1847] Jacquemier and Negrier on Obstetric Medicine.

MANUEL DES ACCOUCHMENTS ET DES

49

MALADIES DES FEMMES

GROSSES ET ACCOUCHEES, CONTENANT LES SOINS A DONNER AUX NOUVEAUX-NES. Par J. Jacquemier, Docteur en Medecine de la Faculte de Paris. Avec 63 figures intercalees dans le texte.

A Manual of Midwifery and the Diseases of Women in the Pregnant and Puerperal States, with the Management of Infancy. By J. Jacquemier, M.D. With sixty-three figures inserted

in the text.

ET

RECHERCHES ET CONSIDERATIONS SUR LA CONSTITUTION LES FONCTIONS DU COL DE L'UTERUS, dans le but d'eclairer l'Etiologie des Insertions Placentaires sur cette Region, et de conduire a un Choix de moyens propres de combattre les Hemorrhagies qui en sont les Consequences. Par C. Negrier. Paris, 1846.

Researches and Considerations on the Structure and Functions of the Neck and Womb, with the design of elucidating the Etiology of Insertions of the Placenta in that Part, and to indicate the Proper Treatment of the Hæmorrhages resulting from them. By C. Negrier.

THE works before us are the most recent on obstetric medicine from our neighbours in France. M. Jacquemier's Manual is necessarily, to a great extent, a compilation, and treats at full length the direct and incidental subjects which belong to midwifery. M. Negrier's is a Monograph on the Anatomy and Physiology of the Neck of the Womb, with the view of illustrating that most important part of practical midwifery, the insertion of the placenta over the os uteri, and the hæmorrhage which results from it.

The Manual is divided into five principal parts. The first includes a description of the Pelvis and the Organs of Generation, considered in their relation to Gestation and Parturition.

The second treats of Fœcundation, Pregnancy and Ovology. The third includes the Diseases of Pregnancy and the Diseases of the Ovum and Fœtus.

The fourth embraces the subject of Practical Midwifery, including Natural Labour and the Varieties of Dystocia.

The fifth is devoted to Puerperal Diseases, and the Management and Diseases of the Infant.

The sixty-three engravings which illustrate the text are immediately copied from Moreau's Atlas, although we believe that M. Jacquemier supplied the preparations from whence Moreau's engravings were taken. We think that the diagrams which M. Chailly has adopted are far better suited for the purpose than the more elaborate drawings which are seen in M. Jacquemier's volume, or in the recent English Midwifery works. They No. 107

4

are clear, pointed, and very intelligible, and appear to us, when inserted in the text, to be of great assistance to the student.

The Chapter on the Pelvis, in its normal and morbid states, is very good. M. Jacquemier follows Naegele in his description of the small and obliquely-ovate pelvis, giving some of his cases at length, and adopting his views. He thinks, with Madame Lachapelle, that the evils resulting from a too large pelvis have been loosely stated, and that the fear of displacement of the womb, abortion, &c. is not warranted by facts.

There is an interesting notice of the secondary effects of congenital or accidental luxations of the femur, and amputation of the leg high up, in deforming the pelvis, for which our author is indebted principally to M. Sedillot.

M. Jacquemier's anatomical descriptions are exact and clear. He details some peculiarities of the cervix of the womb. But M. Negrier enters on this subject at greater length. The latter transcribes in succession various opinions on the disposition of the muscular fibres of this part of the womb, the result of which is in our mind to lead to the impression that they are too intricate to be made out satisfactorily. The general results of Negrier's researches into the arrangement and character of the fibres of the neck of the womb are as follow:

(1.) The tissue of the cervix is of the same muscular nature as the body of the womb.

(2.) The number of fibres is infinitely less in the neck than in the body of the womb-and

(3.) These fibres are not in continuation with those of the body of the womb, excepting only a band posteriorly which descends from the fundus to the lower part of the neck, and even as far as the vaginal cul-de-sac.

(4 & 5.) The number of the circular muscular fibres of the neck, in which two layers are not recognised, as in the body of the womb, diminish towards the inferior aperture, where, according to some anatomists, they collect to form a sphincter.

It is thus that the neck of the womb does not possess, excepting in a very trifling degree, perpendicular fibres which abound in the body of the womb, and hence, so far as muscular fibre is concerned, there is an independence between these two parts.

