SUTURE OF THE EXPERIMENTALLY DIVIDED THORACIC AORTA

1169SUTURE OF THE EXPERIMENTALLY DIVIDED THORACIC AORTA.

Gjor’s estimate, which was published in 1866, shows thatthe consumptive’s expectation of life so far from beinglengthened under present conditions is actually shortened.Such a conclusion is a sad comment on the modern methods

of treating consumption, but it must be remembered that

Dr. Gjor’s and Dr. Ustvedt’s estimates were arrived at

by different methods of calculation, and that in Dr.

Ustvedt’s case, as already shown, an appreciable numberof consumptives were moribund when their disease was

notified. Within a year of notification 46’9 9 per cent. ofthe patients notified in 1901 were dead, but in 1910 this

percentage had fallen to 37’5, the difference being evidently.due to the earlier notification of patients. The proportion ofpatients without symptoms was fairly con stant from year toyear, and constituted 6 per cent. of all cases notified. For

the first eight years of compulsory notification the mortality,estimated in 1911, was over 60 per cent., but for the year1909 it had fallen to 49’ 3 per cent. Of the many compara-tive tables published in the report, one is of special interest,.as it shows in separate columns the fate of notified patientswho had or had not undergone a course of sanatorium

treatment. The expectation of life, it appears, is con-

siderably better for the consumptive who has resided ina sanatorium, but favourable though this report is to thesanatorium, it is not, as Dr. Ustvedt points out, altogetherfair, for advanced disease is often made a contra-indication

for sanatorium treatment. In the period 1906 to 1910

phthisis occurring between the ages 7 to 14 was classified ina separate table. There were 104 boys and 155 girls in thisclass, the incidence of phthisis at this age being therefore atthe rate of 1-41 per 1000 children of the same age. The

report also confirms the old observation that the incidence of

phthisis increases with the density of the population.

SUTURE OF THE EXPERIMENTALLY DIVIDED THORACIC AORTA.

MODERN surgery does not recognise any organ or tissue asbeing out of its scope. All the vital organs-the brain, theheart, the lungs-are subjected to surgical treatment withincreasing safety ; and if the inaccessibility of any region ofthe body is an apparent bar to the surgeon who desires toapply his methods of treatment to the cure of its diseases, hedevises a plan of approach by which vital organs and tissuesare disturbed as little as possible. Much of the recent

advance in the surgery of the larger blood-vessels has beensurveyed and pioneered by experiments on animals, and inthis respect we are particularly in the debt of the Americaninvestigators. 1 In the Annals of Surgery for SeptemberDr. W. M. Boothby describes the technique by which hehas been enabled to divide and subsequently suture

the intrathoracic aorta of the cat with some measure of

success. Six animals were operated on and two died, therest remaining in apparently undisturbed health after theoperation. In one of these latter animals the thoracic duct

was accidentally divided during the operation ; the fact thatthis was not fatal is ascribed by the author to the establish-ment of a collateral channel. The points of technique onwhich he lays special stress are the use cf intratrachealanaesthesia, at a low pressure, careful preparation of the

area of incision, the edges of which are guarded bywrapping them with thin sterilised silk throughout theoperation, an adequate incision extending from the sternumor costal ridge in front to the head of the rib behind, andthe utmost care in the necessary manipulations of the aorta.This is approached in its descending portion by a trans-

pleural route passing behind the left lung, and dividedbetween clamps, two above and one below the line of

1 THE LANCET, Oct. 19th, 1912, p. 1091.

division. There should be an interval of not less than

half an inch between the clamps in order to leave

room for the application of sutures ; on the other hand,

they should lie, if possible, between two neighbouringintercostal arteries, so that no branch springs from

that portion of the aorta which lies between the clamps.It is essential that the " stay " sutures passed into each endof the divided vessel be not dragged upon, lest the aorticwall be torn. When the clamps are removed the distal oneshould come off first, and both are relaxed very slowly. It

is startling at first sight to find that such a drastic procedurecan be carried out with fair prospect of success ; neverthelessit has been done, and perhaps before many years are past thesame method of approach may be applied to the treatment

of lesions of the descending thoracic aorta in man.

BIRTH AND DEATH REGISTRATION AT HOMEAND ABROAD.

AMONG students of vital statistics the conviction has

recently prevailed that the methods obtaining in England,as well as in some foreign countries, for the measure-ment of infantile mortality are unreliable, and the results inmany cases misleading. In view of the great and increasingimportance now attaching to this subject the RoyalStatistical Society has rendered a welcome service bypublishing the report of a Special Committee 1 of their

members on the system adopted in different countries for theregistration of births (including the stillborn) and of deathsin the first year of life. For the necessary investigation thesociety has been fortunate in securing the coöperation of

several distinguished statisticians whose official relationswith public health may be accepted as a guaranteeof their proficiency. Among these investigators we noticethe familiar names of Sir William C. DanbAr (lateRegistrar-General), Sir Shirley F. Murphy, Dr. ReginaldDudfield, and Dr. T. H. C. Stevenson. The terms

of reference to this committee were to the followingeffect-" To enquire into the systems adopted in different

countries for the registration of births (including stillbirths)and deaths, with reference to infantile mortality....,.."Letters of enquiry were sent to the registration authorities ofa large number of foreign countries, from about 100 of whichreplies have been received. The report itself has been

placed on sale and a copy of it should be secured by thoseof our readers who are specially interested in the subject,and this must be a large number. It has been drawn

up in four sections, as follows :-(1) History of Registra-tion ; (2) The Practice of Registration Generally; (3) Still-births ; and (4) Statistical Methods. Having regard to

the great value of the information received, the investi-

gators have thought it desirable to extend their survey tothe methods of calculating the general rates of mortality,although it was originally intended that the report should belimited to the methods of calculating infantile mortality.At the present time the principal function of vital statisticsis generally recognised as being the examination of the

causes of unnecessary and preventable wastage of humanlife. In the words of the report, "vital statistics may,in effect, be regarded as taking the place of laboratory ex-periment in social physiology and pathology." Accordingly,it is obvious that sound conclusions cannot be obtained

unless the basic data are trustworthy, and the methodsof calculation uniform, or at least comparable. From the

observations recorded, however, it is evident that these con-ditions only rarely obtain ; and that there is need of greateruniformity in the practice of calculating fertility and

1 Report of Special Committee on Infantile Mortality, RoyalStatistical Society, Adelphi-terrace, Strand, W.C. Pp. 61. Price ls.