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THE RISKS OF BREECH DELIVERY
790 THE RISKS OF BREECH DELIVERY
DURING the years 1913 to 1934 inclusive 30,655 were delivered on the house service of the Boston Lying-in Hospital, Massachusetts, and of these 1219 were delivered, through the pelvis, of 1242 infants by the primary breech mechanism. Dr. Thomas R. Goethals has used this extensive material for an inquiry into the risk to the infant in breech delivery, which, it will be observed, occurred in a fraction under 4 per cent. of all patients. Of the 1242 infants thus delivered 922, or 74-3 per cent., left the hospital alive, 13-1 per cent. were stillborn, and 12’6 per cent. died in the neonatal period. Comparable percentages for all deliveries over 1924-34 were 6-2 stillbirths and 2.2 neonatal deaths, and this shows the big increase in risk to which the infant is exposed by the circumstance of breech delivery. A part of this high mortality is due to the fact that in over a fifth of the breech deliveries either the pregnancy was pathological-with such complications as pre-eclamptic toxaemia, eclampsia, nephritis, syphilis, or diabetes-or labour was complicated by such conditions as placenta prsevia, ablatio placent2e, or prolapse of the cord. The total mortality (stillbirths plus neonatal deaths) was in these cases as high as 52 per cent. compared with 18-5 per cent. in the uncomplicated breech deliveries. It might be argued that the risk of breech delivery per se should be assessed only from cases in which labour is uncomplicated, but it should be borne in mind that this series shows the incidence of placenta praevia, ablatio placentae, and prolapse of the cord to be respectively three, five, and five times as frequently associated with breech presentation as with all types of delivery. When from the uncomplicated breech deliveries those cases are excluded which resulted in the birth of macerated and grossly malformed infants and the remainder are taken as a standard for uncomplicated breech delivery, the total mortality was 13-6 per cent., this figure being derived from a rate of 53-6 per cent. for the premature, 10 per cent. for the immature, and 6’9 per cent. for mature infants. This last figure of 6-9 per cent.based upon 691 deliveries-Goethals takes to represent " the risk to the living, undeformed, full term infant in utero who is destined to be born by pelvic breech delivery in the absence of pathological pregnancy on the part of the mother, and of hemorrhagia and other accidents of labor due to abnormalities of the placenta or of the umbilical cord." Prematurity was relatively common and contributed considerably to the mortality. Goethals takes the birth weight to the best standard and classifies an infant weighing less than 5 pounds at birth as premature, one weighing between 5 and 6 pounds as
patients
and
or to intercurrent causes rather than to an increased risk from mechanical causes. Dr. Goethals can take satisfaction in concluding his statistical survey from the fact that in this series the mortality-rate among mature infants born by breech delivery has declined very substantially His figures are set out over the years of his review. clearly and fully and should prove helpful both in themselves and as a standard for comparison.
immature, pounds mature. weighing In this classification approximately 20 per cent. of the breech deliveries were of premature infants, a figure which is more than three times as high as the 6 per cent. incidence of prematurity in the hospital deliveries at large. In mortality the breech deliveries did not differ from the general series until a weight of about 3 pounds is reached, but above that weight the breech deliveries suffer a substantially higher over
one
6
as
death-rate. In the breech-delivered the mortality is lowest with infants of 7t-8 pounds birth weight, and rises steeply on either side to 100 per cent. for infants of under 2 pounds, and to 33 per cent. for those over 10 pounds, the mortality of the latter being frequently due to maceration, malformation, 1 Surg., Gyn.,
and
Obst., March, 1936, p. 525.
JHIN JHINIA
THE Indian Medical Gazette for February publishes account of a new disease which appeared last Christmas in Calcutta. There was one constant symptom-namely, a tingling sensation in the sole of one or both feet, usually in the big toe. This symptom-jhin-jhin in Bengali means tinglinggave the disease its name. Other symptoms were a feeling of pressure in the head with or without a
"
lively
headache and
a
violent
trembling
"
of the whole
body.
