INFECTIOUS DISEASES OF THE NEWBORN Tetanus neonatorum is classed with the wound infections of the newborn, just as erysipelas of the newborn, because its port of infection is regularly the umbilical wound. Tetanus in the newborn runs a sim ilar course to that in the adult and differs in no wise from the latter in etiology or symptoniatology. The healing of the navel wound is usually complete in about 14 days and this implies that. tetanus nconatorum is limited to the first three weeks of life, except when the virus gains entrance elsewhere than at the navel.
Symptoms.—The disease starts shortly after birth, usually in the second week, less often at the end of the first or during the third week of life. The onset is accompanied by great restlessness and frequent piercing cries. It soon becomes evident that the child has some diffi culty in sucking. When the infant is put to the breast or given the bottle, it makes only one or at the most a few sucking movements and then desists. The examining physician at this time finds a spasm of the muscles of mastication (trismus) which is elicited as often as the child is induced to suck and which later becomes permanent. This tetanic spasm, the principal symptom of the disease, is not, however, long limited to the masseters. Within a few days or even hours the recurring attacks of tonic convulsions spread to the muscles of the face and therewith the face takes on a characteristic appearance (risus sar donicus, facies tetanica). The forehead is gathered into deep wrinkles, very striking for a child of this age; the eyelids are squeezed together, the puckered mouth is protruded more or less; at. times the corners of the mouth are drawn sharply downwards, in other cases the upper lip alone is contracted or else to a greater degree than the lower lip, thus drawing the skin here into radiating folds. The spasm next extends to the muscles of the neck and back; the head is strongly retroflexed, opisthotonos begins, the abdominal walls become rigidily contracted, the upper extremities usually rigidly flexed to an acute angle and the legs extended. The hands are usually flexed in all joints and the feet held in dorsal flexion. The position of the extremities varies according
to the muscle group which is most intensely affected by the tetanic convulsions.
At this stage on account of the spasm of the masseters and the muscles of deglutition, sucking and swallowing become impossible. Not uncommonly tonic spasms of the larynx and diaphragm occur. Emit ting no sounds, the child lies prostrate, becomes cyanotic and breathes irregularly and superficially. The attacks become more frequent and of longer duration so that they seem to be almost uninterrupted. They are aggravated by external stimuli. Touching the skin, taking hold of the nipple, or cooling the body surface by uncovering the child serve to arouse stormy, jerky, tetanic contractions. In many cases the disease runs an afebrile course, in. others however it is accompanied by irregu lar fever which at times is very high. A post-mortem rise in the body temperature has been found very often in cases of tetanus. The complete clinical picture is not always encountered. In many cases the spasms extend no fur ther than the masseters, accom panied by slight contractions of one or the other muscle groups, usually of the face and neck.
In the further course of such light cases, the spasms gradually diminish in frequency and intensity and finally cease entirely. Even fully developed cases of tetanus may end in re covery; the spasms diminish gradually, especially the trismus and spasms of deglutition; then the rigidity diminishes, and convulsions occur only after powerful stimuli and later not at all; in such cases I have observed, even after the disappearance of the tonic spasms, a slow contraction of the mus cles, elicited by the tap of a hammer, which persisted quite a -vhile.
As a rule, in uncomplicated eases the other organs show nothing noteworthy. It must be noted, however, that septic infection may often accompany tetanus in the newborn. The navel wound presents either nothing abnormal, or else exudes a serous, sero-sanguinolent or purulent secretion. In many cases the umbilical wound has a lardy exudate and has the characteristics of an umbilical ulcer.