Besides the difference which is to be noticed in the number and texture of the fibres of the neck of the womb, M. Negrier remarks on the differences in the vascular and nervous supply to these two parts of the same organ. The neck of the womb derives its blood from two large arteries, the uterine, whose primary trunks envelop and penetrate the walls of the cervix, while the body of the womb is supplied from a less considerable source, the spermatic arteries. The cervix possesses spinal nerves principally; the body, nerves from the ganglionic system. And it is impossible, says M. Negrier, but that this disposition must exercise a most important influence in the functions of the organ. Still further to mark the distinction between the cervix and the body of the uterus, M. Negrier passes rapidly in review the functions of menstruation, fecundation, parturition, the delivery of the placenta, and the changes which follow labour. The pains of menstruation, especially those which accompany the ex

1847]

Negrier on the Neck of the Womb.

51

pulsion of false membranes, are referred to the difficult passage of the blood along the canal of the cervix. M. Negrier omits to notice the fact that the cavity of the womb and not the cervix yields the menstrual blood. The peculiar faintness, sometimes amounting to syncope, which is noticed by some women when a fruitful coitus has taken place, results, according to Negrier, from a dilatation of the neck of the womb in its efforts to draw in (aspirer) the semen, and the increased sensibility of the part from the venereal orgasm. M. Negrier notices the formation of the decidua from the cavity of the womb, and the closing of the cervix by the plug of mucus. He speaks of the decidua as a pulpy matter, forming after a time a serous sac; and he states that the upper part of the mucous plug becomes solid, and organised, resembling the pulp of the decidua, and that blood passes into it, which is not held in regular vessels, but imbibed at that part of the plug in contact with the ovum. He noticed this in ova of the fourth to the seventh month. M. Jacquemier's views of the formation of the decidua are similar to those of M. Negrier. He speaks of its "organisation as very simple. At first it is not distinct from the fluid secreted by the uterus under the influence of the specific excitement caused by fecundation; a coagulable fluid separating itself into solid parts, which are deposited over the uterus and the ovum in semi-solid layers, offering the most simple form of false membrane; the remainder of the fluid remains in the cavity of the decidua to disappear at a later time." Our authors do not appear to be aware of the investigations of Dr. Sharpey, Mr. Goodsir and others, into the structure of the decidua. We believe that its glandular origin is now indisputably made out. It is in fact nothing more than a swelling of the mucous membrane, the follicles, blood-vessels, and the lining epithelium of the follicles, all growing rapidly. We are somewhat surprised that these most interesting researches should not have been recognised by M. Negrier or M. Jacquemier.

M. Negrier refers the vomiting which attends the early months of pregnancy to a relation subsisting between the stomach and the fundus of the uterus-the latter, in contra-distinction to the cervix, being supplied with organic nerves. It is the dilatation of the fundus during the first period of pregnancy, and the sympathetic effect of this, which occasions the morning and other sickness.

M Negrier makes a great distinction between the upper and the lower opening of the cervix, the os uteri internum and externum of our anatomists. It is the closure of the upper opening which holds the ovum within the cavity of the womb, and not the parietes of the neck. "The upper opening or sphincter belongs completely, both in its nature and its mode of action, to the body of the uterus-it is its mouth, and the inferior aperture or sphincter approaches rather the tissues of the vagina, both in its structure and in some of its functions." There is a difference in the restoration of the neck of the womb after delivery in primiparæ, and in those who have previously borne children; and M. Negrier traces the difference day by day, up to the tenth day after parturition. The result is, that in primiparæ the orifices of the neck close up sooner than the parietes of the cavity of the neck, whilst in multiparæ the lips of the external opening close up more slowly than the walls of the cavity. Among all women the walls of the cervix are folded up from above to below, and these per

pendicular folds result from the closure of the upper opening of the neck. We shall refer to the practical part of M. Negrier's work by and by.

The disorders of menstruation are divided by Mons. Jacquemier into two classes-Amenorrhoea and Dysmenorrhea. In the former, are included the same class of cases as most authors have described under this title, while the latter is greatly extended, and is made to take in Menorrhagia and Vicarious Menstruation. "The line of demarcation between amenorrhoea and dysmenorrhoea is not always well defined. If we except amenorrhoea caused by an imperfect state of the sexual organs, and amenorrhoea which is symptomatic of some other disease, all other known species will more naturally be ranked as dysmenorrhoea."

Our author describes amenorrhoea by obliteration of the vulvo-uterine canal, which, as he justly remarks, is a retention of the menses and not an amenorrhoea--and amenorrhoea the result of a deficiency in the sexual organs, whether in the absence of the uterus or ovaries, or an undeveloped or rudimentary state of these parts.

