546 THE BRITISH MEDICAL ASSOCIATION.

but the deaths could not be attributed to this method oftreatment. One was a case of ruptured uterus or a case

of extreme contraction of the pelvis in which the husbandrefused to allow any interference ; the second was a

fatal hemorrhage due to placenta proevia. The methodis also free from danger to the child. Ten children out of ahundred are born in a state called oligopna3, which is also

entirely free from danger. The mortality of children haseven decreased since the introduction of this method of treat-ment. Taking the last 500 cases treated with scopolamineI have had only to deplore the death of one child intra-partum, and three children died within the first three daysafter birth. To sum up this, scopolamine treatment is with-out danger to the mother or child, and attains the desiredend-namely, of completely suspending the perception ofpain during labour or at any rate of reducing it to a

minimum. "

Dr. R. C. BuiST (Dundee) read a paper onScopolamine Morphine Anaesthesia in Labour,

in the course of which he reported shortly a series of 65 casesobserved in hospital since the hypodermic injection ofhyoscine and morphine had been employed as a routinetreatment for the relief of pain in labour. Uterine contrac-tion was in the main unaffected and the patient was drowsybetween the contractions and sometimes during them. Hehad no evil results to record in his cases, the temporarymental confusion being of no importance. The methodwas especially useful in cases of slowly dilating os or

prolonged moulding of the head. In private practice he hadfound it of great advantage and used as an initial dose hyos-cine hydrobromide 0 ’ 00065 (gr. 1-100th), morphine sulphate0 ’ 016 (gr. -). The effects usually showed in about 15 minutesand diminished after about three to four hours, when therepetition of one or both drugs might be indicated. Hedid not use it if delivery was expected in less than one hour.Dr. Buist also mentioned some cases that had been treatedwith this method in addition to chloroform by Dr. H. M.Macnaughton-Jones. They were cases of serious abdominalsections-viz., three hysterectomies, two appendicectomieswith pelvic complications, 12 salpingo-oophorectomies, someprolonged vaginal operations, and two very extensive post-operative hernias. All the operations were prolonged andmany of the patients old. In most of the cases the nightbefore the operation from one-sixth to one-eighth of a grainof morphine and 1-100th of a grain of scopolamine hadbeen injected. On the following morning a similar injectionwas given, another half an hour before the operation 1-30thof a grain of strychnine and 1-100th of a grain of atropine.Chloroform was administered with a Vernon Harcourt’s regu-lator. The patients under the influence of scopolamine andmorphine need less chloroform to put and keep them under thanthose who were not. The after-effects of the anesthetic wereless severe and Dr. Macnaughton-Jones, who had been led touse this method after visiting Professor von Krönig’s clinicat Freiburg, thought it was especially useful in old and feeblepatients and where the operation was likely to be prolonged.The PRESIDENT of the section (Mr. RICHARD FAVELL,

Sheffield) thanked Professor Kronig very heartily for bring-ing such a valuable paper before the section.The draft report of the committee appointed last year at

Exeter to considerThe Best Means to be Taken to Promote the Earlier

-Recogn?,tioib of Uterine Ca2tcerwas then considered by the section.

Dr. F. J. MCCANN (London), as chairman of the com-mittee, said that he would like to make a few remarks.

Unfortunately, the committee was not successful in obtainingthe cooperation of the Central Midwives Board in drawing upthis report. The Central Midwives Board had already issueda circular, but this was not nearly such a good one as

that now before the section, and whereas the Central Mid-wives Board would only issue its circular to midwives in

England the committee appointed by the council of theBritish Medical Association wished its report sent to allmidwives in England, Scotland, Ireland, and Wales.

Dr. E. MALINS (Birmingham) in a few words praised themanner in which the report had been drawn up.

Dr. J. J. MACAN (Cheam) proposed, and Dr. H. ROBERTS(London) seconded, the following motion :-This section approves generally of the draft report of the committee

appointed for the early recognitfon of uterine cancer and requests thecouncil of the British Medical Association to re-appoint the committee.

This was carried unanimously.

Dr. BLAIR BELL (Liverpool) read a paper based uponA Case of -Der?2zoid Gyst of the Jejllnal11Iesentery.

The case had been under the care of Dr. J. B. Yeoman ofNeston and himself. The patient was a young marriedwoman, aged 24 years, who had suffered from distressingbackache for many years, for which she had beentreated by ten months’ rest in the dorsal position.On examination a tumour was found lying between theuterus and the bladder which proved at the operation to be a.dermoid cyst of the mesentery of the jejunum equal in sizeto a large orange. This was excised, aad although the bowellooked congested it was thought it would recover. Sub-

sequently the patient suffered a good deal from colic and.other abdominal symptoms, but eventually made an

apparently good recovery. A small fascal fistula had, how-ever formed, but as the discharge was very slight andoccasional it was confidently expected that she would soonbe quite well. In view of the experience of others-whichshowed a mortality of 40 per cent when excision of mesen-teric cysts was practised-the following methods of treat-ment were recommended. 1. If the cyst were very large,suture to the abdominal wound and drainage. 2. If small,an attempt at enucleation should be made, and failing this.the cyst should be excised together with the loop of bowelsurrounding it, for it was too unsafe to excise the cyst alone.

