PLACENTA PRÆVIA. By H. A. Sweetapple, M.D., B.S., L.R.C.P., &c., Adelaide. DOUBTLESS there are cases of placenta prævia producing abortion in the earlier months of pregnancy which have been unobserved, and cases in which the placenta is situated low enough in the uterus to produce slight hæmorrhage during uterine contractions of the first stage of labour, yet too high to be felt by the examining finger. The cases, however, which now concern us are those in which the placenta is implanted wholly or partially over the internal os uteri. The interesting case reported by Dr. Todd, and which I had the opportunity of observing, is in my experience far from common. Here, where I should have expected to find relaxation of cervix and os produced by the loss of blood, the condition was quite the reverse,; the lower uterine segment was one of the most unyielding I have met. This state of things also was little altered either by the action of chloral or chloroform. When, however, the os did seem to relax, many attempts were made to insert the forceps, but the rigidity would simply return, as though to mock one. At length the instruments were applied, and Dr. Todd carefully delivered. We both agreed that the labour should be terminated as speedily as possible, and I consider that the proper course adopted in applying the forceps in this case. Firstly, because, though the membranes were ruptured, and the placenta separated as far as possible, the patient was still in great danger from hæmorrhage, and it was impossible to bring down a foot. Secondly, because it appeared certain that the child was being asphyxiated. was I have notes of a few cases of placenta prævia which I have met with since being in practice, and which may be of interest. 1. Mrs. B., æt. 28, living about three miles out of Maidstone, Kent, engaged Dr. Plomley, whom I was assisting in that town, to attend in her third confinement. One morning, when about full term, a message came to go to the case. My principal asked me to attend. On my arrival at the house about an hour after the message came, I was told that the patient was dead. I found the woman lying on her back in a large pool of blood, and on examination found the foetus in utero, the os only large enough to feel that the placenta was partially covering the internal os, and the membranes unruptured. On inquiry from the old monthly nurse I learnt that a sudden hæmorrhage had occurred about 20 minutes before the patient collapsed. 2. Mrs. H., æt. 40, in the eighth month of her ninth pregnancy. This case I was called to one night when acting as locum in Dunmow, Essex. Considerable hæmorrhage had occurred, which caused much alarm. There was a history of slight hæmorrhages having occurred at intervals since the sixth month. On examination I found the os widely dilated, the liquor amnii evacuated, a partial placenta prævia, and the head presenting. Pains were infrequent and feeble, and hæmorrhage occurring with each pain, the uterus appearing very flabby. I at once applied a tight binder, gave ergot (Richardson's), and terminated labour by applying the forceps. 3. Mrs. B., at. 30.-This patient sent for me at the seventh month on account of slight hæmorrhages occurring every four or five days since the sixth month. I This was her fourth pregnancy. She had pains and hæmorrhage when I arrived. examined the os, but could not insert much more than the tip of the index finger. I then and there plugged the vagina with boiled cotton wool, and instructed the patient to rest in bed. Four or five hours afterwards I removed the plugs. The os was just large enough to feel a part of the placenta. I again plugged, and on removing these some hours afterwards was prepared to rupture the membranes and turn, but found the hæmorrhage entirely stopped and the os firmly closed. From this time the patient never had a return of the hæmorrhage until at full term, when there was a slight return which was stopped by rupture of the membranes, labour terminating shortly afterwards. The 4. Mrs. O'D, æt. 27 (her third pregnancy), sent for me at about the seventh month. patient was losing a great deal of blood per vaginam. On examination the os was found about the size of a crown and was completely blocked by the placenta. On rupturing the membranes the pains became strong; the placenta was partially forced through the os at each uterine contraction, and I had no difficulty, after giving the patient chloroform, in extracting the whole of the placenta. I was then able to bring down a foot, and the rest was easy. The uterus was washed out with 1 per cent. creolin lotion, and she made a very good recovery. In the four cases I have reported, the first would show how rapidly placenta prævia may prove fatal, and how needful for medical skill when hæmorrhage occurs. The second would remind