r 
 
 v 
 

 THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 
 MRS. PRUDENCE W. KOFOID 
 
^ TEEATISE 
 
 ON THE 
 
 HISTORY, ETIOLOGY AND PROPHYLAXIS. 
 
 BY JOHN M. WATSON, M. D., 
 
 PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND CHILDREN, IN THE MKDICAI 
 DEPARTMENT OF THE UNIVERSITY OF NASHVILLE. 
 
 THIRD EDITIOU. 
 
 NASHVILLE, TENN. : 
 
 E. Q. EA3TMAN & CO., PRINTERS, UNION AND AMERICAN BLOCK 
 
 1859. 
 

 TO 
 
 JAMES E. WENDEL, M. D., 
 
 This Volume 
 IS MOST KINDLY AND RESPECTFULLY INSCRIBED, 
 
 IN HIGH CONSIDERATION OF 
 
 His Great Professional Attainments, Practical Skill, 
 and; Sterling: Qualities, 
 
 Closely tested by the Author during ten years association with him, as a 
 co-partner in the practice of Medicine. 
 
 M35$6m 
 
PREFACE. 
 
 It is scarcely expected that in this age of book-making, 
 an author should stop to apologize for publishing his work, 
 jet it may not be amiss to make a few statements in regard 
 to the one now about to be offered to the professional public. 
 This monograph was first published in a series of numbers 
 in the Nashville Journal of Medicine and Surgery. It was 
 then well received by the profession, and favorably reviewed. 
 Shortly after appearing in the aforesaid Journal, it was 
 published a second time, in a pamphlet form. The work" in 
 its present, or third edition, will be greatly enlarged, and will 
 contain two costly original plates, and consist of about eighty 
 pages neatly and substantially bound in one volume. 
 
 The author has just cause to hope that it will again meet 
 with a kind reception by the profession, especially as he is 
 not aware that any regular monograph has ever been pub- 
 lished on the fatal malady of which this treats, a reason 
 which he may offer as a further apology for the present one. 
 
 Trismus Nascentium, or Lock- J aw of Infants, is no 
 uncommon disease, but one which is constantly occurring in 
 our midst. No condition or habits of life, peculiarity of 
 'climate or race, give immunities from its attacks. The 
 umbilical cord must of necessity separate from its vital 
 
VI. PREFACE. 
 
 connections with the umbilicus, either by a healthy or a 
 diseased action, and to show how the latter may be counter- 
 acted, and tetanus thereby prevented, constitutes the main 
 design of the writer. The physiology of the separation of 
 the cord has been studied only by a few, while its pathology 
 has been almost disregarded ! Even the special anatomy 
 of the umbilicus of the infant has by no means received 
 the attention and consideration which it so justly deserves. 
 The parts which enter into the formation of the infantile 
 umbilicus are, of course known and described by anatomists, 
 but neither their physiological nor pathological changes, 
 which they undergo while the cord is separating, are 
 studied or regarded by the practitioner as they should be, 
 especially that diseased state of the parts which is so apt to 
 excite infantile tetanus. 
 
 The funis with its membraneous covering, its gelatine two 
 arteries and vein may desiccate Kindly, and separate from its 
 connections with the umbilical ring without irritation, inflam- 
 mation, suppuration, or sloughing. After which the navel 
 may contract and close up without disease of any kind what- 
 ever ; but we are bound to admit that there is often a failure 
 in this remarkable physiology, and that the parts are greatly 
 disposed, all this time to pass into a diseased state which may 
 produce the lock-jaw of infants. Even if the cord come 
 away without leaving any obvious appearances of inflamma- 
 tion and irritation, though imperceptible, they may follow and 
 even produce the fatal malady ! Hence, the special anatomy, 
 peculiar physiology, and dangerous pathology of these parts 
 should be studied both by students and practitioners with 
 
PREFACE. TO 
 
 great care. The writer has therefore, been at great pains in 
 getting up a colored plate of this hitherto neglected anatomy; 
 and also another representing very finely the patho-phjsiog- 
 nomy of infantile tetanus. These two original plates will 
 add greatly to the value of the work. The author is 
 not aware that any of this kind has been heretofore pub- 
 lished. 
 
 Could the tetanus of adults be as often traced to any par- 
 ticular part as that of infants can, and were such a part as 
 constantly liable to pass into a morbid state at a particular 
 time, as is the umbilicus of the child, its special anatomy, 
 morbid changes, and time of liability thereunto, would be 
 most accurately and minutely described, demonstrated, and 
 studied with a careful regard to its great importance. Why 
 less important on the part of the infant? -Merely because it 
 is not generally understood and appreciated. I do not by 
 any means charge the profession with a disregard of infantile 
 life, but insist that this constant, palpable source of a great 
 mortality among infants is not regarded by many as it evi- 
 dently should be. If the real source of this mortality was 
 generally known and appreciated, it would doubtless receive 
 as much careful attention as if it appertained to adults. 
 
 Besides, the profession has done much by writing and 
 otherwise for the elucidation and cure of infantile diseases. 
 Hence, it is more astonishing that the chief cause of this 
 dreadful and fatal disease has not been more generally admit- 
 ted, and proper and timely measures employed to counteract 
 it. This failure has been highly prejudicial to the safety of 
 infants wherever it has prevailed; for a thorough conviction 
 
Vlli. PREFACE. 
 
 of the true cause of this mortal, affection would have 
 secured to them a sure prophylaxis. 
 
 The notion, so fatal to many infants, that Trismus Nascen- 
 tium is an undefined, nervous disorder, having its source in a 
 variety of imaginary causes, differing radically in its patho- 
 logy from the lock-jaw of adults, has prevented many from 
 giving the navels of children the protection which they so 
 justly deserve at our hands. Much praise should be awarded 
 to those writers who have called the attention of practitioners 
 to that morbid state of the child's navel which produces ihe 
 tetanus of infants, showing that it is only an infantile modi- 
 fication of the traumatic lock-jaw of adults. But as they have 
 not presented and insisted on the only reliable prophylaxis, I 
 feel that I am justifiable in publishing, this volume, in order 
 that I may, if possible, direct the attention of practitioners 
 to, and a solicitous regard for, the state of the navel, pending 
 the first two weeks of infantile life. If proper measures be 
 then employed, children will escape this disease. Besides, 
 those writers who have incidentally written on this subject, 
 have also written about many Other things in the same work — 
 things which are generally more regarded than the one which 
 I am now trying to bring forward, in all its exclusive, weighty 
 importance, more prominently before the profession. 
 
 Although we cannot cure this disease after it is developed, 
 yet we can prevent it. We may not be able to expel the 
 enemy after he has entered the house, yet in this instance we 
 may bar the door most effectually against him. A preven- 
 tion will, however, require on the part of the practitioner a 
 thorough conviction of the truth that, this hopeless malady 
 
PREFACE. IX. 
 
 originates in a diseased condition of the umbilicus, and great 
 and unremitting care on his part to prevent this state from 
 coming on, or if it should, to mollify and change it, during 
 the first eight or ten days of early life. 
 
 The writer has always been very forward to employ proper 
 means to prevent a diseased action of the umbilicus during 
 the separation of the funis and a few days afterwards ; and 
 also for its subdual when it occurred. He finds in his inter- 
 course with practitioners, that he has uniformly on his part 
 given more attention to these things than any physician with 
 whom he has conversed on the subject. He, therefore, feels 
 very confident that his great and constant care has given his 
 patients immunity from this much dreaded malady. He has 
 never had a case to occur in his very extensive practice in an 
 infant of which he had the management! This remark was 
 made by him eight years ago, when this treatise was first pub- 
 lished ; and he is now happy in not having, in any way, to 
 qualify it. May he not then, most truthfully say that pre- 
 vention is better than cure. To prevent the occurrence of a 
 disease is much better, in every sense, than to relieve it after 
 it has occurred, were it in our power to do so, but when we 
 think of its incurability, the prophylactic treatment rises, in 
 our estimation above all other considerations. Were it even 
 occasionally curable, the great suffering of the little patient, 
 its doubtful condition, the maternal anxieties, so acutely felt 
 at such times,, are enough to excite our greatest professional 
 efforts to prevent it. 
 
 There is more professional good and disinterested conduct 
 practiced in preventing, than in curing a disease after it has 
 
X. PREFACE. 
 
 developed: much "suffering, valuable time, painful anxiety and 
 needful fees are saved in that way. The immense and incal- 
 culable amount which has been done by Prophulaktikos, 
 from the prevention of small-pox down to that of a bad cold, 
 cannot possibly fail to impress the mind of the reader with 
 the importance of this subject. The hand, though it be 
 scarcely seen, which from moral motives, or by professional 
 skill, wards off an impending evil, deserves far more praise 
 than the one that, even amidst professional glare cures It 
 after it has come. But the statesman who by his well-timed 
 policy prevents a war, never acquires the renown of a hero 
 who successfully fights the battles of one. So with the doc- 
 tor ! Yet there are exceptions in both cases. Dr. Jenner 
 gained a greater renown by his wonderful prophylaxis against 
 small-pox than any have done by treating it. Although sani- 
 tary measures, from quarantine regulations down to fastidious 
 teaching about diet and dress, have been much insisted on, 
 yet for the want of a proper respect for them, they have 
 often failed to do good. It is very difficult to direct the pub- 
 lic mind in the proper ,way of prophylaxis. Hence the great 
 neglect of vaccination, the greatest boon which has ever been 
 conferred on mankind by scientific medicine. In these fast 
 times many are willing to run the risk of small-pox rather 
 than stop to vaccinate ! The public mind does not seem to 
 appreciate preventives, and they are often regarded as useless 
 hindrances ! How can I then hope for the employment of 
 my prophylactic ? What practitioner will, in his professional 
 hurry, stop long enough to manage the infantile umbilicus as 
 he should ? Few I fear ! Yet this painful consideration does 
 
PREFACE. XI. 
 
 not annul the obligations I am under to the profession and 
 to parents to point it out, and insist on its employment. 
 
 It is not for the want of professional magnanimity that 
 these are not employed ; for there is enough to prevent all 
 diseases were it practicable, either by our administration of 
 them, or by a general adoption of them by the people. It is 
 not of this that I complain. It is of too much indifference 
 about those already known, both to physicians and communi- 
 ties, especially of those which may be deemed minor ones. 
 These have lost their great importance, both in professional 
 estimation and general regard. 
 
 Physicians have written much on this topic, indeed, much 
 in point, but they have not been heeded : those in health will 
 not stop to learn prophylactics from the doctor, nor to employ 
 them when advised. Such essays have not been written in 
 a manner to impress the public mind with their value, 
 nor do physicians themselves stop to advise and insist on 
 them as they should. We want a modern work on this sub- 
 ject ; few only read old books. The improvements of our 
 times are so great, that many suppose things written centuries 
 ago can possess but little value. Hence, this important sub- 
 ject must, so to speak, be re-taken in hand, by some good and 
 efficient writer, and re-written for the present time, and 
 thereby fully adapted to the spirit, taste, and general course 
 of things before it will be regarded as it should be. I there- 
 fore must be excused for trying, so zealously, to adapt the 
 one under consideration to this state of things. 
 
 I will now remind the reader that my prophylactic has for its 
 object the mother's chief concern, her babe: which is to her a 
 
Xll. PREFACE. 
 
 moral, oblivious anodyne, causing her to forget her past suf- 
 ferings; and is also the incarnation of her maternal hopes, 
 her puerperal joys and prospective delights which take the 
 "ways of many agreeable and encouraging fancies. This, her 
 reward and compensation for so much solicitude and suffering, 
 must be protected, whereby her maternity may be preserved. 
 Without this living joy, what will become of her? In her 
 puerperal state she sustains not only a peculiar physical rela- 
 tion to her offspring, which differs from all others, but also a 
 sublime moral one, which also has its peculiarities in her 
 early confinement. At this time she becomes almost one 
 with "her child. So many of her moral and physical feelings 
 concenter in it that she feels she could not hope and live 
 without it! "A new center exists, the cradle^ around which 
 every thing revolves. The milky age, the supreme innocence 
 of the little one, throws its spell over all. Compassion and 
 tenderness enslave the family to him. The father serves the 
 mother, and the mother the child. It is seemingly a world, 
 ordered not like the outer world, but according to the law of 
 love, and of God ; in it the strong wait on the weak ; domin- 
 ion belongs to the least." The mother will do her part, and 
 shall the doctor fail to perform his ? If he through his 
 neglect let the child die, she may die. This tender vine 
 entwines itself so closely around the maternal heart, pene- 
 trating it at every point with its prehensile embraces that 
 it cannot be removed without deep, dangerous lacerations. 
 Thus would her puerperal convalescence be retarded or 
 decline into disease ; and how acutely painful would be the 
 remembrance of her past travail ! Says one, just in point 
 
PREFACE. Xlll. 
 
 here : " I have tears in my heart, and for more than one 
 thing. I have not passed (in history) the Styx, the river of 
 the dead, so many times with impunity. I am not insensible 
 to my times, and I feel their mortal wounds. Woll, all this, 
 which should deaden me to private sorrows, leaves a place in 
 my heart plainly bleeding for what I have beheld so often, 
 the mother separated suddenly from her child." 
 
