and Verson mention a peculiar contraction of the mouth to a point, as always to be observed at the onset of the malady, and that the difficulty of swallowing is so great, that the child at every trial made to give it food, rejects it through the nose. Dr. West remarks that the power of sucking is Rad early lost, but for some time the child continues able to swallow. Dr. Sims (American Journal of Medical Sciences, 1846-8) is of opinion that the disease is ult's caused by displacements and pressure of the occipital or the parietal bones upon the nervous centre; that if the proper position of the infant be attended to, nature will correct the evil, but it may require the interference of the surgeon to liberate the confined, depressed, or misplaced bone, which may be effected by elevating the depressed occipital with an instrument something like an awl; that the disease depends more upon the improper management of children than on anything else. But these views cannot explain the epidemic which occurred in the Lying-in Hospital at Stockholm in 1834, nor the frequency of the affection sixtyosielal years ago in that at Dublin. In these cases it would appear to have been produced by a highly vitiated state of the atmosphere; for in adopting means to secure the rich room efficient ventilation of the latter hospital the ratio of mortality of every sixth child within a fortnight after birth and trismus the cause of the death of 19-20ths of their children, fell at once to 1 in 194; and from 1826 to 1833 was only 1 in 584, and but funder little more than the ninth part of the mortality depended on trismus.-Collins' Treatise on Midwifery, p. 513. Dr. Weber states that he always found the chief pathological changes in the vertebral column, and not in the umbilical vessels; but Dr. Bednàr writes that the most careful examination of the dead body has not allowed us to discover any visible material foundation of tetanus; even preparations of the separated nerves lead to no desirable end, and we must therefore conclude, that the tetanus of new-born children is a nervous affection, of whose essence we are in ignorance, and which consists neither in anæmia, nor in hyperæmia, nor of inflammation of any part of the nerves system, or still less of any other organ.-Die Krankheiten der Neugebornen und Sauglinge, &c., p. 157. Dr. Bednar examined thirty-three children who died from tetanus: three times he found hyperæmia of the spinal membranes, three times blood in the arachnoidal sac, and once serious infiltration of the covering of the cord, &c. The views of Barrier, Ollivier, Billard, and others are, that Trismus is due to spinal apoplexy, or to the effusion of the semi-coagulated fluid in the spinal canal. The testimony of Clarke, Labatt, and Collins renders further information necessary before we fully coincide in the above views. Although trismus is undoubtedly a spinal affection, yet the researches of West offer some serious obstacles to associating the above frequently observed lesions with the symptomatic phenomena in the light of essential or necessary cause.-P.H.B.] TREATMENT. The remedies against tetanus are, prolonged warm baths, narcotic bellis 4 fomentations over the contracted parts, frictions with camphorated oil, ned, blisters behind the ears, calomel when there is constipation, enemata of assafoetida, tincture of opium, and Hoffman's drops in small and gradually increasing doses, tincture of Indian hemp, as used by Ludun O'Shaughnessy, O'Brien, Miller, who, in the adult, have effected the cure of from ten to twelve cases of traumatic tetanus, by doses of an buth sixty to eighty drops every hour. We may commence by giving an infant five drops every hour the first day, then ten drops the next day, and continue it until sleep comes on. This tincture of Indian Rechok, -extract to one ounce of alcohol, which makes about seven grains to CHAPTER XI. ON CHOREA. Chorea, or St. Vitus's dance, is a disease unaccompanied by fever, and characterized by the constant presence of irregular and involuntary movements in the muscles of animal life. It is very common in the second period of childhood, but is scarcely ever met with amongst children at the breast. Underwood and Billard do not mention it in their works; Baron has never seen it amongst the "Enfants trouvès" during a practice extending over more than thirty years. The only physicians who have observed chorea in infants, are M. Michaud, who states that he has seen a case of it in a child even at the moment of birth, and Constant, who cites an example in a child four months old. The case has been published.