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ACUTE TORSION OF THE SPLEEN.
944 outside Bombay and brought hack to the city after birth, In the year referred to 8636 such children were primarily vaccinated ; in addition to these a large number must have escaped vaccination either by postponement for medical reasons or by death. Calculated in this manner, the birth-rate of Bombay is 32-4 per 1000 of the population against 38-4 per 1000 for the whole of India. The infant mortality, corrected thus, appears to be equal to a rate of 286 per 1000 births, or 58 per 1000 more than the average rate for India generally. Although both these rates are excessive their difference is not surprising, seeing that the higher rate is experienced in a large city. At any rate, it is not greater than the difference between urban and rural rates which obtains in many other countries. In an interesting table the death-rates are shown in monthly periods of the first year of life. Out of 20,166 children whose births were registered during the year 3078 died before reaching the age of one month, 2807 died between the ages of one and six months, and 3192 others between the ages of seven and twelve months. The deaths of most of the infants within the first month after birth are stated to be due to "debility," by which term are meant want of vitality, premature birth, wilful neglect, and malpractice by ignorant midwives. Among children aged from one to six months the chief causes of death are respiratory diseases, which give the highest mortality of all, nervous diseases, and diarrhoea ; or, in other words, exposure and improper feeding. Among children from seven to 12 months old respiratory diseases are again the chief causes of death. Dr. Turner concludes his report with certain practical suggestions for the reduction of infant mortality, and the improvement of the health and physique of the survivors, as well as for the prevention of mortality among puerperal women, not fewer than 360 of whom died last year from diseases consequent on parturition. Briefly stated, the remedies he suggests are the following : (a) the establishment of additional lying-in hospitals and the provision of more nurses for the poor before and after confinement ; (b) the training and licensing of native women as midwives, and the prohibition of midwifery practice by other than licensed persons ; and (e) the establishment of municipal dep6ts where poor women can In pressing these recomobtain pure milk at a small cost. mendations on his sanitary authority Dr. Turner assures them that similar measures are already in force in most cities of Europe and America, where the State acknowledges its duty towards the people. At the present time 74 per cent. of the total births are attended by untrained women. There are in Bombay three hospitals for lying-in women, at which 2220 women were delivered last year; two of these hospitals are Government institutions, and the third is a Parsi institution established by Dr. T. B. Nariman. Dr. Turner speaks of the latter as "a splendid example of progressive sanitation which has ameliorated the lot of hundreds of mothers and children."
wrought out in a decade, and not till the two magnificent edifices-the ’Monument"and the’’ Chamber "-will, on their completion, so accentuate the contrast between he new and the old, between the modern structures and bhe mediaeval rookeries abutting on them, as to quicken the sense of civic shame, may we expect the work of demolition to be carried out and that of reconstruction to be fairly begun. It is certainly something of a reproach to United Italy that her capital should witness the erection of one or more palatial hotels every year, and leave its poorer quarters in the squalor they have inherited from the Middle Ages-to evoke the comments, not always amiable, of the foreign visitor for whose accommodation these hotels are reared and managed. With the substitution of sanitary dwelling-houses for the high-tiered hovels now exposed to view some chance will be given to their tenants of that moral rehabilitation so pointedly indicated. The ’’ tessuti necrotizzati " (necrosed tissues) of the lower strata of Roman life (to use the language of the hygienic reformer) will slough away and give place to sounder, healthier structure under improved conditions of living-the first, if not the most important, of these being the housing of the family, with room enough for the individual as for the whole, securing observance of the decencies, and providing for the comfort, which are the most effective antidote to the attractions of theosterie"(public-houses), of which in Rome, as elsewhere, there are far more than enough. INFANT MORTALITY IN BOMBAY.