 When the death of the infant occurs from Trismus it 
 most commonly occurs about the eighth, tenth, or twelfth day 
 of the mother's confinement. May I not say that this is the 
 very worst time for her to meet with such a trying calamity ? 
 She has just had time enough to forget her sorrows for joy 
 that a child is born unto her, and to place all her maternal 
 affection on her child ; and a little sore on the nav r el has 
 killed it ! which the doctor might have prevented by a timely 
 employment of the prophylactic under consideration. Should 
 the like occur to any physician, knowing that it might have 
 been prevented by proper attention to the umbilicus, how 
 shall he deal afterwards with his conscience and the mother's 
 sorrow? Not by telling her that it could have been pre- 
 vented, nor that it occurred by his neglect. That would 
 increase her grief and ruin his professional character with 
 the family. Fortunately, in one sense, mothers and families 
 are ignorant of this means of protecting the lives of infants; 
 but we hope the time will come when they will be well 
 informed on this subject, and require of their attendants a 
 faithful employment of this prophylactic, even if the attend- 
 ing physician should, from a wrong theory, abjure it. At the 
 present time many infants perish of this disease, that have 
 
.XIV. PREFACE. 
 
 received no protecting treatment from the physicians who 
 attended their mothers. Great, indeed, would be their self- 
 reproach were they fully aware of the dreadful consequences 
 of such neglect. No theory whatever of the cause of 
 Trismus should excuse him for neglect of the child's umbilicus. 
 When physicians and nurses shall be constrained by prac- 
 tical results to pay proper attention to the umbilicus, then 
 but few if any children will die of Trismus. Then the great 
 object of this work will be accomplished. 
 
 The reader must bear with my great earnestness ; no luke- 
 warm expressions, no cold declarations, however truthful and 
 much in point, will suffice. For I feel that I should not only 
 state facts, but enforce them, also, by associating them with 
 the moral considerations which should constrain us to regard 
 them as duties incumbent on us, not only professionally, but 
 conscientiously. When our moral feelings are properly 
 awakened under impressive truths, we shall scarcely fail to 
 perform the duties which they enjoin on our hands and bind 
 on our consciences ! Let the physician only look at the 
 painful scenes of infantile death in the puerperal room, with 
 its moral and physical influence on the bereaved mother, the 
 sorrow of the father, and the general distress of the family, 
 resulting from a neglect of his duty, or that of another, and 
 he cannot fail to appreciate the weighty subject now under 
 consideration. These are no idle fancies, for scenes' of this 
 kind, enough, forsooth, to move the heart of stone, often 
 occur ! 
 
 It is well said, that he who disregards truth in little 
 things is very apt to not regard it in great things, 
 
PREFACE. .XV. 
 
 i 
 Nothing should be professionally small which contains a 
 
 grain of practical truth, especially when infantile life 
 may be bound up with it. Things may be small in them- 
 selves, and yet capable of producing great results. The 
 hand which in judgment and compassion turns the child 
 aside from the viper, may save life by the simple act, while 
 the one which is withheld may destroy life. Thus we see 
 that' both positive and negative evils, however great in them- 
 selves, may be occasioned by very little things. 
 
 Thus I have labored to raise my prophylactics prospec- 
 tively, in the estimation of the reader, that he may not un- 
 dervalue them because they may, in ignorance, be called 
 little things. 
 
 After all, did these simple means, called in a this treatise 
 prophylactics, require great mental effort to obtain a know- 
 ledge of them, great surgical or clinical tact to employ 
 them, and great confidence to admit of their employment, 
 they would be more highly respected and more constantly 
 practiced. As they are capable of doing as much or even 
 more general good than if they were of the character just 
 stated, why should they not, in point of utility, at least, be 
 equally respected and as constantly employed ? No good 
 reason can be assigned. Professional pride may murmur and 
 hint that it cannot stoop to such little things. He who can- 
 not stoop professionally to save life, can never stand consci- 
 entiously erect in his profession. It is a profession which 
 has much to do with the conscience of the practitioner as 
 well as with the lives of patients. Hence, nothing in the 
 estimation of the true physician can be small which secures 
 
XVI. PREFACE. 
 
 life. Lastly — can anything however apparently little 
 in itself, be considered trifling or small in the esti- 
 mation of a bereaved family, which they knew would have 
 saved the life of the child that was destroyed by tetanus the 
 day before ? Our negative answer here should bind us to 
 our duty, which we should constantly perform though it may 
 lead us in the way of little things, as some in the blindness 
 of professional pride have termed them. Pride constantly 
 stands in the way of the performance of some of our greatest 
 duties, and often requires for its correction and subdual, the 
 exercise of great moral courage. And he who has not a 
 sufficient amount thereof firmly and indignantly to meet the 
 taunts and jeers of the ignorant or the proud in regard to his 
 means of saving life, is not worthy of the confidence of any 
 community. Let the young practitioner not be afraid or 
 ashamed to employ useful prophylactics, let them be regarded 
 in whatever light they may be by others. 
 
TRISMUS NASCENTIUM, 
 
 ITS HISTORY, ETIOLOGY AND PROPHYLAXIS. 
 
 This great outlet of infantile life has not received that 
 notice and investigation from our best writers, which its 
 great importance so justly merits:- — some passing it by 
 in reprehensible silence, have written copiously enough 
 on other opprobia medicorum, while others have given us 
 only a few formal pages or paragraphs on a subject which 
 required at their hands a most elaborate treatise. All that 
 has been published about this fatal malady, is, for the rqpst 
 part, well calculated to embarrass and disappoint the reader 
 — leaving him uninformed of its history, in doubt about 
 its etiology, and uninstructed in a reliable prophylaxis — 
 not remedy, for there is none ! 
 
 Moschion, who wrote a manual of midwifery about the 
 end of the first century, entertained an opinion vaguely 
 correct in regard to the exciting cause of this disease ; so 
 did Levret. They thought that the stagnant blood in the 
 umbilical cord might produce dangerous disease ; probably 
 they had seen this malady consequent upon inflammation 
 and irritation of the navel. M. Bajon also concurred in 
 this opinion, distinctly regarding a pathological condition 
 
of the umbilicus as the cause of this affection — a view 
 which Dr. Colles has very nearly confirmed by his. dissec- 
 tions and observations. It has, however, been attributed 
 to very different causes by Evans, Bartram, Clark, Under- 
 wood, Labatt and others. Hence, we meet with a great 
 contrariety of opinion, as expressed by those writers — all 
 disagreeing in their etiological expositions, indeed, so much 
 so, as greatly to impair our confidence in their writings. 
 
 Dr. Cullen, a copious writer on other subjects, has treated 
 the one under consideration with great brevity ; conscious 
 of his apparent neglect, he says apologetically : " It is a 
 disease that has been almost constantly fatal, and this, 
 also, commonly in the course of a. few days. The women 
 are so much persuaded of its inevitable fatality, that they 
 seldom or ever call for the assistance of our art. This has 
 occasioned our being little acquainted with the history of 
 the disease, or with the effects of remedies in it." But 
 this is not the secret ; physicians had seen this disease 
 often enough, but did not understand it ; they had also 
 treated it, but had not cured it ; had sought out its cause 
 and pathology, but had not found them ; hence, forsooth, 
 so many writers have avoided the great difficulties involved 
 in its obscure history, controverted etiology, unknown 
 pathology and intractable course. Colley, Condie, Church- 
 hill, and others, though greatly skilled in eclecticism, have 
 gathered but little valuable or satisfactory information from 
 the writings of others on this subject. Journalists, know- 
 ing that systematic writers have failed to account for the 
 phenomena of this disease, and being unrestrained by any 
 known facts, have propagated, and vainly attempted, by 
 
reporting cases, to prove, many fanciful and untenable 
 conjectures. To a particular instance of this kind, I will 
 now refer : 
 
 Dr. J. Marion Sims, of Montgomery, Alabama, has pub- 
 lished in the Medical Journal of the Medical Sciences some 
 interesting "Observations on Trismus Nascentium, with 
 cases illustrating its etiology and treatment." From all 
 of which he deduces the following strange and unwarrant- 
 able conclusions : " That Trismus Nascentium is a disease 
 of centric origin, depending upon a mechanical pressure, 
 exerted on the medulla oblongata and its nerves ; that this 
 pressure is the result, most generally, of an inward dis- 
 placement of the occipital bone, often very perceptible, but 
 sometimes so slight as to be detected with difficulty ; that 
 this displaced condition of the occiput is one of the fixed 
 physiological laws of the parturient state ; that when it 
 persits for any length of time after birth, it becomes a 
 pathological condition, capable of producing all the symp- 
 toms of Trismus Nascentium, which are instantly relieved 
 simply by rectifying this abnormal displacement, and there- 
 by removing the pressure from the base of the brain." 
 
 I have made this lengthy quotation in justice to Dr. 
 Sims, as I intend to make some critical remarks on his 
 observations, cases and conclusions. I will endeavor to do 
 this fairly at least, yet faithfully His strange views, 
 wonderful practice, and doubtful cases, require a very rigid 
 examination \ which, when fairly and faithfully made, may 
 seem a little severe; therefore, I will here remark, that 
 nothing like.wanton severity is intended ; on the contrary, 
 I am ready to acknowledge his merits as an independent 
 
thinker and actor, by which, great difficulties have some- 
 times been overcome, at other times signal failures have 
 ensued. The latter sequence has followed in the present 
 instance. The Doctor has failed in his commendable enter- 
 prise ; but his failure is a splendid one ! Had he succeeded 
 in directing one ray of light into the deep, dark plasis of 
 this mortifer morbus, he would have merited the everlast- 
 ing gratitude of the profession. Signal as his failure has 
 been, judging from his writings, he does not seem to be 
 conscious of it; but on the contrary, contends that he has 
 succeeded in finding out the etiology of this disease, and 
 for it, also a remedy ! The occasional displacement of the 
 cranial bones is a subject to which the attention of prac- 
 titioners of medicine should be directed ; but while we feel 
 under great obligations to Dr. Sims for calling our atten- 
 tion to this source of disease, we are far from admitting 
 that it is ever a cause of Trismus, be it the source of what- 
 ever other affections it may. 
 
 The Doctor has investigated this subject according to 
 the following ■" fixed ideas :" 1. Dorsal decubitus; 2. Oc- 
 cipital depression ; 3. Trismus Nascentium ; 4. Chang* of 
 position; 5. Recovery. These five things always obtain 
 in the mind of Dr. S. whether they do in his patients or 
 not ; when, for instance, they cannot be seen *by other 
 physicians, he seems to recognize them none the less clear- 
 ly, as we shall discover presently. 
 
 His case the II presents the following particulars : The 
 patient had been ill of Trismus Nascentium two days — the 
 attending physician, had declared that the disease was in- 
 flammation of the brain, and that death was inevitable — 
 
there were frequent spasms — mouth closed tightly — swal- 
 lowing impossible — the back of the head sunk in. A 
 change of position was made, which in four hours gave 
 relief, and in eighteen hours cured the disease ! All this 
 was done, too, without the aid of homoeopathy, hydropathy, 
 or mysticism of any kind. pathetism, where wert thou ! 
 
 In this case the depressed occiput was relieved by a 
 mere change of position, and the patient cured in eighteen 
 hours. How shall we reconcile these statements ? A case 
 of Trismus Nascentium, presenting the foregoing array of 
 symptoms, of two days continuance — the patient just 
 ready to die, and then cured by a mere change of position 
 in eighteen hours ! 
 
 To the credit of Dr. Sims I will here state that this case 
 was obtained from a non-medical correspondent ; although 
 he has endorsed it, yet I am willing he should have all the 
 benefit of the foregoing fact. 
 
 The very next case, however, is both marvelous and in- 
 consistent, although reported by the Doctor himself: The 
 child " was born trismal," had had the disease thirty-six 
 hours when seen by him, then by his magic change of posi- 
 tion was cured in two hours ! 
 
 His statements in case the IV, in regard to the symptom 
 of the child's inability to suck, do not accord with my own 
 observations. " This inability to sack,'' says he, "is path- 
 ognomonic of the disease." This symptom does not always 
 exist in the tetanus of children, especially in that variety 
 termed chronic : this inability to swallow may be absent 
 just as it is sometimes in the tetanus of adults. I have 
 seen fatal cases of infantile tetanus, when the symptom of 
 
8 
 
 trismus did not obtain — there was rather a disinclination 
 than an inability to suck. But if he supposes that the 
 mere symptom of trismus constitutes the whole of the 
 disease, then is he correct in saying that u an inability to 
 suck is pathognomonic of the disease." Let his views be 
 what they may in this respect, there would be no less im- 
 propriety in saying that the varieties of the opisthotonos 
 and emprosthotonos are not tetanus in the strict sense of 
 that term, than to conclude that trismus, another variety, 
 is not. This reminds me of Dr. Cullen's acknowledgment : 
 " I have in my nosology put the trismus or locked jaw, as 
 a genus distinct from the tetanus ; all this, however, I now 
 judge to be improper, and am of opinion, that all the gen- 
 eral terms mentioned denote and are only applicable to 
 different degrees of one and the same disease." Surely 
 trismus in the infant or adult, is a mere variety of tetanus, 
 and like the other varieties depend upon a pathological 
 condition of some of the cerebro-spinal centres. 
 
