1130 MEDICO-LEGAL SOCIETY.

showed, the observation of the radiographer was correct.The X ray findings, whatever the explanation, suggested anabnormal condition of the appendix, and operation wasrecommended in the hope that an appendectomy mightrelieve the symptoms.

Operation on April 24th, 1928, revealed an appendix9-5 cm. long containing what appeared to be a great numberof small shot. Later computation showed the actual numberto be 48, and, with two exceptions, they were collected andcemented together in the distal half of the organ (see figure).The peritoneal coat of the appendix showed no trace ofinflammatory change, and a later microscopical examinationrevealed no infection or reaction in the underlying layers.As far as could be ascertained, all the shot were uniform insize, and one pellet submitted to a gunsmith was classedas No. 6.The post-operative course was uneventful, and it is

satisfactory to record that the operation was successful inrelieving the symptoms.

Certain Related Facts.Such are the simple details of the case, but there are

certain related facts which are of interest. " And thusthe whirligig of time brings in his revenges," for thevictim of this occurrence is a well-known sportsmanand game shot. The figures in his game book totala number close upon 250,000, and, as the edict of thephysicians who treated his gout forbade the use ofbutcher meat, there was a liberal consumption ofgame. It is evident that to this we may ascribe theremarkable collection which the appendix displayed,and that yet another " record bag " was added to thelist. It may be that the ghost of some grouse willecho with V alentinian. 3

" I love a dire revenge. Give me the man that will all otherskill and then himself."

In a more serious vein, however, there is no doubtthat the presence of this heavy collection of lead shot(one-seventh of an ounce) was responsible for the trainof symptoms complained of-the dragging discomfortin the right side, and, as a result, of recurrent attacks ofcaecal spasm, the more acute and short-lived pains.The appendix wall itself showed no sign of inflammatoryreaction ; in fact it was probably in some measureprotected from infection, partly by the matter whichoccupied the interior and partly by the potential anti-septic properties of the contents, but its weight andthe reflex disturbance which this engendered no doubtresulted in a mesenteric drag and its associated signsand symptoms.One clinical point there was into which significance

might be read, and one regrets that the matter wasnot more carefully noted-there was an area ofcutaneous hyperalgesia, perhaps unduly prominentand corresponding to the skin distribution of theappendix. It seems possible that the irritation ofthe mucous surface by the foreign bodies instituted thereflex, for a similar observation has been made inconnexion with threadworms in the appendix. Apartfrom secondary perforation of the appendix, one of thedangers quoted in connexion with foreign bodies isthe development of a tumour. An example of thishas recently been recorded by Thorek. In the presentinstance there was no trace of anything suggesting acell reaction or degeneration, and it was evident thatworse things than lead may gain entrance to or evolvewithin the lumen of the vermiform appendix.

It may be that a record of this kind adds little tothe store of knowledge upon which our art accrues,but to me it was an unusual occurrence, and I said tomyself " rara juvant."

References.—1. Mahoney, S. A. : Boston Med. and Surg. Jour.,clxxxiv., No. 5, p. 113. 2. Houston, J. : Dublin Med. Press,1840, xl., 333. 3. The Tragedy of Valentinian, iv., 1. 4. Thorek,M. : Med. Rev. of Rev., 1925, xxxi., 449.

STORNOWAY HOSPITALS.-Mr. T. B. Macaulay, ofMontreal, President of the Sun Life Assurance Company ofCanada, has within the past two years given nearly 20,000to various institutions in Stornoway. He has now given98000 to the endowment fund of the Lewis Hospital and with.612,000 capital money contributed by the Treasury, throughthe Scottish Board of Health, this should make it possibleconsiderably to increase the efficiency of the institution.

Medical Societies.MEDICO-LEGAL SOCIETY.

A MEETING of this Society was held on Nov. 22nod..with the President, Sir WILLIAM WILLCOX, in the-chair. Dr. L. A. WEATHERLY read a paper on