WE have received from Dr. J. A. Turner, the executive health officer of Bombay, a report on the high infant mortality in that city during the year 1908, together with a summary of his recommendations to his sanitary authority for its reduction. The report, which is systematically arranged and tersely written, conveys precisely the kind of information needed by the Bombay sanitary authority in order to deal effectually with the excessive waste of infant life that still continues to prevail in their midst. Taking into account the imperfect character of the statistical information at his disposal, Dr. Turner’s report certainly compares very favourably with the majority of similar reports that have been hitherto published in our own country. At the outset the writer warns his readers that in consequence of the incompleteness of birth registration it is impossible to guarantee the accuracy of the returns of infant mortality in Bombay. As a matter of fact, the births of many of the infants dying below the age of one year have never been registered. Familiar with the methods used by the Registrar-General for the correction of crude deathrates in England Dr. Turner has adapted them, as far as practicable, to the widely different conditions obtaining in his own city. Among the factors affecting the Indian birthrate he refers particularly to the changing age constitution of the married female population, and especially to that of the native women within the conceptive period of life. He also draws attention to the custom prevailing in Bombay ACUTE TORSION OF THE SPLEEN. for a pregnant woman to leave the city and to return ELSEWHERE in this issue we publish an account of a case after confinement, bringing with her a child two or three i which the pedicle of a malarious spleen underwent acut months old, whose birth has in this way escaped registra- in tion. With respect to the crude or uncorrected birth- torsion. The case was under the care of Dr. Ian rate Dr. Turner remarks that whilst in other countriesMacdonald and Dr. W. A. Mackay of Huelva, whom we conit affords, in conjunction with the death-rate, a readygratulate on the fact that complete recovery of the patient ffollowed removal of the spleen and dangerous complications. means of determining the natural increase of the population, this is not the case in India, because the local birth-rateTo the account itself we refer readers for a fuller description takes no account of the changing age constitution of the cof the case, and there they will find a valuable and c0.mpreliving in regard to age and sex or in regard to condition as 1hensive abstract of the chief literature of the subject. to marriage. In Dr. Turner’s opinion the nearest approachThe spleen rarely undergoes torsion, chiefly because it is rare to an accurate estimate of the birth-rate will be attained by ffor it to have a sufficiently long pedicle. The pedicle including all children of native mothers that are born of the spleen is formed by the gastrosplenic omentum, and ____
o
945 while this varies in length it is seldom very long. Sometimes the spleen is closely applied to the stomach so that hardly any pedicle exists, but occasionally the pedicle may measure some inches in length, so that the organ can occupy Commonly the very different positions in the abdomen. is between these the extremes, and it is pedicle length of to allow the spleen to be generally just sufficiently long brought forward beyond the margin of the ribs. In some cases a long pedicle may be congenital, while it also seems probable that the pedicle may be lengthened by the abdominal conditions, for the majority of cases occur in women, especially in those who have been pregnant. It will be noticed that in the case we report this week the patient, a paludic, was also a multipara.
the coroners for Birmingham and the county of Durham affords conclusive evidence of the undesirability of a decision that inquests in such cases are unnecessary. Except in the case of sudden deaths the absence of a medical certificate of the cause of death implies in most cases neglect to provide medical assistance during the last illness of the deceased, which neglect can only be duly investigated and checked by holding formal inquests on such cases.
ULCERATIVE PNEUMOCOCCIC PHARYNGITIS IN AN INFANT.
ATTENTION has only recently been called to the fact that the pneumococcus is a not uncommon cause of inflammations of the throat. At a meeting of the Societe Medicale des Hopitaux of Paris on July 23rd M. Menetrier and M. R. Mallet pointed out that among the infections of the main CORONERS AND UNCERTIFIED CAUSES OF respiratory passages of young children capable of producing DEATH. dyspnoœa, and even asphyxia, and simulating diphtheria the They are most frequently SEVERAL of the coroners who have recently given evidence pneumococcic are frequent. before the Departmental Committee appointed to consider catarrhal, but may be membranous or suppurative, and very the law relating to coroners and to coroners’ inquests have rarely are necrotic or ulcerative, as in the following case. A expressed the opinion that a large number of unnecessary male infant, aged 13 months, was admitted into the Tenon inquests are held. Mr. Isaac Bradley, coroner for the city Hospital on May 2nd, 1909. He had been in good health of Birmingham, and Mr. John Graham, one of the coroners until the previous evening, when fever and dyspncea sudfor the county of Durham, specially claimed credit for denly began. On the next day there was an abundant nasal having economised city and county rates by reducing the discharge and the respiration became more and more On the following day diphtheria was diagnosed number of inquests ; in the exercise of their statutory dis- difficult. On examination the child cretion they appear, in a considerable proportion of the and antitoxin was injected. was in a state of prostration, the face was asphyxial, cases reported to them, to have decided, after careful preliminary inquiry, that formal inquests were unnecessary. and