30

man-made. It is unfortunate that an infant who for somereason has to be bottle-fed, should be further penalisedby too strict a feeding schedule taking no account of hisindividual needs. In comparison with the automaticregulation of the intake of the breast-fed infant day byday and feed by feed, the precise instructions so ofteninsisted upon are too rigid. Wide variation of intake bynormal infants was demonstrated by Wallgren (1945),who concluded that there is no significant correlationbetween body-weight and breast-milk consumption at agiven age, and that at a given weight one baby may takenearly twice as much as another over a forty-eight-hourperiod of test-weighing. It seems probable that mostfeeding problems are recruited from the ranks of theseeccentric feeders when they are subjected to too rigida diet.

Aldrich and Hewitt (1947) used the term " offer "rather than " give," and allowed the baby to feed untilsatisfied. On this self-regulating system some infants tookand retained twice as much as before-a strong argumentfor greater flexibility on the lines suggested by Geselland Ilg (1937). Babies stop and refuse to suck when theyhave had enough( whether from breast or bottle ; but ifthey are still hungry when the bottle is empty, theircries of hunger are often attributed to wind, colic, oreven overfeeding. The statement of Naish (1948) thatcases of underfeeding in breast-fed babies are legionwhile those of overfeeding are very rare may have evenmore general application. Vomiting is often accompaniedby crying, insomnia, constipation, loss of weight, andincreased muscle tone. These symptoms were describedby Haas (1918) in hypertonia and these children are oftendiagnosed as such. Such symptoms do not seem todiffer very much from those of hunger ; indeed Nelson(1940), describing the hypertonic infant, states that " henever seems satisfied with his feed." Perhaps in somecases this dissatisfaction is the cause and not the resultof his hypertonia. Gordon (1948) has stated his beliefthat the hypertonic infant is on the increase owing to thepace of modern life. Might not this be due to rigid,so-called "scientific" feeding methods replacing thecommon sense and motherliness essential to satisfactoryinfant care ? ‘?

SUMMARY

A review of 46 cases of vomiting of uncertain originreferred to hospital suggests that in 16 of them thecause of vomiting was underfeeding.

In 10 of these 16 cases underfeeding had not beensuspected during the infant’s stay in hospital.

It is suggested that underfeeding may be even morecommon outside hospital practice.A plea is made for more flexibility in feeding schedules

for artificially fed infants.I am very grateful for the help given to me by Prof. J. M.

Smellie and the consultants at the Children’s Hospital,Birmingham, and for permission to examine cases under theircare. I am indebted to Mr. J. Gregory Williamson, A.I.B.p.,and Miss B. Field for the photographic work. Finally Iwant to thank the sisters and nurses in charge of the variouswards for their cooperation and helpful criticism, and themothers of the infants studied, many of whom kept carefulrecords.

REFERENCES

Aldrich, C. A., Hewitt, E. S. (1947) J. Amer. Med. Ass., 135, 340.Brown, A. (1948) Lancet, ii, 877.Cameron, H. C. (1925) Brit. med. J. i, 765.Gesell, A., Ilg, F. L. (1937) Feeding Behavior of Infants.

Philadelphia and London.Gordon, D. A. (1948) Arch. Pediat. 65, 70.Haas, S. V. (1918) Amer. J. Dis. Child. 15, 323.Hutchison, R., Moncrieff, A. (1940) Lectures on Diseases of Children.

London; p. 70.Illingworth, R. S. (1949) Brit. med. J. ii, 1077.Naish, F. C. (1948) Breast Feeding. London, p. 98.Nelson, R. L. (1940) Tex. St. J. Med. 35, 832.Paterson, D., Marr-Geddes, A. (1927) Arch. Dis. Childh. 2, 315.Thomson, J. (1921) Edinb. med. J. 27, 313.Wallgren, A. (1945) Acta pœdiatr., Stockh. 32, 778. Wood, B. S. B. (1951) Dissertation for D.M. degree, Oxford.

Medical Societies

ROYAL SOCIETY OF MEDICINE

Criminal ResponsibiltyTHE psychiatric section of the Royal Society of

Medicine met jointly with the Medico-Legal Society onDec. 11, under the chairmanship of Dr. DESMOND CURRANto discuss Different Approaches to the Problem ofCriminal Responsibility.

