neonatorittn, like tetanus in the adult, is due to a specific agent, the tetanus bacillus. The older opinions which attrib uteri tetanus to the use of baths of too high temperature, to the influ ence of drafts, cold, etc., must be regarded as false. Nicolaier in 1SS5 discovered and cultivated the tetanus bacillus and Kitasato obtained it in pure culture. It is a very constant. inhabitant of the ground, in gar dens, and has also been found in the dust of dwellings, in cracks in the floors, in furniture, etc., (BRumler). It gains entrance to the umbili cal wound with dust, probably by contamination from the baby-clothes, the bandage, or the hands of the nurse. There may perhaps be an in fection of the umbilical cord, just as with sepsis. In the newborn, the bacillus of tetanus was demonstrated by Kitasato, in a case of Bagin sky's and later also by Peiper, Baumler, and others. The bacillus of tetanus multiplies at the seat of infection by spore formation and, ex cept, in the rarest instances, does not invade the body; it produces toxins however, which, according to the investigations of H. Meyer and Ransom, are absorbed from the lymph-spaces, for the most part through the ends of the motor nerves, and probably through the axis-cylinders of the motor nerves. These toxins reach the central nervous system, where they become fixed. The combination of these toxins with the cells in the anterior horns of the spinal cord and the nuclei in the medulla, gives rise to an abnormal increase in the irritability of these centres and therein lies the cause of the tetanic contractions. The motor centres then react to very insignificant stimuli. The peripheral nerves and the muscles are not involved, as is proven by the cessation of the tetanic spasms after section of the nerve-trunks.
Before the onsent of the tetanus there is an incubation period vary ing from two days to a few weeks after the infection with the bacillus tetanus. This fact however cannot have any relation to the time needed for the production of a quantity of poison sufficient to produce its effect, but probably depends upon the fact, that the passage of the poison through the nerve-trunks requires a certain time before it reaches the motor centres. Others have assumed that the irritation of the motor centres is not due to the toxins per se, but to a compound of the toxins and body-substances. These poisonous compounds are sup posed to circulate in the blood of the individual infected with tetanus and the blood of such individuals should therefore immediately, with out a latent period, produce tetanic spasms in the mouse, an animal especially susceptible to tetanus. In many cases the tetanus toxin also circulates in considerable quantities in the blood of infected individuals. In such cases experimental injection of the toxin-containing blood may produce tetanus. This has not only been established as regards the blood of adults and of animals, but also in one case of tetanus neo natorum.
Even at the very beginning of the disease the tetanus bacillus is still demonstrable in the navel wound in only a small number of the cases. It probably dies off very quickly. Other septic bacteria are constantly found here.
Escherich recommends curetting the navel wound with a sharp spoon in order to demonstrate the bacillus. The scrapings should be used for the inoculating of mice and making cultures.
Duration and Course. Tetanus neonatorum runs a very violent course in the majority of cases and cases terminating•fatally last only a few days or even hours. in cases ending in recovery the disease runs a more protracted course, extending at times over several weeks. Unfav orable cases terminate as the result of spasm of the diaphragm or less often of exhaustion.
At autopsy nothing is found that might be characteristic of death from tetanus. Even the most careful examinations of the central ner vous system have up to the present time furnished nothing positive. Whatever lurmorrhages have been found in the spinal cord, brain and other organs, must be attributed to stasis following obstructed respi ration.
The diagnosis of tetanus is easily made in both the newborn and the adult. It may be confused with the tonic spasms occurring with
cerebral disease. Such spasms occur in the newborn in consequence of cerebral and meningeal litemorrhages and rarely with purulent cere brospinal meningitis, encephalitis or other cerebral diseases.
The author recently saw a child three weeks old with chronic con genital hydrocephalus in which intermittent tonic spasms occurred, in all the extremities, on moving or handling the child.
Congenital spastic diplegia can give rise to no confusion in diag nosis. In doubtful cases it is advisable to make a bacteriological exam ination or mouse inoculation. A negative result proves nothing how ever against the existence of tetanus, and then the attempt can be made to produce tetanus in the mouse by the injection of the toxic blood.
The prognosis is in general very unfavorable. It appears to he even worse than with older children and adults. Concerning the fre quency of recoveries reports vary, but on the average probably 20-30 per cent. of the cases recover.
Prophylaxis and we know that tetanus is an in fectious disease, it is our duty to protect the navel wound by the use of aseptic dressings. It also appears that amongst the class of people who lay little stress on cleanliness in the care of wounds, tetanus and also tetanus of the newborn occur relatively with greater frequency. On this fact, moreover, probably depends the reported racial predisposition of certain peoples. When tetanus breaks out in a number of persons, for example in an institution or a neighborhood, it is recommended to use prophylactic inoculations with the tetanus antitoxin discovered by Behring and Kitasato. The tetanus antitoxin is produced by injec tions of tetanus toxin in the horse; according to the discoveries of Baring and Kitasato the injection of this toxin causes the appearance, in the blood-serum, of certain bodies which give the scrum the ability to prevent tetanus, when introduced subcutaneously into an animal previously inoculated with tetanus toxins or bacilli. In a few species it has also served to cure the disease when already active. The anti toxin operates by combining with the toxin. The bacilli are not influ enced, the antitoxin not being bactericidal. The combining of the toxins and the antitoxin takes place both in vitro and in the animal body. In case however large quantities of the toxins are already bound to the nerve-cells, the antitoxin is usually unable to break up these com binations and is therefore only able to neutralize the poisons circulating in the blood. When one remembers that even at the onset of the disease the poisons are combined with the nerve-cells, it becomes evident why the serum therapy of tetanus has not given any convincing results up to the present time. Notwithstanding this, the employment of the serum must be recommended in every case, inasmuch as we never know how much, if any, poison still remains in the peripheral nerves or is possibly circulating in the blood or lymphatic vessels; the poisons cir culating in the blood can surely be neutralized. Behring's antitoxin comes in bottles each containing 250 immunizing units (that is, such a quantity of antitoxin as is capable of neutralizing ten times the mini mal fatal dose of toxin for a guinea-pig). Besides this there are other reliable preparations on the market. The injection should be given as early as possible; it is recommended to inject one half the dose subcu taneously and the other into the brain (Roux and Borrel) or, more situ ply, into the subdural space. For this purpose the point which Quincke recommends for lumbar puncture is selected, that is, the space between the spinous processes of the second and third or third and fourth lumbar According to Meyer and Ransom no better result can be expected to follow the subdural than the intravenous injection of the antitoxin. These authors consider injection of the nerve-trunks to be indicated in every case in which the point of entrance of the infec tion is known and in which the nerves involved, as conductors of the poison, are accessible.