In St. Kilda the high rate of mortality may with much probability be attributed to a similar absence of fresh air and cleanliness in their homes. That some cause is there in existence which does not obtain in the neigh bouring islands is evident, for children born of natives of St. Kilda out of the island escape the disease, and hence the occurrence of the affection can not be attributed to intermarriage or any hereditary influence.
Dr. Holland in his " Summary of the Diseases of the Icelanders," re cords the frequency of trismus nascentium in the island of Heimaey, one of a group situated on the southern coast of Iceland. He states that almost every infant born on the island died of this disease, and that consequently the population was supported almost entirely by immigration from the mainland. It appears that there was no vegetable food upon the island, and that the natives lived principally upon sea-birds which they salted and barrelled. Dr. Holland attributes the disease to irritation of the bowels excited by the practice of feeding the infants shortly after birth upon a strong and oily animal food. He fortifies his opinion by the fact that at St. Kilda, where the diet and mode of life of the natives resembled those prevailing at Heimaey, the disease was equally prevalent and equally fatal.
Tetanus is occasionally seen in older children, as a consequence of some cut, or bruise, or other injury, as is the case in the adult. Sometimes it is idiopathic, and is then probably rheumatic in its nature.
Morbid Anatomy.—Extreme injection of the small vessels of the spinal cord and its membranes, with extravasation of blood into the cellular tis sue around the theca, and also into the cavity of the spinal arachnoid, has usually been described as a common consequence of infantile tetanus. In a case which died in the East London Children's Hospital, under the care of my colleague, Mr. Parker, there was a striking absence of congestion of the cord and its membranes. On opening the spinal canal the loose con nective tissue around the cord was found to be ecchyrnosed in patches from the middle to the lower end of the dorsal portion of the cord. On opening the spinal dura mater, the pia mater did not present any unusual appearance. It did not appear abnormally congested. The cord itself was firm to the touch. On cutting into it, the gray matter was clearly mapped out by its pink colour when compared with the white substance. There were no extravasations into its substance at any point.
In some cases in adults Rokitansky and Demme have observed a de velopment of connective tissue in the spinal cord.
Symptoms.—The disease generally begins on the third, fourth, or fifth day after birth. It is rarely delayed longer than the tenth. The first symptom mentioned by the mother is usually that the child cannot take the breast, or that if he attempt to do so he quickly abandons the nipple. Sometimes the milk is noticed to run out of his mouth, as if he had a diffi culty in swallowing it. Soon the jaws become stiff and the face has a rigid, pinched look. The spasms extend from the muscles of the jaw to the neck, the back, and finally the limbs, so that in a short time a general muscular rigidity is observed, which comes on in paroxysms, lasts for a variable time, and then remits to return after a short interval. The infant may utter a pitiful whimper when the paroxysm begins, but at once the muscles become stiff and hard, the eyes are tightly closed, the jaws are set, with the mouth a little open, the head is drawn backwards, the hands are clenched, and the feet are flexed upon the ankles. Sometimes there is opisthotonos. If the paroxysm is short respiration may be suspended and the face become dusky, but in the longer attacks breathing generally continues. Each attack lasts from a few seconds to half a minute, and the intervals between them may be a few minutes or longer. In the inter val the spasm does not completely relax, there is some lividity of the face, the head often remains more or less retracted, the hands continue clenched and the thumbs are twisted inwards. At this time a touch will frequently excite the recurrence of the paroxysm. If milk is put into the mouth the child may be unable to swallow it, or if he attempt to do so the effort may bring on a return of the spasms. The want of nourishment and the exhaustion induced by the convulsions cause rapid emaciation. In most cases the interval between the attacks becomes shorter and shorter, and the child sinks exhausted, or dies asphyxiated from spasm of the muscles of respiration. From the very beginning of the attack the child ceases entirely to cry. Occasionally he may whimper faintly, but a loud cry is never heard. The temperature usually varies from 99.5° to 101° or 102°. It may fall below the normal level before death, or may rise to 104° or 105°. In a case recorded by Ingersley the temperature in some of the attacks reached 107'. In this case albumen and casts were found in the urine, and the kidneys, after death, showed marks of acute nephritis, with extravasations of blood.