Sir NORWOOD EAST surveyed some of the opinionsheld by various authorities. On the subject of " unfitnessto plead" he said that in England and Wales casesdealt with in this way at the beginning of the centurywere only about a quarter as many as those found

"

guiltybut insane," whereas in Scotland prisoners found insanein bar of trial " were four times as numerous as thosefound guilty but insane. In the English courts the accusedwas brought before a jury who could pronounce him" insane and unfit to plead," but in Scotland the equiv-alent finding of

"

insanity in bar of trial’’ was frequentlymade without a jury. This seemed to him an anomaly ; hecould not see why a jury was necessary to find a man guiltybut insane, and yet not necessary to find him insane inbar of trial. Moreover, not being brought before a jurymight be said to deprive the insane person of his chancesof acquittal or of later appeal to the Court of CriminalAppeal, and inevitably gave an air of secrecy to themanner in which he was dealt with by the law. He hadevery sympathy for doctors who refused to be coercedinto declaring an accused insane person to be unfit toplead. In his opinion, insanity did not necessarilyinvolve unfitness to plead ; for an insane or mentallysubnormal person might be quite capable of instructinghis counsel and understanding the procedure of thecourt, just as it was recognised by the law that a certifiedmental patient might be capable of making a valid willor instituting proceedings for divorce. As regards theconcept of

"

guilty but insane " under the McNaughtenrule, he felt that on the whole it worked satisfactorily.The addition of the criterion of " irresistible impulse "had been advised by Lord Justice Atkins’s commissionin 1923 but had been rejected by the House of Lords.It was difficult to be convinced of the existence ofan irresistible impulse unless insanity was present;otherwise, the only proof that an impulse was

irresistible might be the fact that it had not, in fact,been resisted.

After-trial medical inquiry into the state of theprisoner’s mind was a valuable practice. He had givenit as his opinion before the Royal Commission on CapitalPunishment that without this safeguard there was

inevitably a risk of insane murderers being hanged. In

general, Sir Norwood East considered that the presentsystem of determining criminal responsibility in this

country was just and fair. Criminal responsibility wasa legal concept of which the public approved, and crispand clear-cut views were essential : it was necessarythat juries should be protected from the conflictingtheories of disputing medical experts.

Mr. ANTHONY HAWKE said that both the medicaland the legal profession were united in a common desirethat justice should be done, and in the opinion of mostpeople who shared this desire the question of an accusedperson’s criminal responsibility was best left to thedecision of a man’s fellow-citizens, under proper direction.A jury was not required to decide on a man’s insanitybut on his criminal responsibility. He held that theconcept of

" irresistible impulse " was unnecessary as aseparate entity, and that it was adequately covered bythe second limb of the McNaughten rule. He agreedwith Sir Norwood East’s opinions about the import-ance of the procedure of after-trial medical inquiry,

31

and that the accused man’s insanity before trial shouldbe decided by a jury.

Dr. T. C. N. 61BBE--,-S, in a brief account of theattitude to criminal responsibility in the U.S.A., saidthat in 29 of the 48 States some variation of the

McNaughten rule was used, usually with the first clauseincluding the second. In 17 States the concept ofirresistible impulse was recognised. In the State ofNew York two psychiatrists attached to the court decidedon a man’s unfitness to plead, and an insane person wasexempted from trial. This had three disadvantages :(1) the prisoner had less chance of an acquittal ; (2) iflie subsequently recovered from his insanity he couldbe returned to court to stand trial ; and (3) it might alsocause resentment in the insane criminal that he had beendealt with administrativelv and not tried before a court.

Prof. E. W. ANDERSON said that he was against theconcept of irresistible impulse. He did not believe that

psychiatry was yet scientific enough for the law to bealtered in deference to the theories of some of the morevocal psychiatrists. He deplored, in particular, the

way some psychopaths were allowed to get away withserious offences on the grounds of mental instability;and he believed that in some cases psychotherapyproduced no better results than did penal methods.

Dr. J. C. M. MATHESON, speaking as a prison medicalofficer, felt that the powers of the Home Office to removeinsane persons awaiting trial might be used more often.He pointed out that if an accused person, though insane,pleaded guilty and this plea was accepted, that. person-became a convicted prisoner and could be certified onlyunder the Criminal Lunatics Act. This necessitated theconvicted person being sent to prison. He or she couldnot be certified under the Lunacy Act within the precinctsof the court as sometimes defending counsel asked thecourt to order.

Dr. D. STAFFORD-CLARK agreed that medical witnesseswho disliked the McNaughten rule should not try toalter it in the witness-box. He thought, however, thatthe rule was inadequate ; for it paid no attention to theemotional side of mental illness, which it treated as

something that affected only a man’s reason. The

McNaughten rule worked quite well because commonsense and good will " got round it," but he shared theopinion of Sir David Henderson that this was an

unsatisfactory state of affairs.

MANCHESTER MEDICAL SOCIETY

Indications for Therapeutic AbortionIN the section of medicine on Dec. 5, Prof. W. I. C.