 It is a great misfortune that the term trismus nascentium 
 was ever adopted \ tetanus nascentium would have been a 
 better, though a less euphonious one. There was no great- 
 er necessity for changing the name of this disease in the 
 case of infants than there is to change that of pneumonia, 
 dysentery, or colic, when they attack children. We had 
 just as well term tetanus, trismus adultorum, trismus viro- 
 rum, or trismus feminarum, as to call it trismus nascenti- 
 um. In the employment of these terms, that of tetanus, 
 would be kept too much in the back ground, as it really 
 has been, by the use of the term trismus nascentium. Like 
 Dr. Sims, we may lose sight of the true character of a 
 
tetano — pathological condition of some portion of the 
 cerebro-spinal column, which in every instance is the prox- 
 imate cause of the disease ; and which cannot be relieved 
 in a moment in any instance, and often not at all, by a 
 mere removal of the exciting cause. This every careful 
 observer knows ; but more of this presently. 
 
 I will now examine case the V, being the most remark- 
 able the Doctor ever saw. This case was reported in part 
 by a Dr. Vickers, though seen and commented on by Dr. 
 S. himself. The child was four or five months old' — had 
 been sick all its life — the occipital bone was shoved in to 
 an almost incredible extent — it had trismal symptoms, ac- 
 cording to his estimation of them, which were completely 
 under the control of the Doctors ; they were relieved and 
 reproduced at pleasure by simply rectifying and displacing 
 the occiput. This was done according to Dr. Sims' pre- 
 vious proposition, " That the symptoms of Trismus Na~ 
 scentium are instantly relieved by simply rectifying the 
 abnormal displacement of the occipital bone." This is one 
 of his propositions deduced from his cases and observations, 
 and put down in his treatise in all due form. 
 
 Who except Dr. Sims could thus have hooked the Levi- 
 athan, and led the monster to and fro with such trismal 
 docility ! No one, alas ! Surely he had only the pliant 
 dolphin clonus with which to deal, and not the crooked 
 serpent tetanus. That alternate displacement and replace- 
 ment of the occiput should suspend and reproduce some 
 particular forms of paralysis, or nervous affections, I an i 
 prepared to admit ; but that trismus, after being established 
 for days, or even hours, should be thus dealt with, is more- 
 
10 
 
 than any physician who clearly distinguishes this disease 
 from other nervous disorders, can allow, in my humble 
 judgment. The symptoms of trismus may be excited — 
 not cured — by rubbing the epigastrium, which I have my- 
 self often done in obscure cases, to develop the symptoms 
 more fully ; afterwards there would be a reduction of the 
 former symptoms, from the expenditure of nervous excita- 
 bility. The same occurred also, I presume, in the Doctor's 
 cases of nervous disorders, by raising and depressing the 
 cranial bones. 
 
 I shall not follow Dr. Sims through his trismoid cases, 
 as he terms them ; those already mentioned are surely tris- 
 moid enough, in that diminutive sense, so much so in- 
 deed, that even such a term is too strong for them. Be- 
 sides, I did not intend to review his writings in a regular 
 way, yet there are a few things connected with these tris- 
 moid cases, which I will notice. 
 
 Dr. S. has reported but one case of cadaveric autopsy, 
 and strange to relate, this does not contain a single word 
 about lesion of the brain or meninges, from a long contin- 
 ued displacement of the cranial bones — only that the 
 u brain was perfectly bloodless" — no signs of previous con- 
 gestion, irritation or inflammation. 
 
 When the Doctor could not make out a case of dorsal 
 decubitus and depression of the occipital bone, still cling- 
 ing to his fixed idea, or cherished theory, he learned that 
 the child had been nursed on its side, and that lateral, or 
 rather diagonal decubitus had produced a depression of a 
 pariental bone, and laying hold of this opportune succeda- 
 
11 
 
 neuin, he maintains his views with as much confidence as 
 before. 
 
 If any thing was still wanting to show that Dr. S. does 
 not appreciate the danger and mortality of this dreadful 
 disease, I might advert to his notions about the operation 
 of laryngotomy affording relief until it could be cured. I 
 will not, however, detain the reader longer with any further 
 critical remarks on this subject, but advise him to read the 
 treatise for himself, which he may find in the American 
 Journal of the Medical Sciences, in April number, 1846, 
 and in July and October numbers of 1848. If any fur- 
 ther apology be necessary for these strictures it may be 
 found in the remark, that Dr. S.'s theory, cases and treat- 
 ment are all well calculated to mislead the inexperienced 
 and divert their minds from the true sources .of tetanus, 
 and also from the only means by which infants can be pro- 
 tected against an often occuring and incurable malady. 
 
 I will now take my leave of the Doctor in ihe words of 
 Petrarch: "Raro magni errores nisi ex magnis ingeniis 
 prodiere. 
 
 Etiology. — The causes of Trismus Nascentium with 
 their attendant difficulties, like every thing else pertaining 
 to this perplexing malady, have been very much neglected : 
 indeed, I am not aware that any writer has arranged them 
 according to their proper relation to each other, or their 
 usual division in other diseases. Its predisponent, exciting, 
 and proximate causes have often been confounded with 
 each other — one writer mistaking the predisponent for the 
 exciting cause, and another, the latter for the former. It 
 
12 
 
 will be readily conceded that these causes occasionally 
 change their relation to each other, but this is very differ- 
 ent from confounding them with each other in particular 
 instances. While treating this subject according to the 
 foregoing division, I shall have occasionally to introduce 
 other causes in their proper places, such as accidental, ac- 
 cessory, &c. 
 
 It will be necessary to make a clear distinction between 
 the predisponent cause and the habit of body or diathesis, 
 which constitutes the predisposition itself. Two persons, 
 for instance, may be exposed to the same predisponent 
 causes, and in one a predisposition to a particular disease 
 may be produced by the yielding susceptibilities of his 
 system, and be resisted by the opposing energies of the 
 other ; or the same person may be affected by such causes 
 at one period and escape their influences at another. 
 Again, a predisposition to a disease may exist as. a connate 
 diathesis. Then let a predisposition to tetanus be the effect 
 of whatever predisponent causes it may, it must be regard- 
 ed as a pathological state; which though occult and unap- 
 preciable by any pathognomonic symptoms, yet it is doubt- 
 less a tetanic element, capable of being developed by an 
 exciting cause into plain, open, unmistakable symptoms of 
 lock jaw, or of being subdued by a proper prophylaxis, 
 which consists mainly in a protection from exciting causes. 
 The agency of an exciting cause, however potent and ac- 
 tive it may be, fails to produce the disease, when there is 
 no existing predisposition, as may be illustrated by the fol- 
 lowing examples : Two persons of the same age, sex, tem- 
 perament and habits, breathing the same atmosphere, 
 
13 
 
 receive similar wounds in corresponding situations ; one is 
 attacked with tetanus, and the other escapes ; or, an indi- 
 vidual receives a very bad wound and escapes lock jaw, 
 and is afterwards attacked with it from a very slight wound. 
 Such instances certainly show that the disease does not de- 
 pend alone on an exciting cause. Again, the terminal 
 points of wounded nerves may pass into a tetano-patholog- 
 ical condition in a slight wound, and not in a far greater 
 one, and vice versa. So, it is not the situation or size of 
 a wound which determines an attack of this disease, but a 
 peculiar occult state of the general system. This condi- 
 tion may not, however, amount to a direct tetanic tenden- 
 cy, but may be only a mere vitiation of the system that 
 may interfere with the healthy healing of the wound, or 
 the formation of a sound cicatrix; for the simple healing- 
 over of a wound does not afford protection from an attack 
 of this fatal malady, neither in infants nor adults. Then, 
 any thing which impairs health in manhood or infancy 
 may, in this general way act as a predisponent cause of 
 tetanus ; but, 'there are some particular causes which evi- 
 dently exert a more direct predisposing influence, such as 
 cold, impure air, a damp, cold atmosphere, indigestion and 
 high solar heat. And why may not malaria, itself, the 
 frequent and great source of so many maladies, impress 
 the system with a strong tetanic predisposition, by pro- 
 ducing cerebro-spinal irritation, or irritation of some of the 
 other great ganglionic nervous centres. This opinion is 
 confirmed by the fact of Trismus having occurred so fre- 
 quently in foul and badly ventilated lying-in-hospitals, and 
 its occurrence having been prevented by improvements for 
 
14 
 
 ventilation and cleanliness in such institutions, as, for in- 
 stance, in the Dublin lying-in hospital. Dr. Joseph Clarke's 
 account of this institution, in reference to the foregoing, 
 is conclusive on this subject. 
 
 The Exciting Cause of Tetanus Nascentium. — A trauma- 
 tico-tetanic condition of the umbilicus is, with very few 
 exceptions, the constant exciting cause of this disease. 
 This part of my subject I shall now discuss at great length 
 as it is paramount in importance to all others, in a prac- 
 tical point of view. The analogy between traumatic 
 tetanus, as it occurs in the adult and infant, is both stri- 
 king and instructive, and well deserves our most particular 
 consideration. In the adult, this disease generally comes 
 on about the eighth or ninth day after the reception of a 
 wound, and in the infant, it attacks so frequently on the 
 ninth day after the cutting of the funis, that it has been 
 termed "nine-day fits." That portion of the cord which, 
 after its division is left in connection with the navel, is as 
 liable to degenerate into an exciting cause of tetanus in 
 the infant, as is a common wound in the adult. The beauti- 
 ful physiological process of desiccation, contraction and 
 separation of the cord so seldom occurs that it has been 
 disregarded by many eminent writers. Even the great 
 Baron Albert Yon Haller says : " Funiculi quidem ombili- 
 calis particula quam obstetrics solent cum abdomine parvuli 
 conjunctam relinquere abit in sphacelam, quassi ambusta 
 et post biduum, triduumve dilabitur." This is certainly a 
 good pathologcid, though by no means a physiological de- 
 scription of the separation of the funis — a traumatic state 
 
15 
 
 of things however, which frequently occurs. This over- 
 sight has been committed also by other distinguished 
 writers, namely, Chaussier, Beclard, Orfila, Capuron, and 
 Dennis. 
 
 C. M. Billard's explanation of the separation of the funis 
 is quite satisfactory. He very properly maintains that 
 u the desiccation of the cord is altogether a physiological 
 phenomenon, belonging to the assemblage of vital phenom- 
 enon, and entirely dependent on them. That part of the 
 cord attached to the placenta does not exhibit the phenom- 
 enon of desiccation, like the portion remaining with the 
 child, but shrinks and decays like a dead substance, whilst 
 the abdominal portion is not so affected. Here the desic- 
 cation ceases as soon as life is extinct ; it either does not 
 proceed in still-born children, or is considerably retarded. 
 In place of drying and separating at the end of a few days, 
 as is observed during life, the cord undergoes in the dead 
 body a perfect decomposition, differing entirely from its 
 normal desiccation." He further contends that the umbil- 
 ical cord may, under favorable circumstances, separate from 
 the navel, just as the stem of a cucurbitaceous fruit is sep- 
 arated, or by what he terms "a proper suppuration." 
 Of eighty-six infants examined by him, nineteen had red- 
 ness and tumefaction of the umbilicus, without suppuration. 
 The period of the detachment of the cord varies from the 
 second to the seventh day. 
 
 The infrequency of the healthy normal separation of the 
 funis has not only been greatly overlooked by writers, but 
 shows likewise how very liable infants are to irritaiton, in- 
 flammation and sloughing of that portion of it which is left 
 
' 16 
 
 at birth attached to the abdomen. This degeneration of a 
 healthy vital action into a morbid, abnormal one, is easily 
 induced by a great variety of causes, to all of which some 
 children are more exposed than others, and among such 
 tetanus is of far more frequent occurrence. These common 
 causes among the blacks are bad dressings of the umbilicus, 
 improper handling of the infant, wet and soiled dressings, 
 which become alternately wet and dry for several days ; to 
 •which may be added unsuitable applications to the naval 
 itself after the detachment of the cord, that are more cal- 
 culated to irritate and inflame the part, and in that way to 
 provoke lock jaw, than to soothe, heal and prevent its 
 supervention. 
 
 As there is a much greater difference in the manage- 
 ment, comforts and habits between white and black women 
 after their confinement, than in their parturition, the causes 
 which operate on the children of the latter, in occasioning 
 a greater frequency of this disease among them, must occur 
 after birth ; besides it is well known that the negro women 
 generally have safer and easier labors than white women, 
 as a consequence of their active, laborious habits. Hence, 
 neither the imaginary- concussion of the spine during de- 
 livery, nor the vaunted displacement of the occipital bone 
 consequent upon dorsal decubitus, does account for the 
 very great amount of numerical difference between the at- 
 tacks of white and colored children. This difference must 
 be occasioned by some particular causes, both predisponent 
 and exciting, very different from those to which I have 
 just adverted. 
 
 I will now present an arrangement of facts, from which 
 
17 
 
 an opinion of the utmost practical importance may be de- 
 duced, in regard to the exciting eause of this disease — an 
 opinion which when entertained must exert a salutary 
 influence in checking the dreadful outbreaking of this 
 intractable morbus. That this opinion may be embraced 
 and have its proper practical influence, is one of the chief 
 objects of the writer in contending for it so earnestly ; 
 which is done not merely to confirm the fact as he believes, 
 that a diseased umbilicus is the cause of infantile tetanus, 
 but that a safe and easy prophylaxis may be established 
 on a reliable basis, not to be overturned by a constant 
 failure of the remedy in the hands of others, as has unfor- 
 tunately been the case with most of those means prescribed 
 by others in accordance with their peculiar theories. Their 
 is, however, one just exception to this remark, which de- 
 serves to be mentioned : Dr. Joseph Clark and others, re- 
 garding badly ventilated lying-in hospitals, with their bad 
 air and filthy apartments as causes of this malady, have 
 done much good by their accordant prophylactic directions. 
 For, although they mistook the predisposing for the ex^ 
 citing cause, yet by directing that such causes should be 
 avoided and corrected, the exciting cause, which is now so 
 zealously contended for, though present and active in 
 many instances, was in others greatly deprived of it* 
 tetanic influence. 
 