Dr. ALEXANDER DEMPSEY (Belfast) read a short paper onNotes of a Case of Missed Labour.

PUBLIC HEALTH AND FORENSIC MEDICINE.

FRIDAY, JULY 31ST.The meeting was presided over by one of the Vice-

Presidents of the section, Dr. EDMUND HARGREAVES.(Sheffield).

Dr. S. G. MOORE (Huddersfield) read a paper onThe Notification of Births in Relation to the Redzcction of

Infantile Mortality.He gave first of all a short history of the Huddersfield Actwhich preceded the general Act of last year and comparedthe sections dealing with early notification of births with

corresponding sections in the Births and Deaths RegistrationAct, 1874. He stated that in Huddersfield about one-third.of the notifications came from midwives, another third fromparents or relatives, and one-fifth from the medical men illiattendance. He considered that the opposition to the Act.was a grave mistake. Certain measures which the Act had,’rendered possible had been adopted in Huddersfield and he-considered that to those measures was very largely due the-lessening of infantile mortality in the town.

Dr. A. E. NAISH (Sheffield) read a paper onThe Sheffield Corporcct2,on’s Dried Milk Scheme,

in which he stated that in August, 1907, five depots were-opened in various parts of the city to which mothers couldbring their infants to be weighed and for advice about feeding’and management and in suitable cases dried milk was sup-plied at cost price. The depots were placed under the charge.of a medical man with the active cooperation of the ladyhealth inspectors who followed up the cases at the homes ofthe children. The supply of dried milk had given the-

inspectors a more friendly status in certain homes where theyhad on occasion been treated with suspicion, and wheremothers had been lazy or disinclined to carry out instructionxa threat of withholding supplies had been effectual. Thetotal number of babies who had attended the depots was445, and of these 35 had died, giving a mortality rate of 79per 1000 compared with 145 in the city of Sheffield. Dr.Naish very properly pointed out that too much importance-should not be attached to these figures, for although on theone hand many nearly dying babies were brought to thedepots, yet the high mortality of the first few weeks of life-was almost excluded from the dep6t statistics.

Dr. JOHN BROWN (Bacup) disapproved very strongly ofplacing the duty of notifying a birth upon the medicalattendant. It was not a question of payment but he

objected to the principle of compulsory notification. He-was quite in agreement with Dr. Naish that dried milkwas better than cow’s milk for infants. His experience wasthat the very poorest did not make use of milk depôts so’that statistics from those institutions were not of very great.value.

547THE BRITISH MEDICAL ASSOCIATION.

Dr. H. C. PATTIN (Norwich) spoke generally of the successof the Notification of Births Act and argued that it was ofvalue in that it enabled a knowledge to be obtained of thestate of nourishment of the mother. In Norwich they wereendeavouring to feed the ill-nourished mothers through theagency of charitable institutions, which took action uponnotification by the medical officer of health. He expresseda hope that one of the recommendations of the Royal Com-mission on the Poor Laws would be to coordinate the Poor-law medical work with the sanitary administration andmake it a part of the public health service. If this weredone the nourishment of necessitous mothers prior as

well as subsequent to the birth of their children wouldbecome much more systematised than at present was thecase.

Dr. J. C. McWALTER (Dublin) said that the Notification ofBirths Act had not been adopted in Dublin because thecorporation considered it would be useless to notify birthsunless they were in a position to give food to the infants orthe mothers and they had no power under the Irish Poor-lawsto give free supplies of milk. He considered that it was aserious matter for the State to take upon itself the burdenof rearing children and thus relieve parents of their respon-sibilities.

Mr. HERBERT JONES (Hereford) pointed out that there wasan obligation cast upon the medical attendant to notify abirth to the registrar under the Registration of Births andDeaths Act, 1874, and he considered that the opposition tothe Notification of Births Act by the medical professionought now to stop.

Dr. G. Emc C. PRITCHARD (London) strongly approved ofthe early notification of births and suggested that the work ofthe sanitary authorities might very well be supplemented byvoluntary workers. He deprecated the advocacy of anysubstitute for fresh milk. Dried milk might tide them over adifficulty but fresh milk should be introduced as rapidly aspossible.Lieutenant-Colonel A. M. DAVIES, R. A. M. C., stated that

he had found upon examining many brands of dried milkthat if made up according to the directions supplied the milkproduced would be markedly deficient in fat and therefore acomparatively innutritious food. A fluid was producedresembling milk of a poor quality.

Dr. J. H. TAYLOR (Salford) appealed to medical officers ofhealth not to force upon general practitioners the duty ofnotifying births. The latter were quite as anxious as theformer to do all they could for the sake of humanity, but theyconsidered that all the advantages of early notification couldbe obtained without imposing upon medical men a taskwhich they resented.