us, as in Dr. Todd's case, that severe hæmorrhage may continue even though the membranes be ruptured. The third would show that plugging the vagina will sometimes stop the hæmorrhage and enable the pregnancy to go on to full term. The fourth, that extracting the placenta in cases of complete placenta prævia may sometimes be easier than perforating it with the fingers, as advocated by Rigby. (Read before the South Australian Branch of the THREE CASES OF MERALGIA PARÆSTHETICA. By George E. Rennie, M.D., M.R.C.P. (Lond.), Tutor in Medicine, University of Sydney, and Assistant Physician Prince Alfred Hospital, Sydney. IN 1895 Bernhardt published a paper in the Neurologisches Centralblatt detailing reports of several cases which presented a curious group of nerve symptoms, viz., disturbance of sensation on the front and outer aspects of the thigh, unaccompanied by any other signs either of central or peripheral nerve lesion. This condition was subsequently described by Roth, and named by him "Meralgia Paresthetica." Up to the present time not more than about 100 cases of this disease have been recorded, and, so far as I have been able to ascer tain, none of these have been reported by British authors. The disease has been chiefly studied by the American and Continental neurologists, and no case has, I believe, been previously recorded in Australia. CASE I. This case was referred to me by my friend, Dr. Blackwood, of Summer Hill, Sydney. A girl, æt. 19, single, was first seen by me in June, 1900. She complained then of a burning sensation on the outer aspect of the right thigh, with occasional slight swelling of the same leg. She also complained of a burning sensation over a small area about the size of the palm of the hand on the front of the lower third of the left thigh. Family History.-Her father died of phthisis 12 years ago; mother is healthy; one brother and one sister are healthy; her maternal grandmother suffered from rheumatism, but no others in the family. There is no history of gout, paralysis, fits, or any other nerve disease in the family. Personal History.-She was a healthy child from birth up till the age of three when years, she had an attack of chicken pox. She also had scarlet fever at the age of five years, and measles at six years. She has had no other illness. There has been no venereal disease or alcoholic excess; and no history of any accident, injury or strain. History of Present Illness.-About two or three years ago she first noticed some numbness on the outer aspect of the right thigh. This was not preceded by any pain in the back or down the thigh, and she made no complaint of this to anyone; but about 12 months before I saw her she complained to her mother of some pain and burning sensation down the thigh. The pain was so severe at that time that she was unable to get about, and she was considered to be suffering from hip disease. She was kept in bed for three weeks, and during that time all the pain practically disappeared, and she was able to get about and to go to dances, etc., without any discomfort, though she still had the numbness. She remained free from pain for 10 months, but the numbness persisted all the time. Recently she has noticed the numbness and burning sensation on the front of the left thigh. On examination I found the patient to be a She well-developed and well-nourished girl. presented no appearance of suffering; she had gained in weight, and her temperature was normal. On Nervous System.-She had no headache, and there was no sign of any disease or defect in any of the cranial nerves. Her intelligence was normal, and there were no signs at all suggestive of hysteria. The muscular power was good in all the limbs at all the joints. There was absolutely no pain or limitation of movement about either hip joints. There was no tenderness on percussion of the skull or spine. Sensation: The only objective disturbance of sensation was on the right thigh; there was distinct tenderness on pressure along the line of the external cutaneous nerve of the thigh. the anterior and lateral aspects of the right thigh there was of anæsthesia, analgesia, thermal anesthesia, and Faradic anæsthesia. This area corresponded generally with the cutaneous distribution of the posterior root of the third lumbar nerve. The transition from the area of sensation to that of anesthesia was sudden and well defined. There was no anæsthesia detected anywhere else. Over the area of the burning sensation on the front of the left thigh there was no objective disturbance of sensation or anæsthesia detected. an area The knee jerks were active, but not exaggerated; no ankle clonus; the plantar reflexes were flexor in type on both sides. She had no sphincter trouble, and there were no signs of trophic disturbance. The heart, lungs and abdominal viscera were normal; urine normal; menstruation quite regular. On examining this patient a few months later her condition was much the same, except that the area of anæsthesia had extended a little lower down the thigh, and the sensation of burning on the left thigh had disappeared. CASE II. A medical man, aged 50, consulted me about twelve months ago in consequence of a numb feeling in both thighs. He was very nervous about himself, as he thought he was in for locomotor ataxy. Family History.