 Suppose Dr. Clark had said in regard to wounded 
 patients in a hospital, that a vitiated atmosphere was the 
 exciting cause of tetanus among them, and that their 
 attacks of this disease were due to a state of the atmos- 
 phere, and not their wounds. He could scarcely hare 
 2 
 
18 
 
 committed a worse blunder than he has done by writing 
 that tetanus was excited by bad air in the lying-in estab- 
 lishment of which he had charge, instead of the tetanic 
 condition of the navels of the children. 
 
 That the Exciting Cause of this disease may 'be plainly 
 seen and practically regarded, I will now set in order a 
 number of facts, both in their proper relation to each other 
 and their general bearing on its controverted points. From 
 these, surely, a safe and useful conclusion may be easily 
 deduced. By an arrangement of even dim lights in a 
 proper manner, we may discern an object which could not 
 otherwise be seen by them, so in the present instance by 
 a proper collation of facts we may obtain a more correct 
 view of the exciting cause of tetanus nascentium. 
 
 The infant is no sooner born than it becomes a irau- 
 matiaSy a trauma must of necessity be inflicted on its um- 
 bilical cord ; a wound on a part which is, as has already 
 been shown in the first part of this treatise, so very prone 
 to pass into a pathological condition, and thereby excite 
 irritation and inflammation of the umbilicus, that many 
 eminent writers have overlooked its physiological excep- 
 tions. With the brute mammalia, this artificial division 
 of the cord is unnecessary, as theirs break according to an 
 appropriate physical state ; then dry, contract and fall off 
 without producing inflammation of their navels. Hence, 
 though a species of the equus genus of animals is, as is 
 well known, very liable to tetanus from wounds and 
 other causes, yet no one, I presume, ever saw their foals 
 suffering from the disease; as the horse is thus man's 
 *?tf#w-congener, might we not expect to see them attacked 
 
19 
 
 also occasionally with this disease I As adults and horses 
 are, in this particular respect, pathologically congeneric, 
 why should we suppose that their offspring are not so like- 
 w ise ? It is quite reasonable to believe that they are, and 
 that the immunity of colts from the disease is not owing 
 to any connate difference of that kind, but to an exemption 
 from its exciting cause — irritation and inflammation of 
 their navels. The experiment of exciting artificial inflam- 
 mation of the navels of the equinal young might shed 
 some light on this subject. I will here remark that it is 
 not contended that the bare wound on the part of the cord 
 left attached to the child's abdomen, causes a pathological 
 condition of that part, but the state itself of the part is 
 such as to admit of an easy perversion of its normal pro- 
 cess of separation, in which particular, it differs very much 
 from the navel strings of other animals. The infantile 
 umbilical cord, is too strong to be thus safely broken, and 
 too full of the gelatine of Wharton to dry, contract and 
 fall off in the equinal way ; it, therefore, requires some 
 rational management. Really, it seems to have been de- 
 signed by the Great Giver of mind, that the infant should 
 not only receive instinctive, but likewise rational protec- 
 tion at our hands. So, when their navel strings are man- 
 aged in a rational way, they will not induce irritation nor 
 inflammation of the umbilicus. It is necessary then that 
 the cord should be cut, and other appliances be employed, 
 of which I shall treat more fully presently. I must, how- 
 ever, repeat 'that the navels of children, from bad manage- 
 ment and other causes, often become inflamed, and it is a 
 fact of no small consequence that negro children are far 
 
20 
 
 more liable, to a variety of accidental or accessory causes^ 
 which occasion irritation and inflammation of the umbili- 
 cus, and it is well known that they are also more liable to 
 tetanus. This liability to trismus is in a very remarkable 
 degree proportionate to the liability to inflammation of the 
 navel. So, in tracing out the exciting cause of this disease, 
 it will be of great advantage to enquire very particularly 
 into these accessory causes and their morbid influences on 
 that part. By a proper examination and consideration of 
 these advenient causes — nearly always occurring in the 
 cases of negro infants — we may be able to answer the ap- 
 propriate and important question, Why are the infants of 
 our slaves more liable to tetanus than those of the whites ? 
 This is indeed a strong question and much in point ; which 
 when truthfully solved, its answer cannot be much short of 
 a solution of the main problem. No one I presume will 
 assume that the children of our negroes are more obnoxious 
 to tetanus from a connate diathesis peculiar to the African 
 race, than are the whites. An assumption of this kind 
 may be refuted by stating the fact, that when the children 
 of white parents, for instance, paupers, inmates of hospitals, 
 &c, are subjected to the accidental causes which I shall 
 presently relate, they, like the children of the blacks, are 
 equally liable to trismus ; and moreover, when the latter 
 are exempted from such things, they are no more obnoxious 
 to the disease than the former. These facts are of too 
 much importance to rest on mere assertion ; they must, 
 hence, be sustained, for th^y contribute no liftle to the 
 elucidation of our subject. 
 
 I will now relate what must accord with the observations 
 
21 
 
 of most physicians who have done much practice among 
 negroes. When called to see their children we find their 
 clothes wet around their hips, and often up to their arm 
 pits, with urine ; smoking, fretting and kicking, the child 
 is thus presented to us ; when, on examination, we find the 
 umbilical dressings not only wet with urine, but soiled 
 likewise with feces, freely giving off an offensive urinous 
 and fecal odor, combined at times with a gangrenous fetor, 
 arising from the decomposition— not desiccation — of the 
 cord. May I not say, that a vital, physiological drying 
 and separation of the funis under such circumstances is 
 impossible ; hence the frequency of a pathological condition 
 of the umbilicus in such cases, and I will add, the frequent 
 occurrence of lock-jaw also among them. Moreover, these 
 navel dressings are not only thus acted on by the child's 
 urine and feces, but they also become impregnated with a 
 filthy, irritating moisture, constantly exuding from the 
 sphacelated cord ; there comes likewise an occasional inter- 
 vening dry rough state of these foul deathful appliances, 
 during which they rub, irritate and excoriate a surface al- 
 ready excited by those foul agencies just mentioned. 
 Nor is this all. Negro children are often improperly fed. 
 and suffer from colic, and abdominal distention, causing 
 them to fret, cry and kick, thereby producing abdominal 
 movements well caclulated to bring umbilical dressings in 
 rough contact with their navels. Their mothers never think 
 of changing these hurtful dressings ; either from a want of 
 changes, or a disinclination to do so, they let them re- 
 main on — bandage and all — until the funis sloughs ; after 
 this the applications are almost as hurtful as those pre- 
 
22 
 
 viously employed — such as soot., dry dirt out of the back 
 of the chimney, scorched cotton, greasy cloth folded up 
 into a hard compress, and a bandage drawn around these 
 with unmerciful tightness. That there are many excep- 
 tions to this deplorable state of things, I readily admit ; 
 so I might add, there are many exceptions to attacks of 
 tetanus ; more indeed of the latter than the former, for 
 every child that has a sore navel does not consequently 
 have trismus. But more of this presently. 
 
 I have enquired very particularly of the overseers of 
 large plantations with numerous slaves, about the man- 
 agement of their negro children, and in every instance 
 where the mistress attended carefully to the dressing of 
 the umbilicus, very few or no cases of trismus occurred. 
 
 Mrs. P 1, a very motherly intelligent lady, informed 
 
 me that she had raised about twenty little negroes, also, 
 a goodly number of her own children, and that none horn 
 on her place ever died of tetanus. She stated further 
 that she always paid very strict attention to their navels, 
 and in no instance trusted the management of them to 
 their mothers. Now, it is worthy of remark, that Dr. Ii. 
 has a quarter in sight of the place just mentioned, on 
 which thirty or forty negroes constantly reside. This plan- 
 tation has been for more than twenty years under the 
 management of overseers ; one of them had the care of it 
 fifteen years, during which period only two children died 
 of lock-jaw; the next overseer was retained four years, 
 daring which time four children were attacked and died 
 of this disease; the third superintendent remained two 
 years, in which time two deaths occurred from infantile 
 
23 
 
 lock-jaw. The wife of the first overseer was an excellent 
 nurse, and fully appreciated the danger of a sore navel. 
 She paid careful attention to the navels of the little ne- 
 groes, but her appropriate measures were sometimes de- 
 feated by the carelessness of their mothers, during her 
 absence from their houses. Yet, out of the great number 
 of children born on this place in fifteen years, only two 
 died of sore navel or its sequence, trismus. The wife of 
 the next overseer was young, inexperienced and had no 
 turn for attending to little negroes, so four died while she 
 was there ; and the same may be said of the wife of the 
 last mentioned superintendent, and the same result fol- 
 lowed. 
 
 In the last fifteen years, -Mr. B h has had fifteen color- 
 ed infants born on his plantation, during which time, his 
 mother, who was a midwife, resided on the same place, and 
 paid great attention to the umbilk.il dressings, and not a 
 single case of lock-jaw occurred while she lived ; she died 
 a few years ago, and since her death but one negro child 
 had been born on the place, and that died of sore navel 
 and tetanus. 
 
 Mrs. H e, a very intelligent and domestic lady has 
 
 assured me that she has raised upwards of twenty little 
 negroes on their plantation, and not one born on their 
 place had ever been attacked with trismus — that she never 
 in any case, trusted the navel of the child to the care of 
 its mother, but always attended personally to its dressings. 
 
 Mr. W n, who owns a number of slaves, told me, just 
 
 after giving some directions about the management of the 
 navel of a child whose mother I had just delivered, that 
 
24 
 
 he had lost not less than twelve or thirteen little negroes 
 from sore navel. This gentleman had the misfortune to 
 lose his wife many years ago, and the care of the little 
 children had been entrusted exclusively to their mothers. 
 Whence, I ask, is this great difference of mortality in the 
 two last examples? 
 
 Many more illustrations of this kind might be reported 
 but it is scarcely worth while to^ultiply them. Any one 
 who is anxious to obtain additional information on this 
 subject may do so by inquiring of the heads of other 
 families, and they cannot fail to be impressed with 
 the fact, that when physicians or intelligent nurses attend 
 to the little negro children, cases of infantile lock-jaw are 
 very rare ; so much so indeed, that a negative course in 
 that respect towards them plainly, in its consequences, in- 
 dicates the exciting cause of the disease. To conclude the 
 present naration of facts, T will now introduce several com- 
 munications on the subject, which I have lately received. 
 
 The following extracts from a communication which I 
 have just received from Dr. P. D. McCulloch, of this place, 
 on the subject of Trismus Nascentium, will be read with 
 interest by all who are disposed to investigate the phenom- 
 ena of this dreadful pathos : 
 
 " I have only investigated the cases which occurred in 
 two large families, as they presented the largest number of 
 deaths in proportion to the number of births among them. 
 In the first family, comprising sixty or seventy blacks, 
 there have been within the last eight years twenty births ; 
 five of these died within the tenth day of their birth, and 
 all of them with symptoms of Trismus, according to a re- 
 
25 
 
 liable history of the cases. None of these received any 
 attention from the white family until they had plain symp- 
 toms of the disease. In only one of these cases was the 
 umbilicus examined, in which the phenomena of well marked 
 inflammation were present. I examined into the method 
 usually pursued by the attendant with her navel-dressings, 
 and found it had been the custom of the old negress, who 
 always attended to the children, when the funis became 
 partially detached, to remove it and dress the wound with 
 common chimney soot. After this was ascertained, the 
 lady of the farm attended to the children in a great mea- 
 sure herself; since which time — three or four years ago — 
 there has not been a case of the disease, although there 
 has been a number of births since that period. It might 
 not be amiss to add that four or five white children were 
 born on this plantation during the above period, and that 
 none of them were attacked with this disease. 
 
 " In the second family, which contained about the same 
 nnmber of whites and blacks, twenty or twenty-five chil- 
 dren were born during the same period of time. Six of 
 these children died of Trismus. The navels were examined 
 in all these cases, and were found to be in an unhealthy 
 condition in every instance. The dressings used on this 
 farm were usually nothing more than a coarse domestic 
 pad, placed over the severed funis, and bound down by a 
 common bandage. The last of these cases occurred about 
 four J ears ago ; from which time to the present the chil- 
 dren born on this place have been strictly attended to by 
 some of the white family, until they had passed the time 
 
26 
 
 of an attack of this disease. No case occurred at any 
 time among the white children on this plantation." 
 
 Dr. M. Ransom, late of Texas, but now of our county, 
 who resided some time on the Brasos, about thirty miles 
 from Houston, has also kindly furnished me with some in- 
 teresting facts, which I will now adduce : 
 
 u According to your request, I send you a few notes on 
 Trismus Nascentium, which I took during the summer of 
 1849, while in Texas. My information with regard to its 
 occurrence here, until 1849, was obtained chiefly from 
 intelligent citizens very capable of recognizing the disease- 
 It was not observed here, as far as I can learn, until about 
 1845 or '46, since which time its prevalence has gradually 
 increased every summer. Last year the mortality was 
 very great from it, amounting in one or two instances to 
 four-fifths of all the children born on some plantations, 
 while on many others not one died. As a general rule, 
 there has been either a very considerable mortality on a 
 place, or none at all. The disease appears in about one- 
 half of the families, and those families lose about one-half 
 of their infants on an average. The number of deaths 
 from this disease among white children is comparatively 
 small. This malady is much more frequent in negro quar- 
 ters than in families where the children are more directly 
 under the supervision of white persons. It also prevails 
 more extensively in the river bottoms, where the planta- 
 tions are surrounded by dense forests, hung with moss, 
 than in the prairies where the Gulf breezes are unobstruct- 
 ed. It occurs, I may add, much more frequently in filthy, 
 
27 
 
 ill-ventilated houses, than in clean, well aired ones, and is 
 far more prevalent in summer than in winter. 
 