Dr. H. ScuRFmLD (Sheffield) considered that in connexionwith the opposition to the Notification of Births Act a sectionof the Association had lowered the profession in the eyes ofthe community. On the one hand they objected to

divulge a secret and on the other hand they were

willing to do so for a payment of half-a-crown. He

thought it was too much to expect that summer diar-rhcea would be stopped by the use of dried milk.

They were very careful in Sheffield not to substitutedried milk for mother’s milk, but they did not mind sub-stituting it for ordinary cow’s milk. The dried milk inSheffield had had a very severe trial because only a verysmall proportion of the babies fed on it were normal. The

drying of the milk appeared to render the casein more easilydigestible.

Dr. W. F. BROWN (Ayr) was strongly of opinion that therewould have been much less ill-feeling in connexion with theNotification of Births Act if the medical profession had beenconsulted as to the duty which it was proposed to cast uponthem.

Dr. PRITCHARD read a paper onThe State Regulation of the Manufacture and Sale of

Prop1’ietar1j Jlediciiies and Ji’oods,in which he pointed out that the sale of secret remedies hadincreased enormously of late years. Their names were verymisleading and there was no guarantee beyond the goodfaith of the manufacturer that the goods sold answered tcthe description given either as regards the quality or quantityof the ingredients. He considered that medical men hadbecome the unconscious agents of the manufacturers, foi

they had accepted without verification many of their mosiaudacious statements and had found it convenient to pandei

;0 the popular taste for new remedies by prescribing pro-xietary medicines and foods of unknown composition. Heisked for legislation against the uncontrolled manufactureind sale of proprietary medicines and foods, principallybecause it was impossible for the individual to protecthimself and it was extremely difficult for a medical mano offer advice on the subject. No other country in theworld allowed its citizens to be imposed upon by advertise-ments in the way that was permitted in this country. Inmost countries the manufacture and sale of such articles were

regulated and in some the advertisements were under police-supervision.

In the discussion which followed Dr. McWALTER and Dr.E. F. HANRAHAN (Dublin) took part. The latter drewattention to the fact that the advertisements of patentmedicines increased the habit of self-medication. Theintroduction of ready-made prescriptions, he considered,had resulted in the medical students of to-day learning verylittle materia medica and knowing nothing of pharmacy.The meeting of the section concluded with some interesting

comments by Dr. McWalter upon the Public Health Acts.Amendment Act, 1907.

ANATOMY.

WEDNESDAY. JULY 29TH.

At the conclusion of the discussion on the Teaching ofAnatomy, which we have already reported, ProfessorARTHUR KEITH (London) opened a discussion on

The 3feelianisni, of Respiration in Health and Disease.Professor Keith, who illustrated his remarks with ingenious.models and diagrams, said : In every department of medicalknowledge a period of stability and content is followed byone of unrest and dissatisfaction. At the present momentour knowledge of the mechanism of human respiration, aftera quiescent period of some 50 years-for it has changed verylittle since Hutchinson published his article in Todd’s

Encyclopaedia in 1852-seems to be entering a period oftransformation. The discovery and use of the x rays havehad a powerful influence in effecting this change, but anumber of factors have been really at work, not the least ofthese being Sherrington’s brilliant researches into the reflexcoordination of voluntary muscles. The present time, then,one in which the utility of respiratory exercises is beingmuch discussed in the lay and medical press, is most oppor-tune for taking stock of the opinions each one has re-formedof the mechanism of respiration as far as it relates to man inhealth and in disease. What we aim at, I believe, is not ageneral expression of belief, but a frank statement of personalobservation and personal conclusion, and I therefore proposeto introduce the subject briefly to you by recapitulating thevarious steps which led me to investigate the subject andre-formulate the opinions which I had previously held. Some14 years ago,t while investigating the anatomy of apes; Iwas struck with the fact that in the majority of that peculiaranthropoid, the gibbon, the joint between the manubriumand the rest of the sternum occurs at the level of the third

pair of costal cartilages-a variation which is occasionally tobe seen in man. To explain the anomaly I commenced aseries of observations on the movements and utility of this,joint in man, and found it was the site of a free movement,and that the manubrium sterni, the first pair of ribs, withSibson’s fascia, formed a physiological entity-a kind of lid ,

for the thorax. The thoracic lid is hinged behind to the firstdorsal vertebra ; its anterior end articulates with the body ofthe sternum, every elevation of the sternum being accom--panied by a movement at the sterno-manubrial joint inthose with a normal type of respiration. It was clearthat this joint was one, not of minor but of the very utmostimportance in the proper performance of the mechanism ofrespiration. In searching the literature connected with thispart of the body I encountered Freund’s 2 observations onthe malformation of the first pair of ribs, the prematureossification of their cartilages, and the frequent formation inthese circumstances of a false joint between the first rib andmanubrium. In his opinion these anomalies were congenitaland a common cause of apical phthisis. The meaning of

1 A Variation which occurs in the Manubrium Sterni of HigherPrimates, Journal of Anatomy and Physiology, vol. xxx., 1896.

2 Freund, W. A. : Der Zusammenhang gewisser Lungen Krank-heiten mit Primären Rippen Knorpelanomalien. Erlanger, 1859,pp. 127.