JUVENILE PSYCHOLOGIC DELINQUENCIES.He said that the study of human nature must go-hand in hand with the study of the individual’s mind,and physiology, pathology, and sociology must aidpsychology. As Dr. J. Devon had said, " the only one-principle in penology is to find out why the delinquentdid wrong and make it not worth his while to do itagain." Among a wealth of contributory factors one-major cause could always be found. Criminal conductwas instinctive conduct and adapted to savage ratherthan civilised countries. Either the instincts and-emotions were too strong for the intelligence, or the-intelligence was too weak to control the instincts oremotions. The inherited disposition of these instinctsmight be for good or evil, and if they were allowedto run riot unsocial conduct must result. The causesbringing about lack of control over or accentuation ofthe worst features of instinctive emotional activitieswere complicated. Any physical ill-developmentmight have this effect-for instance, defective sight.or hearing and orthopaedic deformities. The lateMr. Thomas Holmes had been convinced that the-most serious causes of crime were more physiologicalthan psychological. Secondly came pathological’causes-mental disease leading to crime. Dementia,.prsecox patients were subject to sudden inexplicable-impulses, usually aggressive and destructive, yet to’the ordinary observer the sufferers seemed normal-and well-behaved. Dr. W. C. Sullivan had said thathomicide was, par excellence, the crime of the epileptic.Encephalitis lethargica entirely altered the characterof its young victims so that they took an absolutelyimmoral attitude to social life. They should be sentto an institution and never to prison. A peculiarpathological condition sometimes followed injuries tothe viscera or abdominal operations ; the characterwould alter and the youth might develop sexualperversions. Sometimes the alteration of sleep inchange from day- to night-work would have a graveeffect on a boy’s emotional centres. Evidence ofcertifiable insanity in these pathological cases was

rarely found, and some were tried and convictedwithout any defence or realisation of the cause of theircriminal act. The present system of probation per-mitted appropriate care and treatment. The third-group of causes was sociological. It was an error tosuggest that every delinquent was the helpless victimof his inborn nature ; there were many contributoryenvironmental causes. Dr. Burt had concluded thatpoverty played only an indirect part and that therewere more good children in the hovels of Hoxton thanin the mansions of Mayfair. The sociological causesof crime were defective discipline, a family history ofvice and crime, detrimental companions, excessive orinadequate amusement, lack of healthy pursuits, anddefective family relationships. Cases of mentaldeficiency should be easily diagnosed and sent toinstitutions ; it was a scandal that the institutionalaccommodation was so inadequate. The subnormal,however, was a much more difficult problem. Shuttle-worth and Potts had described a class of case in whichthe strain of puberty produced a temporary lapse ofmoral sense. Prison was no good for these people, but,tact, confidence, and kindness might make them goodcitizens. Most subnormals required somethingbetween Home Office schools and Borstal institutions.on the one hand and simple supervision underia-probation officer on the other.

Measures to Deal with Young Offenders.Juvenile courts had been introduced in 1908, and

children under 17 could now only be sent to prison

1131MEDICO-LEGAL SOCIETY.

under exceptional circumstances. Reformatory schoolsand industrial schools-now called Home Office schools-had been reorganised, and probation officers wereappointed to every court of summary jurisdiction inthe kingdom. The report of the departmental com-mittee appointed in 1925 was full of interest and

excellent suggestions. It advocated juvenile courtsin every court of summary jurisdiction, to be heldquite apart from the police-court, and urged thatthree special magistrates should be appointed to each,one of the three being a woman. Cooperation betweenjuvenile courts and education authorities was essential,and the help of psychology and psychiatry should beenlisted. The report suggested the establishment ofhostels for probationers whose home environment wasunsuitable, and called attention to the need ofobservation centres and remand homes-such as

existed in America and had been described by Dr.R. G. Gordon in " Autolycus." Farm colonies were,in the speaker’s opinion, the best kind of institutionfor subnormals, and occupational therapy should bethe keynote of their treatment. Rate aid, voluntarycontributions, and " self-help " (by the parents of thechildren) should be sufficient to maintain the colonies.Too many young delinquents still drifted into prison,and the reasons for this were financial stringency, biason the part of magistrate or magistrate’s clerk, and thedislike inherent in every individual to anyone butthemselves putting their house in order. Financeshould be dealt with on a basis of everyone doing theirshare, and bias should be eliminated by making theHome Office suggestions obligatory. The wonderfulwork done by voluntary effort must not be forgotten.There was too great a tendency to think thingsimpossible before testing their possibility.

Discussion.Earl RUSSELL agreed that in a great many cases

delinquency was not so much a matter of consciouscriminal intent as of some physiological, psychological,or environmental factor, and the one thing you shouldnot do with young persons was send them to prison.That idea, however, permeated slowly to the countrymagistracy. The Home Office suggestions must,however, be administered with intelligence andsympathy, and not as a matter of routine becausethey were ordered. The best way to convince lawyersthat the doctors were not " trying to get the better ofthem" was to show them the results of sendingsubnormal cases to suitable institutions.