 " I have never seen a case of Trismus where the umbil- 
 icus was in a healthy condition ; it, on the contrary, was 
 generally swollen, irritable and not suppurating. 
 
 " I have never known a recovery from a well-marked 
 case of this disease, except perhaps in a single instance ; 
 which, if effected by any remedy, it was incisions over 
 the swollen umbilicus. But this was tried at other times 
 without the least success. 
 
 "Nothing had been done by way of preventing this 
 disease until this summer, except the occasional adminis- 
 tration of small doses of calomel or castor oil for a week 
 or two after the birth of the child. During the present 
 summer many of the plantations have employed the means 
 suggested by the above facts for its prevention. The ne- 
 gro houses were freely ventilated, and the bedding and 
 everything about their houses kept clean. The thick 
 greasy musquito bar which was before allowed to hang 
 around the bed, enclosing the woman and her child in a 
 confined, impure atmosphere, was stripped off, and the pure 
 air allowed to circulate freely around them. The nurse 
 was directed to apply some stimulating ointment, such as 
 red precipitate, or calomel to the navel, from the second 
 day until, it was perfectly healed. When these prophylac- 
 tics were properly attended to, they suffered very little 
 from the disease ; while on other plantations, where they 
 were neglected, it prevailed as extensively as it did the 
 previous surnm*. I have had no opportunity of seeing 
 
28 
 
 one of these preventives employed to the exclusion of the 
 others ; hence, have no evidence that one is more efficacious 
 than the other." 
 
 Dr. Thomas C. Black, of our county, well known as a 
 close observer of the phenomena of disease has obligingly 
 furnished me with the following statements : 
 
 u In reply to your inquiry about my opinion in the dis- 
 ease usually called Trismus Nascentium, I can state that 
 during eight or ten years of the early part of my profes- 
 sional life, I was pretty actively engaged in practice, 
 and I suppose treated, at least, my proportion of such 
 cases. I regret that I must say that I have nothing to 
 offer as a remedy nor any treatment to propose which 
 promises much towards the cure of the disease ; for I have 
 never seen a well-marked acute case get well. A very 
 large proportion of the cases which I have met with, have 
 been among negroes. In 1845 or '46, I lost three little 
 negroes, on my plantation in Mississippi, with the disease. 
 The children were at the Quarter, and under the exclusive 
 management of careless negroes, nearly a mile from the 
 dwelling house. 
 
 I have always been of the opinion that the disease had 
 its origin in the unhealthy condition, or unnatural cicatri- 
 zation of the umbilicus; and in most of the cases with 
 which I have met I thought I could trace the result back 
 to bad management of the cord. In one case of the little 
 negroes which I lost, there were evident signs of inflam- 
 mation of the umbilicus. 
 
 I have no recollection of having noticed any symptoms 
 
29 
 
 which indicated cerebral disease in any case that I have 
 treated. The cases which I have seen occurred invariably 
 from the fifth to the tenth day after the falling off of the 
 cord." 
 
 The following communications from Dr. J. W. Morton, 
 give additional confirmation of these views : 
 
 " In answer to your interrogatories on the subject 
 of Trismus Nascentium, I will say, that I commenced 
 the practice of medicine in Williamson county, Ten- 
 nessee, in a section of country very densely populated 
 with negroes. The farmers owning these negroes, had 
 on almost every one of their farms a number of 
 breeding women, all of whom, when confined, were 
 entrusted to female midwives, of the most ignorant order 
 of women, some of them were the old women belonging 
 to the plantation. With such services as could be 
 rendered by these attendants, we could but expect 
 that both mother and child would frequently suffer 
 from neglect, if not from maltreatment, at their 
 hands. This was by no means unfrequently the case. 
 Trismus Nascentium upon some plantations occurred so 
 frequently as to lead the farmers to conclude it was pecu- 
 liarly and particularly confined to the offspring of some 
 of their women, for they would loose a number of children 
 in succession, leading their owners to suspect that the cause 
 of the misfortune depended upon some malicious or bad 
 conduct on the part of the mother. Indeed I have known 
 masters who were ignorant of the cause of this malady, 
 to become much exasperated with favorite servants, 
 
30 
 
 believing they in some way maliciously caused the death 
 of their children, and then sell them to traders with an 
 express injunction they should be carried to the South. 
 This the farmers would do as a punishment to the unfor- 
 tunate mother, as well as to make an example of her to 
 her fellow-servants, to terrify them from a crime of which 
 they thought them guilty. 
 
 Having located in such a region of country, it was my 
 province to be very frequently called to cases of Trismus 
 Nascentium. When I would arrive and enquire of the 
 midwife or nurse what seemed to be the matter with the 
 child, their almost universal reply was, the child had the 
 bold hives, and they could not get them to break out 
 Upon examination, I would find the child far advanced 
 into Trismus Nascentium. In the early part of my pro- 
 fessional career I read almost every authority of which I 
 could get possession to inform myself as to the true 
 cause of this malady ; but in vain. The authors seem to 
 lead their readers to no just conclusion whatever as to 
 what might be its proper source. Sometimes I was ready 
 to conclude the disease depended upon some irritating 
 cause in the abdominal viscera. Again I would conclude 
 it v depended upon irritation of the spinal column, con- 
 nected with irritation of the great sympathetic plexus of 
 nerves. At other times upon some organic disease dis- 
 turbing the brain or its enveloping membranes. Some- 
 times I looked to the umbilicus as being the source of the 
 evil. 
 
 With all these conclusions before me, I was frequently 
 left in very great doubt as to which of these causes I 
 
31 
 
 should attribute the attack, and sometimes, I must admit, 
 I was at very great loss to know whether or not I should 
 lay the cause at the door of any one of them, or to 
 all of them combined. But about fourteen or fifteen 
 years ago, the precise time I do not now recollect, not 
 having the Journal before me, in looking over the original 
 communications published in the American Journal of the 
 Medical Sciences, I saw and read the essay of Dr. Sims, 
 then of Alabama, but now of the city of New York, with 
 a great deal of anxiety as well as interest, upon the sub- 
 ject of Trismus Nascentium. After perusing his essay, I 
 thought he had discovered the cause as well as the treat- 
 ment which would never fail to relieve it, Hence, I made 
 known the discovery of Dr. Sims to my friends and 
 patrons, assuring them I believed by his indefatigable in- 
 dustry and observation he had given to the profession a 
 key that would never fail to unlock the jaws of all tris- 
 matic infants. 
 
 Very soon I was called to a case. I examined carefully 
 the child's head, expecting to find without the least trouble 
 the displacement of the occiput, so graphically described 
 by Dr. Sims; but, to my utter astonishment, the bones 
 seemed to be in their proper position ; yet having so much* 
 confidence in his theory as well as practice, I adopted his 
 treatment of lateral position of the child, for several hours, 
 at the same time using such other means as the case 
 seemed to indicate, without the least beneficial effect what- 
 ever. The result of. this case did not, by any means, de- 
 stroy my confidence in the theory or practice proposed by 
 Dr. Sims; for I continued to try the lateral position 
 
32 
 
 every ease I saw before getting one in whidh I im- 
 agined the occiput had been pressed forward beneath the 
 edges of the parietal bones, all of which terminated in death, 
 as the first had done. At last, I was called to a case, the 
 child of a mother who had lost her two children born pre- 
 viously to tins one. This mother expressed great solici- 
 tude for the relief of her child, and upon my examining the 
 child's head, and finding, as 1 thought, the displacement 
 of the occiput, I immediately communicated to her, as 1 
 fancied, the cause of the distress of her child, and the 
 opinion that I would be able to relieve it. I determined I 
 would adopt Dr. Sims's treatment, first by dislodging the 
 misplaced bone from beneath the parietal bones, secondly 
 by enforcing strictly the lateral position prescribed by 
 him. Having no instrument better suited to the 
 operation, I used a common shoemakers's awl, pressing 
 the point of the instrument sufficiently deep into the 
 external table of the occiput to prevent its breaking outs, 
 when I made very firm pressure backwards, until I con- 
 ceived I had completely restored the bone to its natural 
 position; to my astonishment, when I removed the awl, 
 the bone resumed the position in which I found it. I 
 made this experiment several times upon one side at a 
 time, and then upon both sides simultaneously, with the 
 same result. This child died in a short time after I ceased 
 my experimental operations. Soon after this, I was called 
 to a second case in which I imagined the occiput was 
 pressed forward beneath the parietal bones ; upon this I 
 operated also, with the same result as the other. 
 
33 
 
 I now came to the conclusion, that either Dr. Sims 
 was mistaken both in his theory and practice in 
 Trismus Nascentium, or that I was wanting in dexterity 
 to adopt his lateral position properly, or perform his 
 operation with success. The result of these experi- 
 ments left me in the same doubtful and unsettled opinion 
 about the cause and cure of this malady. In fact, 
 I very soon came to the conclusion, that there was 
 no successful mode of treating it, and frequently when 
 sent for to see a child laboring under the disease, 
 I refused to visit it, acknowledging to those inter- 
 ested I could do nothing that promised any relief 
 whatever, not even as a paliative. For some years I gave 
 up all such cases to their fate, and even now, I have 
 no curative remedy to suggest, and when requested to 
 visit a child with Trismus, I frankly tell the mes- 
 senger that I can do as much for the relief of the 
 little sufferer as any other physician probably could, 
 yet acknowledge I can do nothing that would 
 be of any material service. My experience is, that 
 all such patients die as certainly as adults die of 
 traumatic tetanus, of which disease a physician may 
 probably see one case of recovery in the course of a 
 long professional life. 
 
 We must not think of curing the disease, but as you 
 
 have very justly taught in your essay published some 
 
 eight or ten years ago on the subject of Trismus Nas- 
 
 centium, the safety of the child will depend -on the 
 
 adoption of such hygiene measures as will prevent it. 
 
 Your theory of the cause of this disease, and the ardent 
 3 
 
34 
 
 manner in which yon have impressed it upon the 
 students of the medical classes, to whom you have had 
 the pleasure of lecturing since your connection with the 
 '•University of Nashville as well as upon the profession 
 , generally, through your essay, has saved the lives of more 
 children, which might have died of Trismus, since its publi- 
 cation, than all the remedies that have been employed for 
 its cure since the days of Hippocrates. 
 
 The condition of the umbilicus, it is true, is only an 
 exciting cause of Trismus Nascentium, just as the prick- 
 ing the sole of the foot of an adult with a nail is the 
 cause of traumatic tetanus. There are various other 
 causes acting upon the economy in either disease tend- 
 ing to bring about a tetanic diathesis of the system, which 
 only requires a very small exciting cause to develope 
 the disease. There is scarcely a man in this com- 
 munity who has not seen Tetanus in the adult pro- 
 duced by pricking the sole of the foot with some sharp 
 pointed instrument. Morgagni tells of a young lady 
 who was attacked with the disease in consequence of a 
 bite from a tame sparrow. Dr. Reid relates a case which 
 occurred from the stroke under the eye with the lash of 
 a whip, which was so light as not to destroy the continuity 
 of the skin. Andral relates a case that was the conse- 
 quence of a seton being inserted into the breast of a 
 patient. The extraction of a tooth has been followed by 
 tetanus. I have myself seen tetanus follow wounds so 
 slight as not to excite the least attention whatever until 
 the patient was completely overwhelmed with tetanic 
 spasms. When we see this disease so frequently follow 
 
35 
 
 wounds of so slight a character in the adult, how can we 
 reasonably doubt that the cause of Trismus Nascentium 
 is the irritation, inflammation, suppuration or ulcera- 
 tion of the umbilicus. I am conscious of one fact, that 
 since my attention has been directed to proper dressing 
 and care of the umbilicus in the children of my 
 practice, the mortality from Trismus has been reduced to 
 at least one hundred per cent., even when the care of 
 them has been entrusted to nurses." 
 
 Dr* McCulloeh's cases are in full agreement with the 
 general history of Trismus Nascentium.. The truths ad- 
 duced by him accord not only with my own observations, 
 but with those of others. 
 
 Dr. Hansom's notes, taken while he was in Texas, show 
 the great activity of predisposing causes; also, how gener- 
 ally and easily children are affected by a morbid state of 
 the navel, when they come under the influence of such 
 predisponents. Dr. Clarke's hospital cases illustrate the 
 same truths. After all, it is not very surprising that 
 such predisposing causes should have been mistaken by 
 Dr. Clark, and others, for the exciting cause. So little 
 attention has been paid to the proper relation of causes by 
 writers on this disease, that it seems very few have 
 attached sufficient importance to remote influences, or to 
 a particular diathesis of the system, but have been con- 
 tent to examine alone into the exciting cause ; and this, 
 consequently, when very weak or obscure, has not received 
 that consideration which it even then deserves, in its rela- 
 tion to a predisposition to tetanus. Hence the great 
 
36 
 
 necessity of regarding these causes according to their 
 mutual dependence on each other, that we may see their 
 joint agencies, in producing an attack -of this disease ; 
 also, that they may reflect a reciprocal light on the 
 obscure plastic forces of the invading pathos. The gene- 
 ral history of traumatic tetanus teaches us that it is more 
 easily excited in adults by wounds sometimes than at 
 others, according to the prevalence and activity of predis- 
 posing causes. This all admit. Whence then the neces- 
 sity or propriety of entertaining or propagating different 
 opinions as to these causes, and their effects in cases of 
 infantile tetanus,- associated as it often is with palpable 
 irritation and inflammation of the umbilicus? 
 