-Both parents died from cerebral apoplexy at the age of 90. There is no history of gout or rheumatism, and no nervous disease of any kind in the family. Personal History.-He has had good health all his life. He had an attack of gonorrhoea 25 years ago, but no syphilis. He has been in active practice for several years and has taken no holiday. He suffered heavy financial loss in 1893. Present Illness.--On January 1st, 1901, he was sitting for five hours continuously on a seat on one of the stands erected on the route of the Commonwealth procession in Sydney, but he says he felt no discomfort, and was not cramped in any way; but about a week afterwards he noticed a burning sensation down the left thigh, and on placing his hand on the spot he found it was anaesthetic to touch. He also noticed that there was distinct tenderness along the line of the external cutaneous nerve on the left side. About a month later he observed the same thing on the right side. Since then he has been much worried about himself, fearing the onset of serious spinal cord disease. On examination I found him to be a wellnourished and well-developed man, and found no evidence of disease in the lungs, heart or abdomen; the urine was normal. Nervous System.-There was no disease or affection of any of the cranial nerves; no affection of the cranium or spine; no loss of muscular power in any of his limbs at any of the joints. On testing his sensation I found no evidence of any disturbance in the head, arms On or trunk. But there was marked disturbance in the areas of distribution of the external cutaneous nerves on both sides. the left side at the upper and outer side of the upper half of the thigh tactile sensation was not lost, but only impaired; at the lower third of the outer side of the thigh there was complete anesthesia, and painful sensation much impaired. Heat and cold were only recognised as such after some delay. Faradic sensation was not recognised as an electric stimulation. On the right side, at the lower part of the outer and anterior part of the thigh, there was complete anesthesia, partial anal gesia, and much delayed sensation of heat and cold. Faradic stimulation was not recognised. In addition there was a burning sensation along the line of the nerves on both sides. There was no loss of muscular sense, and no Rombergism. The knee jerks were normal; no ankle clonus, and the plantar reflexes showed the normal flexor response. There was no sphincter affection, and no trophic disturbance or herpes. CASE 3.-The third case was that of a man aged 48 years, an engine-fitter by trade, but who had been engaged in laundry work for the past four years. He had extensive tubercular disease of the larynx and lungs, and was practically dying when I saw him. He complained of a feeling of numbness over the anterior and outer surface of the upper On examination I part of the right thigh. found that there was complete anæsthesia and analgesia over the area corresponding to the cutaneous distribution of the posterior root of the third lumbar nerve on the right side. this region there was also a subjective sensation of formication, but no evidence of any tenderness of nerve trunks. existence for some months. In This had been in He died shortly afterwards, and I had no further opportunity of examining him. 66 Remarks.-Sir William Gowers, in his "Manual of Diseases of the Nervous System," says: Impairment of sensation in an area on the front of the lower half of the thigh is occasionally met with as an isolated symptom, usually in men in the second half of life. It comes on without pain, and may pass away after months, or may persist for years. The loss is greatest in the middle of this region, but the transition to normal sensibility is well defined. Its origin and nature are mysterious, except that the subjects of it are usually gouty. It seems to have little significance.' Again, in speaking of anterior crural neuritis, he says: "Such an affection of the fibrous tissue may be limited to that related to a single nerve, or some other branch of the sacral or lumbar plexus may be the seat of a neuritis like that which underlies sciatica. The anterior crural or a branch suffers most frequently, with resulting symptoms on the front of the thigh or on the outer part. These are chiefly sensory; motor symptoms are seldom conspicuous