there was an abundant muco-purulent nasal disMr. Graham, indeed, stated that in 936 cases reported to him charge with redness of the nostrils and swollen subduring 1907 within his district of the county of Durham he maxillary lymphatic glands. Respiration was rapid and only held 460 inquests, while in the remaining 476 cases heaccompanied by slight suprasternal retraction. The temperadecided that inquests were unnecessary. It is noteworthy, ture was 102 2° F. and examination of the lungs was negahowever, with reference to the action of these two coroners,bive. The tonsils and soft palate were red, and the posterior that coincidently with the reduction of inquests heldwall of the pharynx was covered with a whitish creamy within their respective districts the proportions of uncertifiedcoating which was easily detached with a swab, revealing a deaths have considerably increased. Mr. Graham, coronersuperficially ulcerated and slightly sanguineous surface. for the Chester ward of the county of Durham, stated in hisSmear preparations made from the exudation showed
evidence that he almost invariably inserts the cause of death,]numerous encapsulated diplococci. Cultures on serum and ascertained at the preliminary inquiry, on the form notifying )n agar did not yield colonies of the diphtheria bacillus, but that he considers it unnecessary to hold an inquest, andsypical cultures of the pneumococcus. Feeding was diffiunder these circumstances he expressed the opinion that :ult; liquids produced fits of coughing, which were accomthe cause of death should not be registered as un- 1)anied by the discharge of thick mucus from the nose and certified, Under the present conditions of registrationInouth. Lavage of the nose and throat with boiled water law, however, a coroner has no authority to certify the causevas performed, hot baths were given every three hours, and of a death unless he holds an inquest, in which case he is (;ollargol was rubbed into the chest. On the 6th the child bound to certify the finding of the jury. The suggestedvas worse ; the temperature was 102’ 5°, the respirareduction in the number of inquests without further ttion was more difficult, and scattered subcrepitant statutory provision for the due certification of the cause ofrales were heard in the lungs. The condition of the death, at any rate in all cases reported to the coroner, would throat remained the same, and there was no membrane undoubtedly have the effect of increasing the proportion of iere or in the nose. On the 8th the temperature rose to uncertified causes of death, and would thus depreciate the1.04°, and there was phlyctenular keratitis of the left eye. value of the death register, on which the Registrar-General’sBJlceration took place at the right nostril and at the left reports and statistics are based. There is, however, another a,ngle of the mouth. The child’s condition became proaspect of the increase of uncertified deaths that would g’ressively worse and death occurred on the 13th. At the inevitably result from a general decrease of inquests whichn.ecropsy the pharynx was found covered with a purulent does not appear to have been yet discussed before the greenish-yellow coating under which were ulcers. Some of Departmental Committee. The majority of the cases of the ulcers were small, of the size of a lentil, superficial, of uncertified causes of death are now in infants or young ’regular form, and separated by intervals of sound mucous children, and are due to the fact that no registered niembrane. Others, larger and deeper and sinuous, were medical practitioner had been in attendance during siituated on the lateral and posterior part of the naso-pharynx. the last illness of the deceased. Coroners who decide A.t the lower part of the pharynx the lesions were, on the that inquests in these cases are unnecessary appear ontrary, very small. The epiglottis, the orifice of the therefore to lose sight of the fact that this course of rynx, and the aryteno-epiglottic folds showed redness withaction fails to check the increase in the neglect of parents ctt any ulceration. The lymphatic glands in the neighbourto seek medical advice when their infants or young children ood of the pharynx were swollen, soft, and injected. The 11: almost become The ill. recent (now mgs showed irregularly scattered zones of congestion, and invariably insured) increase of uncertified deaths within the districts served by a1 the bases islets of consolidation from the small bronchi of
wrought out in a decade, and not till the two magnificent edifices-the ’Monument"and the’’ Chamber "-will, on their completion, so accentuate the contrast between he new and the old, between the modern structures and bhe mediaeval rookeries abutting on them, as to quicken the sense of civic shame, may we expect the work of demolition to be carried out and that of reconstruction to be fairly begun. It is certainly something of a reproach to United Italy that her capital should witness the erection of one or more palatial hotels every year, and leave its poorer quarters in the squalor they have inherited from the Middle Ages-to evoke the comments, not always amiable, of the foreign visitor for whose accommodation these hotels are reared and managed. With the substitution of sanitary dwelling-houses for the high-tiered hovels now exposed to view some chance will be given to their tenants of that moral rehabilitation so pointedly indicated. The ’’ tessuti necrotizzati " (necrosed tissues) of the lower strata of Roman life (to use the language of the hygienic reformer) will slough away and give place to sounder, healthier structure under improved conditions of living-the first, if not the most important, of these being the housing of the family, with room enough for the individual as for the whole, securing observance of the decencies, and providing for the comfort, which are the most effective antidote to the attractions of theosterie"(public-houses), of which in Rome, as elsewhere, there are far more than enough. INFANT MORTALITY IN BOMBAY.