 Just here, I must reply to two very specious objections 
 to a proper view of this subject. 
 
 1. That the navel may be badly inflamed, and yet not 
 cause tetanus. - . • 
 
 2. That cases of Trismus have occurred wjien there 
 was no inflammation of the umbilicus. 
 
 But for these considerations many would doubtless have 
 entertained a much greater dread of a morbid state of the 
 umbilicus, and would oftener have employed tetano-pro- 
 phylactic measures in such cases. Indeed, with no little 
 astonishment have I heard well informed physicians say, 
 they did not believe that inflammation of the navel is the 
 exciting cause of Trismus, merely because they had seen 
 very badly inflamed ones, without the occurrence of lock- 
 jaw; or, that they had seen cases where the umbilicus 
 had healed over. Verily my surprise would be only 
 equaled by the assertion, that they did not believe that a 
 
37 
 
 wound was the exciting cause of tetanus in the adult, 
 because they had seen very bad ones fail to produce it, or 
 had seen cases occur after the healing over of wounds. 
 Almost every practitioner knows, from personal obser- 
 vation that an adult may receive a deep, dangerous, and 
 painful wound without incurring lock-jaw as a conse- 
 quence ; also, that, a wound may cause the disease after 
 having healed over. Then, may not severe inflamma- 
 tion, or extensive ulceration of a child's navel run its 
 course without causing trismus? and may not the part 
 heal over and yet, by an occult pathological condition, 
 excite the disease? 
 
 When we are called to see an adult patient laboring 
 under this malady, and learn that he has been suffering 
 from a wound, however great or small, whether from a 
 cannon ball or prick of a needle, we give ourselves no 
 further concern about finding out the exciting cause; 
 or, if we visit one in whom a recent wound has healed 
 over, and who notwithstanding is suffering from an attack 
 of this disease, we feel confident that the cicatrix is in a 
 morbid state and has excited the disease. But when some 
 practitioners are called to see an infant afflicted with teta- 
 nus, they may learn that the child's navel is even badly 
 inflamed, swollen and irritable, and yet ascribe the child's 
 attack to some other exciting cause ! Or, an infant may 
 be seen with the disease, when the umbilicus has healed 
 over, and instead of referring the attack to an unhealthy 
 irritable condition of the navel, though healed, as they 
 do in cases of adults, this occult pathological state of the 
 part is overlooked by them, and the disease is said to 
 
38 
 
 have been brought on by some other exciting cause ! 
 And yet, forsooth, had the little patient been an adult, 
 with a badly inflamed, swollen, and painful umbilicus, or 
 . with one that had just healed over, after having been in a 
 morbid condition, the exciting cause would have been 
 readily enough admitted. Hence, if I have not gained 
 the point which I had in view, the Redudio ad absurdum, 
 I have, at least, that of the Redudio ad discrepantiam. 
 A strange inconsistency has indeed been presented. It is 
 even preposterous, I must insist for any one to admit, 
 that a slight wound, either before or after it has healed 
 over, may produce tetanus in adults, and then deny that 
 inflammation and ulceration of the navel do not excite it 
 in infants, neither before nor after the part has healed. 
 
 Really, when we reflect on the great constitutional deli- 
 cacy of infants, their great proneness to cerebral, spinal, 
 and nervous disorders, as well as their general suscepti- 
 bility of disease, we would err less in supposing that their 
 frequent sore navels were more likely to cause tetanus ia 
 them, than common wounds in adults. Assuredly, both 
 adults and infants are liable to attacks of tetanus after 
 wounds or ulcers have healed over ; all admit that the 
 former are, and that the latter are equally so cannot be 
 either truthfully or consistently denied. A tetano-patho- 
 logical condition of such cicatrices cannot be detected by 
 any known means anterior to an open attack, especially 
 in the cases of children, as they cannot complain of any 
 irritation or pain which may be produced. And yet, we 
 very often hear those of " fixed ideas" about their imagi- 
 nary causes of this malady say, that in their cases the 
 
39 
 
 navel was healed over and looked very well, consequently 
 the disease must have been excited by some other cause 
 than by a morbid state of that part. The fallacy of such 
 a conclusion has been, I hope, fully exposed ; in further 
 proof of which, however, many cases might be adduced, 
 but I will only cite two, both of very recent occurrence : 
 A few days ago I was called to see a negro boy ten or 
 twelve years old suffering from a plain, fatal attack 
 of tetanus, brought on by a small wound which had 
 lately healed over and had been lost sight of until 
 that time. I saw a similar case afterwards, with several 
 physicians, equally as well marked and fatal in its termi- 
 nation. 
 
 I shall presently treat of its symptoms or varieties. 
 My chief aim now is to recommend a reliable prophylaxis, 
 by which, a' disease that cannot be cured, may be prevented. 
 Just here, it might not be amiss to state, that occasionally 
 a patient gets well of this malady; such a recovery is, 
 however, only an exception to a general rule, which the 
 attending physician sometimes mistaking for the general 
 rule itself, has thereby been encouraged to treat a succeed- 
 ing case with the same remedies which were supposed to 
 have cured the case before, when to his surprise and mor- 
 tification he found them of no avail. Many well-informed 
 practitioners have lost all confidence in the common 
 routine treatment of the day ; they entertain no reasona- 
 ble expectation of relief, only as hope may be predicated 
 on the recovery of a few exceptionable cases, independent 
 of therapeutic agents. Hence, the great need of some 
 prophylaxis. 
 
40 
 
 The mother from whose fond embrace the infant has 
 been suddenly removed by this unrelenting foe, at a time 
 when she needed all the joy and comfort which her child 
 could inspire, may well, ask, what is that, prophylaxis? 
 So may the benevolent physician, who has been so often 
 foiled and mortified in his best efforts to cure the malady ; 
 even our farmers may well ask the question also in behalf 
 of their slave interest. 
 
 I will now state by w r ay of introduction to the prophy- 
 laxis which I shall, with great confidence, recommend, that 
 I have seen probably as much obstetric practice, both 
 among whites and blacks, as any practitioner out of the 
 large cities, and never has an infant been attacked with 
 tetanus to my knowledge, of whose umbilicus I had the 
 management. 
 
 Prophylaxis. — Means derive far greater consequence 
 from their salutary effects in particular instances, than we 
 could otherwise attach to them. While we almost despise 
 the enema commune, yet we glory in its effects, when by 
 it, a dangerous and alarming obstruction of the bowels has 
 been relieved. How lightly do we also regard the mere 
 titillation of the throat with a feather until by its employ- 
 ment we cause the stomach to expel from its depths a 
 poison which in a few minutes would have destroyed the 
 patient. Then we respect the means and rejoice in the 
 effects. The lancet cut is but a small thing in itself, and 
 yet we exult greatly in its triumphs over some of our 
 most acute diseases. Then it is to the effects of the pro- 
 phylactic measures, that I will direct the attention of the 
 reader as well as the means themselves. 
 
41 
 
 Physicians have generally given up the dressing and 
 management of the funis too much into the hands of 
 unskilful nurses, lest by a careful attention to such small 
 things, they might compromise their fancied dignity. 
 But every one who is properly impressed with a dread of 
 tetanus from bad management of this part, will rather try 
 to maintain his professional character and dignity by pre- 
 venting a disease which he knows he cannot cure, however 
 trifling the means may seem in the estimation of the 
 ignorant, inexperienced or prejudiced. 
 
 The umbilical cord should be divided as usual about 
 two inches from the abdomen, and well tied with a suita- 
 ble ligature before its division. After the child has been 
 washed by the ■ nurse, another ligature should be applied 
 lest the first one should become too slack from the con- 
 traction of the cord. A hole of a proper size should then 
 be made through a piece of soft old domestic or linen, 
 four inches wide and six long, through which the funis 
 should be passed, and afterwards carefully wrapped with 
 another soft piece of cloth, two inches wide and three or 
 four long. The cord should then be turned up towards 
 the child's breast, and the cloth which was first applied 
 should then be folded in on it from above and below, and 
 from side to side. A soft flannel bandage should then 
 be carefully put around the addomen and pinned with 
 moderate tightness. After this should the navel-dressings 
 become wet with urine or soiled with feces, they should be 
 carefully removed and dry ones employed. This should 
 always be done by an experienced and careful nurse, lest 
 the cord be prematurely detached. 
 
42 
 
 The chief advantage of wrapping the cord, is that of 
 preventing it from adhering to the cloth through which it 
 passes, and thereby preventing its removal when necessa- 
 ry. All awkward, rough handling of the cord should be 
 avoided as the navel string may be, in that way, stretched, 
 torn, or prematurely detached. Our preventives begin 
 in little things ; too little, I fear, to insure the regard 
 which they merit; were they greater in professional esti- 
 mation, they would be more commonly employed. As 
 the danger of an attack of Trismus usually passes away 
 about the tenth or twelfth day of infantile life — cases 
 rarely occurring after that time — it will be the duty of 
 the conscientious physician — no other will — to watch the 
 umbilicus carefully and cautiously up to that period. 
 This duty is not a difficult one, but may be performed 
 with but little inconvenience on the part of the practi- 
 tioner. But unfortunately this duty involves some little 
 particulars, to which he can scarcely stoop. But he must 
 stoop, if not "to conquer," to prevent, knowing that if he 
 does not prevent, he cannot conquer. 
 
 The prevention of an incurable disease, let it require 
 whatever minor duties it may, should dignify and exalt 
 them in professional estimation, and make it honorable to 
 employ them. The umbilical cord, even during delivery, 
 should be carefully managed in reference to this disease. 
 It should be protected against too great an extension at 
 the time of birth : by unwrapping it from around the 
 child's neck, should it be around that part ; by not re- 
 moving the child too far from the mother before it is 
 divided. Any violent extension of the funis, in any way, 
 
43 
 
 may pre-dispose it to separate by suppuration, ulceration, 
 or sloughing. Besides, it might interfere with a healthful 
 contraction of the ventral opening, and that of the vessels 
 passing out through it. A proper contraction of these 
 parts after birth is a part of the wonderful physiology 
 performed by them ; for without, it, the cord cannot sepa- 
 rate in a healthy manner, the abdominal opening cannot 
 be closed nor the vessels which pass out through it. 
 Hemorrhage, hernia, and other evils may ensue as con- 
 sequences thereof. 
 
 The parts which should contract after birth are: 1. 
 The foramen ovale. 2. The ductus arteriosus. 3. The 
 ductus venosus. 4. The umbilical arteries and vein. 5. 
 The ventral ' opening. Should not a physiological con- 
 traction of these foetal parts — now superceded by a change 
 of the circulation of the "blood in extra uterine life— occur, 
 the separation of the cord may be attended with danger: 
 If the foramen ovale should remain too open, asphyxia 
 and death may occur; or if only partially so, carbon 
 may, for the want of free pulmonary circulation, accumu- 
 late in the child's system, and produce debility and con- 
 vulsions. And as the general health thus impaired, and 
 the local congestion of the umbilical parts from partial 
 returns of the foetal circulation, will not admit of a healthy 
 desiccation and separation of the funis, Trismus as a con- 
 sequence may follow. 
 
 If the umbilical arteries were not to contract, the dis- 
 turbances just mentioned might fill them with blood, and 
 hemorrhage at the navel would then take place in all 
 probability ; and if restrained their turgid condition would 
 
44 
 
 not admit of a proper contraction of the umbilical opening, 
 nor of a safe disengagement of the cord. Were the 
 umbilical vein to remain patulous, the blood might regur- 
 gitate through it, and bleed, if not prevented, at • the 
 navel, especially if there were any obstruction of the as- 
 cending cava near the heart. Were the ductus arteriosus 
 to remain pervious, too much blood might pass out of ,the 
 way of the pulmonary circulation. ; and in that way con- 
 tribute its moiety of distress. An open state of the navel 
 itself will, of course, greatly predispose to hernia, a gene- 
 ral derangement of its anatomical parts, congestion of 
 the vessels, hemorrhage, and sloughing of the cord. 
 
 It may be said that there is nothing in all this likely 
 to predispose -to Trismus by those who are not aware 
 of the danger of a sore, navel. Hence, every thing 
 calculated in the least to hinder the funis from coming 
 away in a healthful manner may predispose to a dis- 
 eased action of the umbilical parts. And as this part 
 of my subject relates so directly to the anatomy of the 
 umbilicus, I will give a short description of these parts, 
 which are so strikingly illustrated in the annexed plate, 
 the representation of a dissection, made at my request, 
 by my accomplished and talented young friend, Thomas 
 B. Buchanan, M. D. 
 
 The ,anatomy of the umbilicus consists of almost every 
 kind of tissue : Dermoid, superficial and deep-seated 
 fascia and aponeurosis, muscular fibre, tendon, nerves 
 and cord, with its vessels, covering and gelatine. As 
 the abdominal muscles are well supplied with nerves 
 from "the lower intercostal, ilio-hypogastrrc, and ilio- 
 
45 
 
 inguinal nerves," the umbilicus of course participates in 
 the endowment. 
 