in cases so limited in area. The outer part of the thigh in the upper two-thirds is a specially frequent seat of pain, and occasionally diminished sensibility. Anaesthesia in this region sometimes develops in a very chronic manner, without pain, as an isolated but curious and enduring symptom, usually stationary when discovered, and apparently the result of a limited neuritis It is pretty evident that Sir William Gowers is here describing cases similar to those I have recorded above, though he does not use the same name for them, and seems to incline to the view that the symptoms are due to a neuritis or gouty peri-neuritis of one of the branches of the anterior crural nerve, or of the lumbar or sacral plexus. I would emphasise the fact that though it is not a condition of serious import, yet in my first case the symptoms were severe enough to give rise to the supposition that the patient was the subject of hip disease, and she was treated accordingly for a short time; and in my second case the diagnosis of locomotor ataxy was suggested by the patient himself. Hence, I have thought it well to draw attention to this condition so that the error of mistaking it for serious organic nerve disease may be avoided. In the cases hitherto recorded the etiological factors assigned have been so various that it seems doubtful if there be any real connection between the supposed cause and the pathological condition present. Thus among the causes of this disease are placed the following:-Typhoid fever, influenza, syphilis, pregnancy, alcoholism, gout, exposure to cold, cold douches, the striking of the sword against the thigh in soldiers, etc. In many cases no cause can be assigned. In my first case no satisfactory cause could be elicited, but it is possible that as the girl was much given to dancing, and the nerve appears from a study of the area of disturbed sensation to be somewhat abnormal in distribution, the frequent irritation and compression of the nerve by the fascia of the thigh may have determined a chronic neuritis of the nerve. In the second case the patient was in a low state of health, and it appears probable that the external cutaneous nerves of both thighs were compressed by the fascia during the long occupancy of the seat in what must have been a more or less cramped position, and so a condition of pressure neuritis was set up, just as we get a musculospiral compression neuritis from long pressure on the nerve during sleep. These suggestions, however, involve two assumptions. First, that the nerve can be compressed by the fascia of the thigh to such an extent as to cause either actual neuritis or some pathological change in the nerve sufficiently severe to impair its function. Second, that the dissociation of sensations and paræsthesia, which may persist for months or years, may be caused by a lesion of the nerve trunks, which, however, is not accompanied by any trophic change in the skin, or the development of any herpetic eruption; but which is, nevertheless, severe enough to produce complete tactile anæsthesia. The pathological evidence available to throw any light on the condition is very scanty. One case has come to autopsy. It was that of a man, 80 years of age, who had been under the observation of Navratski. A spindle form swelling was found in each external cutaneous nerve at the place where it crosses over the crest of the ilium, and in the region of the swelling there were the changes characteristic of neuritis and peri-neuritis, with secondary degeneration of nerve fibres. In other cases, however, in which resection of the nerve has been performed as a therapeutic measure, careful examination of the excised fragment of nerve has failed to reveal any abnormality whatsoever. As regards treatment, it seems that absolute rest is essential for the relief of the pain. In cases where this is not possible resection of the nerve may be performed with a reasonable hope of cure. No drug treatment is of any material service, beyond improving the general state of nutrition of the system. [Read before the New South Wales Branch British Medical Association.] Lupus Erythematosus.-The two most common forms in which this disease occurs are the erythematosus and sebaceous varieties. Of these the former is the more difficult to deal with, and a long time is required for treatment. It is questionable even then whether improvement results. The sebaceous form rapidly responds to treatment. As a rule 20 to 30 sittings suffice. Occasionally a reaction occurs producing inflammation of the part under treatment. If due care be not exercised this might even produce alarming effects. I do not consider it essential that any reaction should be produced to effect a cure, for of nine cases of lupus which I have treated thus, five have not suffered any reaction whatsoever. |