MoRRis spoke of the difficulty of laying down broadindications for therapeutic abortion, or, even in theisolated case, of judging whether it has been genuinelyhelpful, or whether refusal to perform it has done harm.The operation is not without its risks, immediate andremote. Among the remote risks must be included thesense of personal guilt which some patients feel, andparadoxically the demand for repetition of the operationin successive pregnancies. The chief justifications fortherapeutic abortion are conditions in which the con-tinuance of pregnancy jeopardises the life of the motheror seriously menaces her physical or spiritual health.Only when the continuance of pregnancy itself con-

stitutes the major risk is the operation soundly indicated.The risks of labour and the dangers of parenthood arenot complete justifications. Conditions in which con-tinuance of a pregnancy is likely to result in the birthof a deformed or unhealthy child are debatable indica-tions : the indication may be accepted more readilywhen such abnormalities as anencephaly are detectedradiologically than when deformity is a mere matterof probability. It seems very doubtful whether rubellain the first twelve weeks of pregnancy is a justificationin all circumstances for the induction of abortion.

In systemic disease, the chief reasons for inducingabortion lie in the management of the failing heart.

Pulmonary tuberculosis rarely presents a clear indication,and the obstetrician must be wary of requests to terminatepregnancy arising from failure to provide adequateinpatient accommodation for the pregnant woman withphthisis. Hypertension, seldom an unquestionableindication, is often accepted with superimposed pre-eclampsia or with a history of previous toxaemia or

accidental haemorrhage. In Bright’s disease, the indica-tion is decidedly obscure, and many patients miscarryspontaneously if treated conservatively. Diabetes,unless complicated by nephropathy, rarely justifiesintervention. Disseminated sclerosis does not seem tobe influenced favourably. The place of therapeuticabortion in the psychoses is very doubtful except inrecurrent psychoses clearly related to pregnancy.

Prof. CRIGHTON BRAMWELL, in considering the cardiaccomplications of pregnancy, thought that therapeuticabortion should be carried out in those patients who havehad congestive heart-failure apart from pregnancy(to be done in the first three months of the pregnancy),those who have gross cardiac insufficiency on slightexertion, those with acute pulmonary oedema in mid-pregnancy, and those with severe mitral lesions.The difficulty in making an unbiased decision was

emphasised by Sir WILLIAM FLETCHER SHAW, who

urged that each case should be judged on its own merits.He was doubtful about the so-called dangers to thefoetus associated with rubella in the mother during thefirst twelve weeks, and he did not believe that rapeever occurred.

Reviews of Books

The Urology of ChildhoodT. TWISTINGTON HIGGINS, O.B.E., F.R.C.S., senior surgeon,Hospital for Sick Children, Great Ormond Street;D. INNES WILLIAMS, M.D., F.R.C.S., surgeon, St. Peter’sand St. Paul’s Hospital, genito-urinary surgeon,Whipps Cross Hospital ; and D. F. ELLISON NASH,F.R.C.S., assistant surgeon, St. Bartholomew’s Hospital,surgeon to the Children’s Hospital, Sydenham. London :Butterworth. 1951. Pp. 286. 458.

THIS welcome book describes congenital malformations,infections, stones, and neoplasms of the kidneys, bladder,ureter, and urethra found in children. A section coversembryology and another enuresis. Some of the condi-tions described are exceedingly rare, and may be seenonly once in a lifetime. The text is commendablywritten and carries no padding or unnecessary words.Every sentence is thus significant, and the book musttherefore be read carefully. It is well illustrated withX-ray plates, supplemented in places with line drawings.Some of the X-ray plates have not reproduced satis-factorily, and a greater profusion of small inset linedrawings would have been useful. The statementthat " fluid is better restored to the body throughthe mouth than by the veins " is worth noting, for itseems that many of the younger generation of surgeonshave forgotten that the patient has a mouth. On thesame page, we find " the value of a biochemist withsufficient clinical contact, to enable him to adjust thenature and amount of parenteral fluids can scarcelybe over-estimated." How many intravenous infusionsin this country today are - controlled by a biochemist ?How many biochemists ever set foot inside a hospitalward ? These are important principles, needing emphasis,and might have been discussed at greater length. Asthe book will be read outside this country, the specialchildren’s cystoscopes and urethroscopes, as well as theapparatus used in cystometry, might have been illustrated.One great advance in the urology of children in recentyears has been the Denis Browne operation for hypo-spadias ; and the description of this operation has beenlargely reproduced in Browne’s own words. Thechapter on tuberculosis is somewhat disappointing,