In an older child the prospect is more favourable if the disease be idiopathic than if it follow upon an injury ; but in any case we cannot look forward without serious anxiety to the termination of his illness.
every case of infantile tetanus our first care should be to remove all sources of irritation, whether internal or external. The infant must be kept quiet in a room carefully darkened, and the bowels should be relieved by a good close of castor-oil, or if he cannot swallow, by a copious enema. Next, the rapid emaciation must be counteracted by regular feeding. The great obstacle to efficient nutrition is the spasm of the muscles of deglutition which makes swallowing so often impossible. Infants cannot be nourished per rectum. It is therefore advisable to put the child under chloroform at regular intervals and administer his mother's milk, if it can be obtained, or if not, asses' milk, cow's milk and barley water (equal parts), or other suitable food, through an elastic catheter passed down the gullet. In this way three or four ounces of food can be administered every three hours ; and with each quantity it is advisable to mix fifteen or twenty drops of sound brandy.
The third indication is to control the spasms. For this purpose some form of sedative must be resorted to. Opium, alone or combined with anti-spasmodics such as sulphate of zinc or assafcetida, Indian hemp, and belladonna or its alkaloid have been all employed. Whatever form be used, it should be given with the food through the catheter or hypoder mically in frequent small closes. Chloroform checks the paroxysms for a time, but they return when the effects of the anaesthetic have passed away. Good results have been obtained from the extract of calabar bean. In Mr. Parker's case, previously narrated, even the small quantity of the remedy absorbed seemed certainly to prolong the intervals of remission, although the seizures when they occurred were not diminished in severity. The drug should be administered hypodermically if the child cannot swal low. The dose should be one-twelfth of a grain by the mouth, or one twentieth by subcutaneous injection, every hour or two hours, watching the effect. It is advisable to produce some decided effect upon the heart and lungs, reducing the rapidity of the pulse and the breathing, if any good result is to be hoped for.
Of all the drugs which have been recommended for this disease the most favourable results appear to have been obtained from chloral. Dr. Widerhofen claims six recoveries in twelve patients by the use of this agent, but the only case referred to in the short extract from his lecture which appeared in the Lancet, was not of a very severe character, as the symptoms came on late and deglutition was not interfered with. In a case which was under my care in the East London Children's Hospital this was employed, and although the baby died the effect of the drug upon the spasms was decidedly encouraging. The difficulty appears to be
to regulate the dose accurately so as to dominate the seizures without pro ducing too serious a depression. For the notes of the case I am indebted to Mr. J. Scott Battams the Resident Medical Officer, who watched the child with great attention.
A little boy, four days old, of healthy Irish parentage, was admitted October 18, 1881. The father and mother with three other children be sides the patient occupied one room, which was said to be clean and large. The bed in which the child lay with his mother was placed in a strong draught, of which the woman had constantly complained. The child was. born to all appearance healthy, and took the breast well until the day be fore admission, when he was noticed for the first time to be unable to suck. That night the infant slept. badly, crying and drawing up his legs. The cry was, however, strong even on the morning of admission.
When first seen (October 18th, noon) the baby was dirty but seemed well nourished ; navel apparently healthy ; cranial bones normal. Every five minutes spasms occurred of moderate severity ; they did not arrest the breathing. In the spasms the legs were drawn up rigidly, the forearms were flexed, the fingers were stretched out and widely separated, the lips pouted a little and there was risus sardonicus, the jaw was fixed and the head was slightly retracted. An attempt to open the eyes or mouth aggra vated the spasms. At this time the person who brought the child refused to leave him without the consent of the mother. At 6 P.M., however, he was brought back and admitted. He had taken no food since 11 P.M. of the previous evening. The spasms had continued all the afternoon and were more severe than at first. The bowels were relieved by enema of a large quantity of curd, and the child was put into bed with an ice-bag to the spine. Between 7 P.M. and midnight three enemata of milk, containing, respectively, four grains, six grains, and six grains of chloral, were admin istered. After three hours the ice-bag was removed. At midnight the child was no better. As he remained unable to swallow, he was put under chloroform, and three ounces of his mother's milk with four grains of chloral were injected through a catheter passed into the stomach. This was repeated at 4.30 A.m., after which the catheter was passed without dif ficulty and without chloroform, and between two and three ounces of his mother's milk with ten drops of brandy were given every two or three hours. During this time the convulsions had varied in intensity as well as in number. They were manifestly influenced by the chloral, so that from 5 A.M. (19th) until 10 A.M. he slept quietly.