WE have received from Dr. J. A. Turner, the executive health officer of Bombay, a report on the high infant mortality in that city during the year 1908, together with a summary of his recommendations to his sanitary authority for its reduction. The report, which is systematically arranged and tersely written, conveys precisely the kind of information needed by the Bombay sanitary authority in order to deal effectually with the excessive waste of infant life that still continues to prevail in their midst. Taking into account the imperfect character of the statistical information at his disposal, Dr. Turner’s report certainly compares very favourably with the majority of similar reports that have been hitherto published in our own country. At the outset the writer warns his readers that in consequence of the incompleteness of birth registration it is impossible to guarantee the accuracy of the returns of infant mortality in Bombay. As a matter of fact, the births of many of the infants dying below the age of one year have never been registered. Familiar with the methods used by the Registrar-General for the correction of crude deathrates in England Dr. Turner has adapted them, as far as practicable, to the widely different conditions obtaining in his own city. Among the factors affecting the Indian birthrate he refers particularly to the changing age constitution of the married female population, and especially to that of the native women within the conceptive period of life. He also draws attention to the custom prevailing in Bombay ACUTE TORSION OF THE SPLEEN. for a pregnant woman to leave the city and to return ELSEWHERE in this issue we publish an account of a case after confinement, bringing with her a child two or three i which the pedicle of a malarious spleen underwent acut months old, whose birth has in this way escaped registra- in tion. With respect to the crude or uncorrected birth- torsion. The case was under the care of Dr. Ian rate Dr. Turner remarks that whilst in other countriesMacdonald and Dr. W. A. Mackay of Huelva, whom we conit affords, in conjunction with the death-rate, a readygratulate on the fact that complete recovery of the patient ffollowed removal of the spleen and dangerous complications. means of determining the natural increase of the population, this is not the case in India, because the local birth-rateTo the account itself we refer readers for a fuller description takes no account of the changing age constitution of the cof the case, and there they will find a valuable and c0.mpreliving in regard to age and sex or in regard to condition as 1hensive abstract of the chief literature of the subject. to marriage. In Dr. Turner’s opinion the nearest approachThe spleen rarely undergoes torsion, chiefly because it is rare to an accurate estimate of the birth-rate will be attained by ffor it to have a sufficiently long pedicle. The pedicle including all children of native mothers that are born of the spleen is formed by the gastrosplenic omentum, and ____
o
945 while this varies in length it is seldom very long. Sometimes the spleen is closely applied to the stomach so that hardly any pedicle exists, but occasionally the pedicle may measure some inches in length, so that the organ can occupy Commonly the very different positions in the abdomen. is between these the extremes, and it is pedicle length of to allow the spleen to be generally just sufficiently long brought forward beyond the margin of the ribs. In some cases a long pedicle may be congenital, while it also seems probable that the pedicle may be lengthened by the abdominal conditions, for the majority of cases occur in women, especially in those who have been pregnant. It will be noticed that in the case we report this week the patient, a paludic, was also a multipara.
the coroners for Birmingham and the county of Durham affords conclusive evidence of the undesirability of a decision that inquests in such cases are unnecessary. Except in the case of sudden deaths the absence of a medical certificate of the cause of death implies in most cases neglect to provide medical assistance during the last illness of the deceased, which neglect can only be duly investigated and checked by holding formal inquests on such cases.
ULCERATIVE PNEUMOCOCCIC PHARYNGITIS IN AN INFANT.