The chapter on the amenorrhea which is secondary to other diseases, contains many of the remarks of M. Brierre de Boismont. Of the physical causes which produce this suppression, the action of cold is the most common. The menses may be stopped by exposing the body when perspiring to the cold air, or by immersing the feet or hands in cold water. But habit diminishes and even destroys this pernicious tendency, and bathing-women are just as regular as other persons. M. Brierre de Boismont says that he has seen cases in which the contact of the surface with cold water caused a very abundant flow.

"The suppression of the sweat of the feet has often been followed by amenorrhea; it has been seen to follow blows, falls, fatigues, acute diseases which have needed profuse bleedings. The linen which women use during the menstrual times is with some an immediate cause of a diminished flow, and it may even stop it. Moral emotions are the most common causes of sudden suppressions of the menses, although they sometimes occasion a profuse discharge. Both the physical and moral causes act most surely at the approach of the periods, or just when they are on. M. Brierre de Boismont having analysed, with reference to these causes, 190 instances of suppression, found 68 were due to physical causes, 92 to moral causes, and in 30 the cause was not known."

There are two particular forms of Dysmenorrhoea which are described, the plethoric and the hysteralgic.

1st.

Dysmenorrhea may present itself under several different forms. With symptoms of active hyperemia, whether local or general. 2nd. With marks of uterine neuralgia, or other nervous symptoms. 3rd. The menses may flow immoderately. 4th. They may show themselves in other organs besides the uterus.

We think that Monsieur Jacqueinier has not done wisely to include the two last disorders of menstruation under the title of Dysmenorrhoea, Already this term is undefined enough, as pain in the performance of a function may represent various and very different pathological states. But it is adding unnecessarily to the confusion to include other disorders of menstruation which are not necessarily attended with local suffering, and have symptoms and morbid actions distinct from them and peculiar to themselves. Our author does not notice that mechanical form of dys

1847]

Jacquemier on the Disorders of Menstruation.

53

menorrhoea which Dr. Macintosh described, resulting from a congenital, narrowing of the os uteri or channel of the cervix, and which yields to the artificial dilatation of the stricture.

M. Jacquemier's description of the plethoric or congestive dysmenorrhea is imperfect. In it, the flow may be very trifling, notwithstanding the hæmorrhagic movement towards the womb. Sometimes it is entirely suppressed, and resembles the sthenic amenorrhoea of some authors. This form of dysmenorrhoea shows itself principally in the first years of menstruation, and among women who have had profuse periods. In the treatment of it M. Jacquemier says "if it be not intense, simple expedients, such as rest, diluents, cataplasms to the hypogastric region, &c. may suffice to dissipate it. But if it be more severe, it requires more active treatment, as baths and loss of blood. If the symptoms of congestion appear more particularly in the genital organs, leeches to the upper part of the thighs or vulva may be applied. If on the contrary general symptoms predominate, bleeding from the arm will do more good. M. Roche has often noticed that, in plethoric women, bleeding from the arm just before the period has speedily brought on the flow, which has gone on freely and without pain."

In the hysteralgic form of dysmenorrhea, our author describes with accuracy the varied symptoms which attend this trying affection. In speaking of the causes which predispose to it, he says that a life of forced celibacy in women of ardent temperament, susceptible of strong attachments, predisposes to it; and those who love a contemplative life, or those devoted to a monastic life, are subject to it. M. Pidoux has noticed a

peculiar character in this affection among the nuns. It consists in a disorder of the digestive organs, which is not attended with severe gastralgia, but with a torpor of the stomach, and a sensation of general sinking. This is accompanied with great weakness and mental inaction, against which these women, so strong in their will and courage, are constantly struggling.

We do not think M. Jacquemier very successful in his resources for the treatment of this disease. He talks generally of sedatives, as assafoetida, castor and opium, of diffusible stimuli, warm baths, and purgatives, &c. as means to relieve the pain during the period; and to prevent the return of the hysteralgia, we are directed during the intervals, to improve the general health, and to use antispasmodics, baths, cold affusion, friction, alkaline baths, &c. There is a want of precise direction in his therapeutics, which in a manual is a great defect. Students or young practitioners need something more than this sort of vague generality in the prescription of remedies, and it detracts from the usefulness of a work when accurate directions are lost in undefined plans of treatment.

The Second Book, which is divided into three Chapters, comprises several interesting physiological subjects, and includes one important practical subject-the Diagnosis of Pregnancy. The physiological subjects are on Fecundation, the Anatomical and Functional Changes consequent on Pregnancy, and Embryology. These are generally speaking well written for an elementary treatise, and M. Jacquemier has evidently worked at them himself, which unfortunately is by no means the rule with writers on midwifery. M. Jacquemier does not appear to be acquainted with