 ' The integument, after the detachment of the cord be- 
 comes wrinkled and is folded in, and presents in front a 
 cicatrix— a cicatrix from a physiological wound ! — in the 
 strictest sense of the term. This cicatrix extends, of 
 couise, through the entire ring — a cicatrix of several tis- 
 sues, as we have just seen. Hence, we may expect often 
 to find it in a diseased condition, which may give rise to 
 tetanus, as well as an open ulcer.* Just under this integu- 
 ment is the superficial fascia and aponeurosis, so finely 
 displayed in Dr. Buchanan's dissection, as seen in the 
 plate. Next may be seen the aponeurosis of the internal 
 oblique and transversalis. Hence, the umbilical ring is 
 formed in part by the marginal contribution of the linea 
 alba, which is itself formed by the " blending of the ante- 
 rior aponeurosis of the oblique and transversales nluscles." 
 The transversalis fascia is also finely displayed. The 
 umbilical cord with its vessels are represented very promi- 
 nently; the two arteries may be seen, as they emerge 
 from the navel, entwined around the vein. 
 
 *Thc writer once attended a well marked case of traumatic tetanus, 
 caused, doubtless, by a physiological lesion in another part. The uterine 
 surface from which the placenta had been detached, like any common 
 wound, passed into amorbid condition, and produced the disease about a 
 week after delivery. 
 
 Dr. B. W. A vent, a very intelligent and well known' Physician and 
 Surgeon, -also, saw this case and concurred fully in the views just stated, 
 both as to the cause and diagnosis. .The prognosis was of course unfavor- 
 able, and was verified in a, few days. 
 
 The physiology of procreation produces more lesions than any other 
 variety thereof, so closely resembling ordinary wounds, that we would re- 
 gard them as such were they to occur in ordinary ways. Thus we have 
 periodical hemorage,, lesions of the Graafian vesicles, severance of the pla- 
 centa from the internal surface cf the* uterus, and on the part of the infant 
 a separation of the cord from its abdomen. Two of these lesions may 
 take on a morbid state and then cause. a traumatic tetanus. 
 
46 
 
 1. The integument everted. 
 
 . 2. 2. 2. Superficial fascia and aponeurosis of external 
 oblique. * 
 
 3. Recti muscles. 
 
 4. 4. Aponeurosis of internal oblique and transversalis. 
 
 5. Transversalis fascia. 
 
 7. Umbilical cord dissected. 
 
 8. Vein. 
 
 9. 9. Arteries. 
 
* 
 
 •^ ** -**-"' ^Mi^r# 
 
 .*•**«•-«•«»#.» 
 
49 
 
 Thus we see that the umbilicus is formed of a variety 
 of tissue, through which a physiological lesion must of 
 course exist, and which must be closed by a cicatrix of 
 the same kind, resembling traumatic lesion and healing 
 so closely that we might almost predicate tetanus on its 
 physiology, independent of its pathological changes. At 
 least no one can deny the necessity of guarding this teta- 
 nic point, for, eight or ten days after birth. A diseased, 
 irritable state of, these parts is well calculated to give rise 
 to tetanus, abounding as they do in nerves, fascia, aponeu- 
 rosis, both superficial and deep-seated, dermoid, and mus- 
 cular structures. They constitute a week point at the 
 ventral opening, to say the least, where a natural state 
 may pass more readily into an unhealthy one, than in any 
 other part of the child's economy. Even a failure in 
 their natural contractions as we have seen may produce 
 many pathological results. 
 
 The best remedy for this state of things is Ashwell's 
 alum bath. About one-fourth of a pound of pulverized 
 alum should be dissolved in a vessel of tepid water, large 
 enough for immersing the child up to the neck, where it 
 should be held and carefully supported for ten or fifteen 
 minutes, two or three times a day, according to the nature 
 of the case. A little spirit of camphor, some pure brandy 
 or aqua ammonia may be added if the child be very feeble. 
 This bath is clearly indicated when symptoms of asphyxia, 
 attended with blue lips, livid countenance, defective respira- 
 tion, and feeble pulse occur in early infancy, denoting a 
 partial recurrence of the foetal circulation. And as all 
 this may be referred to an open state of the parts just 
 
50 
 
 mentioned, it will be highly necessary to promote their 
 closure ; and I feel confident that" there is nothing better 
 for immediate use than the bath just recommended. As 
 the infant, while in this condition, may lose its ability to 
 nurse at the breast, it should be fed by a spoon with 
 warm maternal milk. A few drops of the aromatic 
 spirit of ammonia, with sugar, well diluted and carefully 
 administered may also do good. As soon as the child 
 is taken out of the bath, the abdominal bandage and 
 navel -clothes should be removed, and dry soft ones re- 
 applied. The umbilical surface should also be anointed 
 with simple cerate, to prevent ill effects from the alum 
 and ammonia. 
 
 As the crying of the child is very apt to disturb the 
 navel, as well as its dressings, great care should be taken 
 during the first eight or ten days to prevent hard spells 
 of it. The abdominal bandage should be applied in anti- 
 cipation of such paroxysms ; and the dressings should be 
 examined daily. Should they become soiled with feces or 
 urine, they must be removed, and clean, soft ones applied. 
 All jolting or improper handling of the infant should be 
 avoided, as much injury is often done in that way ; by it 
 the cord may be ruptured or injuriously stretched. 
 
 The umbilicus may suffer from an improper mode of 
 dressing : nurses have a bad habit of clouting by pinning 
 the cloth in a bulk over the navel, which will press directly 
 on it, whenever the child cries, strains, kicks, or draws up 
 its lower extremities. This error should be corrected. 
 
 Spells of colic also have a bad effect on this part, and 
 afford an .additional consideration for giving as prompt 
 
51 
 
 relief as passible. Entire cleanliness must also be regarded 
 as one of our prophylactics. 
 
 It will sometimes, though not often, be necessary to 
 employ local medication of the umbilicus before the funis 
 is detached. Should the cord become dry and hard, without 
 separating at the proper time, and the surrounding surface 
 irritated by it, it will be necessary to raise the dressings 
 and apply a little warm olive oil ; or remove a portion of 
 it, if it be thoroughly dried, and the parts well contracted, 
 with a sharp pair of scissors. No portion of the cord 
 should be thus divided, except it be entirely dry, and its 
 vessels impervious. Occasionally it will be necessary 
 to divide a small remaining thread of the cord, especially 
 if any local applications are necessary. But even this 
 should be done circumspectly. On the contrary, should 
 healthful desiccation not take place, or only partially, and 
 the navel string remain soft and large, attended with ul- 
 ceration and suppuration around its base, the dressings 
 may be carefully removed and a soft astringent poultice 
 applied, with the double motive of producing contraction 
 of the ring and allaying irritation of the inflamed sur- 
 face. A little corn meal cooked with a decoction of oak 
 bark, will make the best poultice. 
 
 The funis occasionally separates by sloughing, emitting 
 a bad odor, and exhaling an irritating moisture. In such 
 cases, the part should be well secured in a dry soft cloth, 
 the surface under it washed with milk and water, and well 
 oiled, to protect it against the irritating effects of tho 
 exuding fluids. 
 
 A little fungus may spring up just at the point where 
 
52 
 
 the cord separates, this should be carefully touched 
 with caustic a few times, according to results. — 
 Always after the detachment of the part the surface 
 around the navel should be washed with warm milk and 
 water, then well dried, and a little simple cerate applied 
 to the surface, and a good abdominal bandage put around 
 as before ; the use of which should be continued for some 
 time; more especially if there be any tendency to a 
 pouting of the part. 
 
 Lastly, after the funis has separated, the umbilicus 
 should be carefully washed with castile soapsuds, and if 
 there be the least appearance of irritation or inflamma- 
 tion, a soft mush poultice, twice the size of a dollar and 
 about twice as thick, throughout its whole extent — lest 
 the edges become dry — should be neatly spread on a soft 
 piece of cloth, then moistened on its surface with a little 
 lead water and olive oil, or prepared as before with oak 
 bark tea, and laid with care immediately over the navel, 
 and should be retained in its place by a proper application 
 of the bandage. This poultice should be removed in 
 six or eight hours and another applied, and so on 
 until all signs of a morbid state of the part entirely 
 disappear. It will sometimes be necessary to continue 
 this course of poulticing for five or six days, to the entire 
 exclusion of all other topical applications, such as calomel, 
 red precipitate, spirits of turpentine, &c, as their prophy- 
 lactic powers are very inferior to those of the compound 
 poultice just recommended. All predisposing, accessory or 
 accidental causes of irritation should be guarded against with 
 great care; the general health of the child should be 
 
53 
 
 -closely watched, and internal remedies employed if neces- 
 sary. 
 
 Soft, emollient poultices, certainly afford even an adult, 
 suffering from a wound, greater protectiou than any other 
 means. Who «ver saw a patient attacked with traumatic 
 tetanus, who had had all the prophylactic benefits of good 
 poultices, a well regulated temperature of his room, and 
 appropriate internal remedies? The soothing action of 
 the poultice seems indeed to prevent a wound from passing 
 into that condition which excites lock-jaw. The terminal 
 extremities of the wounded nerves, or those that have been 
 exposed by ulceration, or irritated by inflammation, are 
 protected by a poultice against that tetano pathological 
 condition into which they pass sometimes, when not thus 
 guarded, with great facility. 
 
 But alas! because the inflammation of the navel is 
 trifling, or the ulcer on it small, the physician does not 
 consider either worthy of his attention, when, really, the 
 the very elements of death 'are more actively at work 
 than in many cases which so readily engage his closest 
 attention and greatest skill. It is probable that a greater 
 amount of human life might be saved by these simple 
 preventives, than most physicians or nurses are aware of; 
 and it is always far more difficult to procure the employ- 
 ment of such prophylactics, than those uncertain remedies 
 which are so zealously administered sometimes for the 
 relief of an incurable malady. 
 
 Nurses should be properly directed to employ these 
 means, especially among our negroes ; and every practi- 
 tioner should constantly urge their adoption in negro 
 
54 
 
 quarters. When these means are faithfully employed, 
 negro children escape tetanus to as great an extent 
 as do white children. It should be the resolve of 
 every practitioner never to allow an infant to 
 be attacked with trismus that may be delivered by him, 
 or placed under his care at birth, since by a patient and 
 careful employment of appropriate prophylactics it may 
 be prevented. These means, simple and unpretending as 
 they are, require some oversight and tact for their benefi- 
 cial employment : if the poultice be not well applied, of 
 improper consistence, or become dry and hard, it may do 
 more harm than good. Besides, if the child be not pro- 
 tected against wet and soiled clothing, bad air, variable 
 temperature of its room, a bad habit of body, bad feeding 
 and nursing, these predisposing, accessory and accidental 
 causes, may determine the morbid umbilicus to pass into a 
 traumato-tetanic condition in despite of poultices or any 
 other topical applications whatever ; so it is highly neces- 
 sary that all these things — little in themselves though 
 great in their effects — should be scrupulously regarded 
 by every practitioner. 
 
 The writer of this treatise, while faithfully discharging 
 his duty to infants in the employment of these prophy- 
 lactic measures, has often experienced the jeers and 
 taunts of nurses on such occasions. Every practitioner 
 should, however, perform his duty to his little patient, be 
 it white or black, in protecting it against an attack of a 
 disease which he may prevent but cannot cure, and there- 
 by impress nurses, parents, and even communities with 
 the great utility of such a course. In that way our pro- 
 
55 
 
 phylactics may be raised above the contempt of ignorant 
 crones or those too wise to learn. 
 
 Admitting, as we are compelled to do, that we can but 
 seldom treat this disease successfully, yet it will be pro- 
 per to give a full detail of its symptoms, diagnosis/prog- 
 nosis, pathology and treatment. 
 
 Symptoms. — These at first are vevy obscure, and may 
 be overlooked both by the physician and nurse. It is 
 so very common for infants to cry, and thereby manifest 
 only slight ailments that the early symptoms are usual- 
 ly referred to some ordinary indisposition which does 
 not excite much concern. 
 
