Spinal accessory nerve injury: eight cases and review of the literature.

The spinal accessory nerve (SAN) is the major motor supply to the trapezius and sternocleidomastoid muscles. The superficial course of the SAN in the posterior cervical triangle makes it vulnerable to injuries. The most common reason is an iatrogenic injury during surgery but other causes such as stretch or traction injury have also been reported. Five iatrogenic SAN injuries were occurred after radical neck dissection (RND) for laryngeal carcinoma in two patients, lymphadenectomy for oral mucosal tumor in one patient, surgery for lipoma in one patient, and lymph node biopsy for tuberculosis in one patient, traumatic SAN injuries were occurred after the carrying and lifting in three patients. Our eight patients were followed conservatively and 6 of them had significant improvement of pain and function of the shoulder. However, the remaining two patients with radical neck dissection showed moderate improvement in both pain and function including shoulder range of motion and activities of daily living. We report the eight cases with SAN injury that had admitted to our outpatient clinic in the last one year with neck, back and shoulder pain as well as limitation in the shoulder range of motion and difficulty in the activities of daily living.

Diagnosis of carcinoma cervix uteri.

Carcinoma cervix should ideally be diagnosed in the pre-invasive or micro-invasive stage, or even earlier in the stage of cervical intra-epithelial neoplasia (CIN) by mass screening. As this has not been possible in our country awareness should be created amongst general population and practitioners about the urgent necessity of reporting to a proper clinic as soon as possible after appearance of early symptoms. Downstaging of the cancer should also be performed utilising nurses and paramedical health workers. Early diagnosis would give the best possible results of treatment.

Maternal mortality in a district hospital in West Bengal.

PIP: To ascertain the causes of high maternal mortality in West Bengal, the author examined maternal mortality between 1964-68. It was intended that measures to improve the situation in rural areas could be suggested. Women in labor often arrive at the hospital very late and few antenatal care facilities are available in rural areas. High risk cases often are delivered at home, a situation which often results in fetal complications. Maternal deaths have declined, but not dramatically. Of the 24,265 deliveries at the Burdwan district hospital, there were 333 maternal deaths for an incidence of 13.7/1000, along with another 42 cases where death was due to pregnancy-associated causes. In contrast, the maternal mortality rate in a district hospital in Calcutta was 4/1000 in 1968. Eclampsia accounted for 42.34% (141) of maternal deaths making it the major cause of death. In Calcutta this cause of death is receding gradually but in the districts it still accounts for a heavy loss of life (an incidence of 1 in 38). Adequate antenatal care would reduce this high mortality. 2 factors which have contributed to the high mortality are the hours lost in transporting a patient from a rural area and inadequate hospital staff. Postpartum hemorrhage and/or retained placenta was responsible for 39 deaths and none of the cases admitted from outside had received antenatal care. A shortage of blood was also a contributory factor. Severe anemia was responsible for 34 deaths and abortions resulted in another 29 deaths (16 because of severe sepsis; 13 due to hemorrhage or shock). An emergency service would help reduce the number of deaths but at present such a service does not even exist in the urban areas. Ruptured uterus resulted in 29 deaths and obstructed labor in 27 deaths. Placenta previa brought about 14 deaths and the remaining 20 deaths were due to such causes as accidental hemorrhage (10), hydatidiform mole (4), puerperal sepsis (3), ectopic pregnancy (2), and uterine inversion (1). Timely admission would have helped most of these cases. In summation, the preventive measures which would help to lower maternal mortality are: 1) mass education about the need for antenatal care, 2) provision of good obstetrical service, 3) provision of quick transport, 4) adequate staffing of hospitals, 5) refresher courses for medical personnel, and 6) 24 hour blood transfusion service.^ieng

Infertility and amenorrhoea following abortions.

PIP: Of 410 cases of spontaneous or induced abortion in the first or second trimester that were followed up, 95 were infertile. 18 of these had amenorrhea and 12 had oligomenorrhea. Amenorrhea and oligorrhea were more prevalent among the women who were over 31. Amenorrhea, oligomenorrhea, and infertility were more frequent after spontaneous than after induced abortion. Asymptomatic tubal block resulting from reflux of blood from the uterus into the fallopian tube after spontaneous abortion could have been responsible in a number of other cases. Definite causal link with abortion could not be established in any of the other cases of infertility without amenorrhea or oligorrhea. Amenorrhea following abortion was most often due to an endocrinal or mechanical defect (often uterine synechiae). Partial pituitary necrosis, premature ovarian failure, and endometrial tuberculosis were other postabortal causes of amenorrhea and oligomenorrhea.^ieng