* [Dr. Mauthner's report for 1851 contains two cases of chorea occurring in girls; but it is by no means of common occurrence; Dr. West, at the Infirmary for Children, not meeting with it in above one out of one thousand cases. When it is observed in early life, sudden fright seems to be one of its most frequent exciting causes. At other times, it would appear to be connected with a state of intestinal disorder, or with some irregularity in the progress of the second dentition, while it is occasionally difficult to discover to what the involuntary muscular movements are to be attributed. Purgatives should be administered at the commencement and when the bowels are constipated in the course of the disease; calomel and scammony form a good combination; tonics of the preparations of iron and zinc, or arsenic, as recommended by Romberg, should be given, and the general hygiene of the child attended to, to which end change of air, sea bathing, and a well-regulated but nutritious diet will be found beneficial. Partial chorea is also occasionally met with, in which some muscles only are affected, and very peculiar cases in which an alternating rotary motion of the * Bulletin de Therapeutique, for the year 1833. head and the whole body are observed, and these are much more difficult to cure; quinine, steel, and occasional' purgatives are the most promising remedies. Partial Romberg (On Diseases of the Nervous System, vol. ii, p. 55) has only met Chera with two cases in children in whom the muscles of the external and internal respiratory apparatus were attacked. In a child of eight years, the choreic movements of the right half of the body were associated with dyspnoea, whistling inspiration, and palpitation. In the other case, a boy of eight years, at first only the muscles of the extremities, of the face, and the eyes were attacked. The affection subsequently left these parts, and seized upon the muscles of respiration. Dr. Churchill, while treating of the subject of chorea, observes, "that in other cases the paroxysm consists in hammering the knees with the hands, or of a constant series of bowing. Such cases as these latter, however, have one peculiarity not usual in chorea, i. e., the muscular movements appear independent of the will, neither excited by it, nor under its control; and it is almost certain that t in some of these cases the patient is unconscious;" this class of cases would appear to come under the head of "salaam convulsion" of Sir Charles Clark, and is that eclampsia nutans of Mr. Newnham, who has ably illustrated this peculiar affection in a paper detailing four cases.-British Record of Obstetric Medicine. Attention While was first drawn to it by Mr. West, of Tunbridge (Lancet, 1841); and it was anthrop exemplified in his own child, and a paper was lately read upon the subject before the Westminster Medical Society, by Dr. Willshire, who added another case to the only four British examples on record, given by Mr. Newnham. of the These cases hardly come under the definition of chorea. The general convulsions which sooner or later accompany the "salaam" movement head, sometimes partake of an epileptiform, sometimes of a tetanoid character. Moreover, paralysis and complete idiocy have followed. Dr. Faber (Smidt's Jahrb; vol. lxvii, p. 213) relates two cases of this curious affection. The first occurred in a girl at three, who though pale and weakly, had not suffered from any decided disease until three months before, when she complained of headache and sleepiness, began to squint somewhat, and sometimes to nod her head towards the left side. This nodding action was at first continued only for a few minutes, three times a-day, during which the head was making constant salutation movements. After awhile the attacks increased in frequency, and were fearfully violent. The child was much disposed to sleep, and became, on waking, convulsed in the extremities; this passing on to complete epilepsy.! She was backward in mental development, and had an idiotic expression of countenance. The second occurred in a boy at six, who showed great capabilities for instruction up to the commencement of his sixth year, when he fell into the water. He remained in bed several days afterwards in a drowsy state, and was never again so lively and quick. After awhile he was observed to nod his head for two or three minutes, and this several times in the course of the day, the motions being sometimes so rapid that eighty could be counted in a minute. They commenced at first slowly, like real salutations, but gradually increased in quickness, when the child would fall back in a passion. During the time they continued, his face was distorted, and great fatigue was induced. He was aware when the attacks were coming on, and his consciousness continued during their prevalence. He was pale and feeble, and had acquired a peculiar stupid look. The most careful examination of these two cases did not lead to the determination whether this was a partial chorea or a peculiar form of spasm, or whether it was dependent upon morbid conditions of the brain or spinal marrow. The most careful examination of his two cases did not enable him to decide. No pain 2' |