The appearance of trembling was often delayed till treatment had been administered. According to local tradition, the disease was caused by a perverse tendency of the blood to desert the extremities and to fly to the head. The object of treatment was to reverse this process. The patient, male, or more often female, was accordingly tied to a post to prevent her lying down, and cold water was then poured over the head. Pneumonia was an occasionally fatal complication of the illness or, possibly, a sequela oftreatment. Other grave sequelee were meningitis, apoplexy, and fractured skull. The disease spread rapidly and seemed usually to attack persons in crowded places. Though it was sometimes mis-
diagnosed as encephalitis, meningitis, or Landry’s ascending paralysis, complete investigation of cases admitted to the large hospitals in Calcutta revealed no organic lesions. The condition is therefore almost certainly a neuromimesis probably the result of mass suggestion among an illiterate populace. Opportunist healers " were not slow to exploit the possibilities of the situation, and quack remedies and prophylactics found a ready sale. Local practitioners and health authorities are blamed, perhaps unfairly, for taking too serious a view of the " epidemic " in its early stages and the scare-mongering press for adding fuel "
to the fire. One peaceable citizen of Calcutta was seized by four men who accused him of having jhin.
jhinia, wallet
heavy
soused him under a tap and departed with his containing a hundred rupees. It seems a price to pay for advice unsought.
FILARIAL MIGRATION IN THE
AT
a
MOSQUITO laboratory meeting of the Royal Society of
Tropical Medicine and Hygiene held at the Royal Army Medical College, Millbank, on March 19th, there was set out a series of microscope slides and photomicrographs prepared by Prof. F. W. O’Connor and Mr. Harry Beatty in the laboratory of Dr. James Knott, chief medical officer in the Virgin Islands. They illustrated what is believed to be a new observation regarding the behaviour of the larvae of Wuchereria bancrofti in the mosquito Culex fatigans. It has been held hitherto that these larvae force their way through the wall of the posterior, or saccular, part of the mid-gut (usually called the stomach) which lies in the abdomen of the mosquito, and that from there they make their way forward to the thoracio muscles where they undergo that development which is necessary before they again become infective for man. In these new investigations this was the
DURING the years 1913 to 1934 inclusive 30,655 were delivered on the house service of the Boston Lying-in Hospital, Massachusetts, and of these 1219 were delivered, through the pelvis, of 1242 infants by the primary breech mechanism. Dr. Thomas R. Goethals has used this extensive material for an inquiry into the risk to the infant in breech delivery, which, it will be observed, occurred in a fraction under 4 per cent. of all patients. Of the 1242 infants thus delivered 922, or 74-3 per cent., left the hospital alive, 13-1 per cent. were stillborn, and 12’6 per cent. died in the neonatal period. Comparable percentages for all deliveries over 1924-34 were 6-2 stillbirths and 2.2 neonatal deaths, and this shows the big increase in risk to which the infant is exposed by the circumstance of breech delivery. A part of this high mortality is due to the fact that in over a fifth of the breech deliveries either the pregnancy was pathological-with such complications as pre-eclamptic toxaemia, eclampsia, nephritis, syphilis, or diabetes-or labour was complicated by such conditions as placenta prsevia, ablatio placent2e, or prolapse of the cord. The total mortality (stillbirths plus neonatal deaths) was in these cases as high as 52 per cent. compared with 18-5 per cent. in the uncomplicated breech deliveries. It might be argued that the risk of breech delivery per se should be assessed only from cases in which labour is uncomplicated, but it should be borne in mind that this series shows the incidence of placenta praevia, ablatio placentae, and prolapse of the cord to be respectively three, five, and five times as frequently associated with breech presentation as with all types of delivery. When from the uncomplicated breech deliveries those cases are excluded which resulted in the birth of macerated and grossly malformed infants and the remainder are taken as a standard for uncomplicated breech delivery, the total mortality was 13-6 per cent., this figure being derived from a rate of 53-6 per cent. for the premature, 10 per cent. for the immature, and 6’9 per cent. for mature infants. This last figure of 6-9 per cent.based upon 691 deliveries-Goethals takes to represent " the risk to the living, undeformed, full term infant in utero who is destined to be born by pelvic breech delivery in the absence of pathological pregnancy on the part of the mother, and of hemorrhagia and other accidents of labor due to abnormalities of the placenta or of the umbilical cord." Prematurity was relatively common and contributed considerably to the mortality. Goethals takes the birth weight to the best standard and classifies an infant weighing less than 5 pounds at birth as premature, one weighing between 5 and 6 pounds as
patients
and
or to intercurrent causes rather than to an increased risk from mechanical causes. Dr. Goethals can take satisfaction in concluding his statistical survey from the fact that in this series the mortality-rate among mature infants born by breech delivery has declined very substantially His figures are set out over the years of his review. clearly and fully and should prove helpful both in themselves and as a standard for comparison.