 During the first week the child has probably been quite 
 healthy; has nursed well, slept well, and has done so 
 well in every respect, that scarcely any apprehension is 
 entertained about its safety, until on the eighth or ninth 
 day, when the child's cry is modified, and evinces dis- 
 tress ; it also whimpers and does not rest so well. 
 These premonitory symptoms will soon be followed by a 
 quickened pulse, distress of countenance. These will 
 be associated with other symptoms about this time, such 
 as rigidity of the muscles about the neck and face, a 
 disinclination on the part of the child to nurse, while 
 the endeavors of the anxious mother to get it to do so 
 may be unavailing. The child will either push the nip- 
 ple out with its tongue, or in the attempt to nurse, 
 should it draw any milk into its mouth, will strangle 
 and sometimes very badly. The alarmed mother will 
 try again and again to get her child to nurse, supposing 
 that it has the colic, hives or something of the kind. She 
 
56 
 
 will then probably try to get her babe to swallow some 
 domestic remedies, and failing in that also, the family 
 physician will be sent for; on his arrival he will find the 
 child's countenance greatly changed; the skin on the 
 forefiSd will be wrinkled, the eyebrows knit, the skin 
 on the cheek drawn upwards and backwards, also the 
 angles of the mouth, thereby thinning and compressing 
 the lips against the gums. The eyes will be partially 
 closed, and will roll upwards or become fixed in their 
 sockets. The contour of the mouth will be changed, 
 sometimes remaining slightly open in an elliptical form. 
 The under jaw is fixed and cannot be separated from 
 ;he upper one, presenting now the unequivocal symptom 
 )f Trismus. The patho-physiognomy of the disease is 
 now fully established. There will now be great rigidity of 
 the muscles of the neck, spine, abdomen and extremities. 
 The abdomen will feel hard, the extremities will be more 
 or less stiff, and the back will be curved either backwards 
 — episthotonos — or forwards — emprosthotonos — and in 
 some rare instances laterally — pleurosthotonos. The 
 lateral tetanic flexure is the most unusual, the procurva- 
 tion the most favorable, and the recurvation the most 
 fatal. If the umbilicus be examined it will in all pro- 
 bability be found in a pathological state of some kind, 
 most commonly inflamed and irritable. As the disease 
 advances the flexure of the spine backwards — the most 
 common variety — along with the reversion of the head 
 increases. The tonic spasms become greater and faster; 
 they will occur every twenty, thirty or forty minutes, 
 without complete relaxation of the muscles during their 
 
57 
 
 intervals. All ability to swallow is occasionally lost, 
 the jaws become immovably fixed, and in the course of 
 twelve, twenty-four, or forty-eight hours the infant will be 
 destroyed by a hard spasm or die comatose. Sometimes, 
 however, infants live eight or ten days, the disease then 
 becomes chronic, and they may recover. 
 
 There is seldom much or any febrile excitement, but on 
 the contrary often coldness of the surface and extremities. 
 The pulse is generally quickened, and the bowels torpid. 
 The brain is not much disturbed until towards the close of 
 the malady. The symptom of Trismus may be com- 
 plete, partial or not exist at all. In the latter instance 
 the child may continue to nurse and swallow through the 
 whole course of the disease. The writer once attended 
 a fatal case of this kind, which, a learned professor, who 
 incidentally saw the case while under treatment, attempt- 
 ed to relieve by the use of chloroform, but failed most 
 signally. 
 
 Hence, I infer that the absence of trismus, in this dread- 
 ful complaint does not lessen the danger, though the 
 disease presents a much more favorable appearance; for 
 when seen in its trismatic features, of unyielding spasm 
 and intense suffering, the appearances are horribly dis- 
 tressing, and cannot be easily forgotten. 
 
 I have procured a very excellent likeness of this infan- 
 tile patho-physiognomy. By the professional courtesy of 
 Dr. Conwell of our city, I ob f ained leave of one of his 
 families to have a drawing taken of a fully developed 
 case, by a very adroit lithographist, Mr. Wagner. It 
 
58 
 
 may be seen and examined on the annexed plate. In 
 this case, the umbilicus was badly inflamed, swollen, and 
 presented a very irritable appearance. The disease came 
 on about the sixth or seventh day. No remedies did any 
 good, and the child died in forty-eight hours from the attack. 
 The extremities were more affected than usual, and the 
 spine though recurvated considerably, yet the flexure was 
 not as great as sometimes occurs, nor was the head drawn 
 backwards as far as I have seen it in other cases. But 
 it was a very plain, rapid arid fatal case of infantile traumatic 
 tetanus. I should further state that in this case the cord 
 sloughed, which is the worst manner in which it can separate. 
 Diagnosis. — This disease has been confounded by most 
 writers with clonic spasms or convulsions ! Even Condie, 
 a systematic writer on the diseases of children, has done 
 so. If we may judge from Jtiis few remarks we may infer 
 that he cared but little about it. Other good writers are 
 equally culpable. Evanson and Maunsell of Ireland, 
 evade responsibility about it by stating that, " It may 
 justly be considered as an hospital disease." Whether the 
 children of Ireland ever suffer from it out of their hos- 
 pitals or not, I am not now prepared to answer; but I 
 know very well that infants of Irish parents frequently 
 do in our country ; hence I infer that it is most 
 reprehensively overlooked among the poor of that coun- 
 try. Even the practical Dewees says he can see nothing 
 positively dangerous in a diseased navel ! And West, a copi- 
 ous writer on other infantile disorders, writes impatiently 
 and confusedly about this. He even questions the pa- 
 thological signs which he has stated in regard to it. 
 
1 
 
 Mr* 
 
 
59 
 
 This much neglected pathos is by no means without 
 its diagnostic symptoms ; signs by which it may be con- 
 tradistinguished from all other infantile convulsions. These 
 are so characteristic of the complaint that it is very 
 astonishing it should ever have been confounded with 
 other nervous disorders. They are as plainly differ- 
 ent from those attending such affections, as are Epileptic 
 convulsions from tetanic spasms in the adult. And there 
 is no more reason for confounding infantile tetanus 
 with ordinary clonic spasms, than that of adults with 
 epilepsy. There is about the same variety of tetanic 
 cases among the former as is among the latter; and 
 each variety is of course attended with a corresponding 
 modification of symptoms. These may in both instan- 
 ces be sometimes very mild and obscure, and in others 
 very active and plain. 
 
 The symptom of Trismus — rarely ever absent — aids 
 us more than any other in forming a correct diagnosis. 
 But even in its absence the rigidity of the muscles of 
 the neck, distortion of the spine, and the tonic unrelenting 
 spasm, would determine the true nature of the case. 
 Besides, tetanic spasms are unlike all other varieties 
 for they never intermit completely, but continue 
 in degree all the while; nor do patients lose all con- 
 sciousness during their continuance, as they do generally 
 in convulsions. 
 
 When all these symptoms are present, such as trismus, 
 reversion of the head, incurvation of the spine, tonic 
 spasm of the voluntary muscles, inability to swallow 
 without strangling, with an inflamed umbilicus, how, I 
 
60 
 
 ask, could we have a plainer case of traumatic tetanus, 
 taking into consideration the fact that these charac- 
 teristic symptoms came on about the same time in which 
 they would in the person of an adult after the reception 
 of a wound. Were they to occur in an adult case about 
 the same time after a wound the merest tyro in medicine 
 could hardly fail in diagnosing the disease. Why then 
 should good observers admit that the disease has its 
 source in the one case evidently in a wound, and not in 
 the other? 
 
 On one occasion I was requested to examine an infant 
 with all the plain diagnostic symptoms of traumatic 
 tetanus, by an old, experienced and respectable physician 
 who had the case in hand, and to my great astonishment, 
 he had entirely overlooked the true nature thereof, 
 and but for maternal solicitude would have given the 
 case but little consideration. He said that I was over- 
 anxious about the child, that it would be well in a few days, 
 but in this he was mistaken, for it died in a short time. 
 This infant had a badly inflamed navel, of which he was 
 ignorant until I directed his attention to it. The symp- 
 toms of traumatic tetanus were plain, but because they 
 occurred in an infant they were disregarded by this prac- 
 titioner, and had I not seen the child the disease would 
 have passed for something else. Thus we see how this 
 fatal malady is doubtless often regarded. 
 
 The observing physician who understands the diag- 
 nostic signs of this disease, will have but little difficulty in 
 making out an acute case, but in its chronic form there 
 may be some difficulty, especially if the child be recov- 
 
61 
 
 ering and the symptoms mild. The previous history of 
 the case must be patiently enquired into, and the 
 symptoms just enumerated, however mild, have diag- 
 nostic characteristics. Most of these signs are pathog- 
 nomonic, and generally there are but few adjunctive 
 ones to mislead. Probably there is no infantile dis- 
 order more, clearly pronounced by its symptoms than this 
 one, and yet none has been more overlooked, mistaken 
 and maltreated! 
 
 Prognosis. — This, if our diagnosis be correct, should of 
 course be unfavorable. A few cases become chronic and 
 recover, but not a sufficient number to justify a favor- 
 able, or even an equivocal opinion. An unfavorable 
 prognosis might, however, be followed by the statement 
 that a few recover. This will temper the harsh declar- 
 ation a little; but we should be particularly cautious 
 not to raise hopes which in all probability may not be 
 realized. The physician's opinion should be cautiously 
 communicated to the mother, lest the shock of an unfa- 
 vorable one injure her. Her puerperal state will re- 
 quire this. It will suffice at first to let her know that 
 her child is ill, and a short time afterwards that it is 
 dangerously so, and at a proper time that it may die 
 very soon. A little maternal hope will soften and qual- 
 ify all these painful statements, and greatly lessen their 
 injurious effects. Let her hope be gradually extin- 
 guished, not too suddenly," for we should not forget that 
 we may be dealing with two lives ! Besides, the physi- 
 cian should be very certain of the correctness of his 
 diagnosis, before he expresses so grave an opinion. How 
 
62 
 
 could a mother excuse a mistake which might torture 
 her unnecessarily for several days and nights? 
 
 Pathology. — We know of scarcely any pathological 
 lesions beyond the umbilicus. Post mortem examin- 
 ations have revealed but few if any. Although the 
 chief seat of the disease be in the spinal cord and spinal 
 nerves, yet they do not manifest any appreciable patho- 
 logical changes after death, significant thereof, according 
 to our most accurate observers. West, in his work on 
 the diseases of children, states that he found in his ex- 
 aminations of three cases after death, there was an 
 effusion of blood in the cellular tissue surrounding the 
 theca of the cord, and a congested state of the vessels of 
 the spinal arachnoid, and sometimes an effusion of blood or 
 serum into its cavity. But in consequence of finding 
 similar appearances in the bodies of infants which had 
 died of other affections, he hesitates to accept those just 
 mentioned as true pathological lesions of Trismus Nas- 
 centium. It seems very reasonable to suppose that the 
 pharanx and esophagus, will be found after death con- 
 tracted and inflamed. Doubtless in bad cases, the chief pa- 
 thological signs after death, will be found in the spinal cord,, 
 teaching us the importance of addressing active remedies du- 
 ring life to that part. As this morbus pervades the whole 
 spinal cord, our remedies, for its relief, must be prompt, 
 active and well directed, probably more so than has gen- 
 erally been done. 
 
 Treatment. — The management of cases of this kind 
 would be a better term than the treatment of them in a 
 medical sense. Treatment will be required, and we must 
 
63 
 
 manage them in the best manner. Although we may 
 have lost confidence in all remedies in consequence of 
 their constant failures, yet we must continue to employ 
 them ; for the particular case of which we may have the 
 management may be an exceptional one, " and unlike 
 others, may be amenable to our remedies. 
 
 Prof. W. T. Briggs, my present co-partner, has just in- 
 formed me that he lately treated a well marked case suc- 
 cessfully. It came on about the usual time after birth, 
 and was attended with a very bad state of the umbilicus. 
 The cord sloughed partially at first, and left a portion in 
 a half sphacelated condition, adhering to the navel, from 
 which an irritating discharge constantly exuded, and 
 kept up a great deal of irritation and inflammation of 
 the umbilicus. But by means of a soft emollient poul- 
 tice to the part and the internal use of two drops of 
 laudanum every two or three hours he succeeded in relieving 
 the little patient. The result of this and similar cases 
 is encouraging, and teaches us that we should always 
 try to cure the disease. I will, therefore, advise the 
 following plan of treatment : — In the first place apply a 
 soft emollient poultice to the child's navel, let its condi- 
 tion be as it may. Give from one to two drops of lauda- 
 num every two hours, watching its effects : but should 
 the child not be able to swallow the medicine, employ it 
 as an enema with a thin solution of starch — lour or five 
 drops repeated in that way every three or four hours, and 
 if this be voided too early, clothes saturated with it 
 should be applied to the epigastrum, taking care that too 
 much of the drug be not absorbed. If the child be 
 
64 
 
 plethoric a leech or two should be applied to the spine, 
 and immediately afterwards, its whole course from the 
 occiput to the coccygis should be vesicated, either by 
 the vinegar of cantharides or strong aqua ammonia. It 
 is easy enough to prevail on mothers and nurses to give 
 laudanum and similar drugs in this disease, but they 
 may object to extensive vesication of the spine; hence it 
 will often be necessary to explain and insist on this 
 particular remedy. 
 
 EfttUTi..— In note, page 45> for " heinorage,'* read hemorrhage, At page 1^ 14th line, fef 
 " their, * read there. 
 
I3STDE-X 
 
 Introductory i-xvi 
 
 History 4 
 
 Dr. Sim's Theory 5 
 
 Strictures thereon 6 
 
 Predisposing Causes 11 
 
 The Exciting Cause 14 
 
 Separation of the Umbilical Cord 15 
 
 Remarks on Dr. Joseph Clark's views 17 
 
 Condition of Infant at Birth 18 
 
 Negro Children 20 
 
 Prevalence of the Disease at Particular places 22 
 
 Contribution from Dr. McCulloch 24 
 
 " " " Dr. Ransom 26 
 
 " . " " Dr. Black 28 
 
 " " " Dr. Morton 29 
 
 Inflammation of the Umbilicus 36 
 
 Trismus Nascentium. essentially the same as traumatic tetanus in the adult. 37 
 
 Prophylaxis 30 
 
 Division of the Umbilical chord 41 
 
 Mode of dressing the Umbilicus 41 
 
 The fetal parts which contract at birth 43 
 
 The Anatomy of the Umbilicus 44 
 
 Plate, with references 46 
 
 Physiological Lesions 45 
 
 Management of the Umbilicus 1 50 
 
 Poultices 52 
 
 Symptoms of the Disease 55 
 
 Diagnosis 58 
 
 Plate 2 58 
 
 Prognosis 61 
 
 Pathology 62 
 
 Treatment 62 
 

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