ATTENTION has only recently been called to the fact that the pneumococcus is a not uncommon cause of inflammations of the throat. At a meeting of the Societe Medicale des Hopitaux of Paris on July 23rd M. Menetrier and M. R. Mallet pointed out that among the infections of the main CORONERS AND UNCERTIFIED CAUSES OF respiratory passages of young children capable of producing DEATH. dyspnoœa, and even asphyxia, and simulating diphtheria the They are most frequently SEVERAL of the coroners who have recently given evidence pneumococcic are frequent. before the Departmental Committee appointed to consider catarrhal, but may be membranous or suppurative, and very the law relating to coroners and to coroners’ inquests have rarely are necrotic or ulcerative, as in the following case. A expressed the opinion that a large number of unnecessary male infant, aged 13 months, was admitted into the Tenon inquests are held. Mr. Isaac Bradley, coroner for the city Hospital on May 2nd, 1909. He had been in good health of Birmingham, and Mr. John Graham, one of the coroners until the previous evening, when fever and dyspncea sudfor the county of Durham, specially claimed credit for denly began. On the next day there was an abundant nasal having economised city and county rates by reducing the discharge and the respiration became more and more On the following day diphtheria was diagnosed number of inquests ; in the exercise of their statutory dis- difficult. On examination the child cretion they appear, in a considerable proportion of the and antitoxin was injected. was in a state of prostration, the face was asphyxial, cases reported to them, to have decided, after careful preliminary inquiry, that formal inquests were unnecessary. and there was an abundant muco-purulent nasal disMr. Graham, indeed, stated that in 936 cases reported to him charge with redness of the nostrils and swollen subduring 1907 within his district of the county of Durham he maxillary lymphatic glands. Respiration was rapid and only held 460 inquests, while in the remaining 476 cases heaccompanied by slight suprasternal retraction. The temperadecided that inquests were unnecessary. It is noteworthy, ture was 102 2° F. and examination of the lungs was negahowever, with reference to the action of these two coroners,bive. The tonsils and soft palate were red, and the posterior that coincidently with the reduction of inquests heldwall of the pharynx was covered with a whitish creamy within their respective districts the proportions of uncertifiedcoating which was easily detached with a swab, revealing a deaths have considerably increased. Mr. Graham, coronersuperficially ulcerated and slightly sanguineous surface. for the Chester ward of the county of Durham, stated in hisSmear preparations made from the exudation showed
evidence that he almost invariably inserts the cause of death,]numerous encapsulated diplococci. Cultures on serum and ascertained at the preliminary inquiry, on the form notifying )n agar did not yield colonies of the diphtheria bacillus, but that he considers it unnecessary to hold an inquest, andsypical cultures of the pneumococcus. Feeding was diffiunder these circumstances he expressed the opinion that :ult; liquids produced fits of coughing, which were accomthe cause of death should not be registered as un- 1)anied by the discharge of thick mucus from the nose and certified, Under the present conditions of registrationInouth. Lavage of the nose and throat with boiled water law, however, a coroner has no authority to certify the causevas performed, hot baths were given every three hours, and of a death unless he holds an inquest, in which case he is (;ollargol was rubbed into the chest. On the 6th the child bound to certify the finding of the jury. The suggestedvas worse ; the temperature was 102’ 5°, the respirareduction in the number of inquests without further ttion was more difficult, and scattered subcrepitant statutory provision for the due certification of the cause ofrales were heard in the lungs. The condition of the death, at any rate in all cases reported to the coroner, would throat remained the same, and there was no membrane undoubtedly have the effect of increasing the proportion of iere or in the nose. On the 8th the temperature rose to uncertified causes of death, and would thus depreciate the1.04°, and there was phlyctenular keratitis of the left eye. value of the death register, on which the Registrar-General’sBJlceration took place at the right nostril and at the left reports and statistics are based. There is, however, another a,ngle of the mouth. The child’s condition became proaspect of the increase of uncertified deaths that would g’ressively worse and death occurred on the 13th. At the inevitably result from a general decrease of inquests whichn.ecropsy the pharynx was found covered with a purulent does not appear to have been yet discussed before the greenish-yellow coating under which were ulcers. Some of Departmental Committee. The majority of the cases of the ulcers were small, of the size of a lentil, superficial, of uncertified causes of death are now in infants or young ’regular form, and separated by intervals of sound mucous children, and are due to the fact that no registered niembrane. Others, larger and deeper and sinuous, were medical practitioner had been in attendance during siituated on the lateral and posterior part of the naso-pharynx. the last illness of the deceased. Coroners who decide A.t the lower part of the pharynx the lesions were, on the that inquests in these cases are unnecessary appear ontrary, very small. The epiglottis, the orifice of the therefore to lose sight of the fact that this course of rynx, and the aryteno-epiglottic folds showed redness withaction fails to check the increase in the neglect of parents ctt any ulceration. The lymphatic glands in the neighbourto seek medical advice when their infants or young children ood of the pharynx were swollen, soft, and injected. The 11: almost become The ill. recent (now mgs showed irregularly scattered zones of congestion, and invariably insured) increase of uncertified deaths within the districts served by a1 the bases islets of consolidation from the small bronchi of