immature, pounds mature. weighing In this classification approximately 20 per cent. of the breech deliveries were of premature infants, a figure which is more than three times as high as the 6 per cent. incidence of prematurity in the hospital deliveries at large. In mortality the breech deliveries did not differ from the general series until a weight of about 3 pounds is reached, but above that weight the breech deliveries suffer a substantially higher over
one
6
as
death-rate. In the breech-delivered the mortality is lowest with infants of 7t-8 pounds birth weight, and rises steeply on either side to 100 per cent. for infants of under 2 pounds, and to 33 per cent. for those over 10 pounds, the mortality of the latter being frequently due to maceration, malformation, 1 Surg., Gyn.,
and
Obst., March, 1936, p. 525.
JHIN JHINIA
THE Indian Medical Gazette for February publishes account of a new disease which appeared last Christmas in Calcutta. There was one constant symptom-namely, a tingling sensation in the sole of one or both feet, usually in the big toe. This symptom-jhin-jhin in Bengali means tinglinggave the disease its name. Other symptoms were a feeling of pressure in the head with or without a
"
lively
headache and
a
violent
trembling
"
of the whole
body.
The appearance of trembling was often delayed till treatment had been administered. According to local tradition, the disease was caused by a perverse tendency of the blood to desert the extremities and to fly to the head. The object of treatment was to reverse this process. The patient, male, or more often female, was accordingly tied to a post to prevent her lying down, and cold water was then poured over the head. Pneumonia was an occasionally fatal complication of the illness or, possibly, a sequela oftreatment. Other grave sequelee were meningitis, apoplexy, and fractured skull. The disease spread rapidly and seemed usually to attack persons in crowded places. Though it was sometimes mis-
diagnosed as encephalitis, meningitis, or Landry’s ascending paralysis, complete investigation of cases admitted to the large hospitals in Calcutta revealed no organic lesions. The condition is therefore almost certainly a neuromimesis probably the result of mass suggestion among an illiterate populace. Opportunist healers " were not slow to exploit the possibilities of the situation, and quack remedies and prophylactics found a ready sale. Local practitioners and health authorities are blamed, perhaps unfairly, for taking too serious a view of the " epidemic " in its early stages and the scare-mongering press for adding fuel "
to the fire. One peaceable citizen of Calcutta was seized by four men who accused him of having jhin.
jhinia, wallet
heavy
soused him under a tap and departed with his containing a hundred rupees. It seems a price to pay for advice unsought.
FILARIAL MIGRATION IN THE
AT
a
MOSQUITO laboratory meeting of the Royal Society of
Tropical Medicine and Hygiene held at the Royal Army Medical College, Millbank, on March 19th, there was set out a series of microscope slides and photomicrographs prepared by Prof. F. W. O’Connor and Mr. Harry Beatty in the laboratory of Dr. James Knott, chief medical officer in the Virgin Islands. They illustrated what is believed to be a new observation regarding the behaviour of the larvae of Wuchereria bancrofti in the mosquito Culex fatigans. It has been held hitherto that these larvae force their way through the wall of the posterior, or saccular, part of the mid-gut (usually called the stomach) which lies in the abdomen of the mosquito, and that from there they make their way forward to the thoracio muscles where they undergo that development which is necessary before they again become infective for man. In these new investigations this was the