Dr. T. B. HYSLOP thought on the whole it wasworse for a child to be branded as of unsound mindthan to be found guilty of an offence. The former wasmore far-reaching, passing down, as " insanity in thefamily " to the third and fourth generation, whofeared, and indeed anticipated their trouble. Thelaw must come to realise the existence of physiologicalexplanations of offences.

Lieut.-Colonel C. T. SAMMAN said that a hundredyears ago we hanged a man for stealing a sheep andnow we gave him six months for diabolical murder ;we were much too lenient with the juvenile offender.He advocated sterilisation of all criminals.

Dr. W. A. PoTTS doubted whether, if all criminalswere sterilised, there would be enough of us left tosee the result of our experiment. Crime would not bestopped by making it " not worth the criminal’swhile," for often it was not worth his while already.Juvenile crime might be the result of ignorance andmisunderstanding or misleading education. Forinstance, a child from a very poor home, where allthe few possess’ons were common property, would notunderstand that the same conditions did not apply atschool. A child who had seen its parents take whatthey liked from a shop, murmuring " Put that downto me," might find it very hard to see the differencewhen it went and took what it liked itself. Encephalitislethargica was a very important cause of delinquency,and the initial attack was easy to overlook. Thedelinquency should not be looked on as an after-result, but as a later manifestation of a condition thatwas still active and that required full and adequate

treatment. The establishment of a juvenile court anda sympathetic magistrate was not going to solve theproblem and " get at the mind of the child." Thatcould only be done by heart-to-heart talks in private.It was most important that probation should beconditional and long enough. Young people were notsent to universities for three or six months, and whenthey had been misled and miseducated all their livesthey needed still longer periods for education.

Mr. W. E. OHADWIÇK spoke of the importance oftreating the child in the home at the " difficult "

stage before it became delinquent. The real problemwas to prevent delinquency and to find some way ofteaching parents how to deal with these children.

Dr. R. G. GORDON pointed out that the childwho came to the juvenile court was never a " firstoffender." Parents regarded a child who stole eitheras amusing or as something too dreadful to talk about.Parents must be taught to seek advice, and if thatadvice were to be given in the juvenile court theremust be a change in its atmosphere. Alternativelythere might be some kind of advisory clinic, such asthat at Bath, which had proved very successful. Thedifficulty was almost always a failure of adjustmentbetween the child and society ; this ability to adjustwas an important part of the personality about whichtoo little was known. Simple mental backwardnesswas by no means the only cause of delinquency.’ Dr. F. C. SHRUBSALL emphasised the difficulty thechild had in adapting to town life. We could pickblackberries off a country hedge as much as we

liked, but if a child took a blackberry from a basketin town it became a delinquent. There was a hundredtimes as much juvenile crime in America as in thiscountry, but it was least in the Middle West, wherethe children lived an outdoor life and had moreopportunity for games and exercise. The school andnot the court was the place to stop crime ; theincreasing size of the schools had destroyed thepersonal contact between master and boys, so theclinic had to take its place. Only 10 per cent. ofjuvenile delinquency was due to ill-health or

abnormality. The real old lag never did anything tocorrupt a child ; it was the boy a year or two olderwho was the danger.

Dr. LETITIA FAIRFIELD said that institutions werea very important part of social reform, but they werevery expensive. A cheap institution was a nastyinstitution and would do its inmates no good. Youcould not make a home from home by calling it acolony, and so long as the child was forced to remainthere he would long for home and the fried fish shops.The children were not delinquent because they weresubnormal, but because the schools were not adaptedto their mentalitv. The school had to deal with theaverage. The bright child, who ought to be pushingahead, was quite likely to become a burglar, but hewas better catered for than the subnormal, whose lifewas one continuous failure and snubbing and hopelesscompetition. The few gifts-often ’manual-of thesubnormal child had no chance of development becausehe did not reach standard IV. or V., where there wasa manual class. Much could be done to give him aworld in which he could be happy if we would caterfor him in our educational system. Another way ofrelieving his lot was through clinics. There was nowish to dodge punishment for children for whom itwould do good. There was no kindness to a child inletting it think it could " get away with " crime.But unintelligent punishment had been tried again andagain; history was littered with the cruel failures ofthat system. These children should be treated as weshould like to be treated ourselves, and put in a,

position where they could exercise responsibility.They were struggling with a problem they could notunderstand and forces they could not control. If lawrested on the intelligent consent of the governed thechild who had been treated like that would surely bea better citizen and able to give something back tothe law.Lord RIDDELL said that if it was possible to change

a child’s mind and disposition by proper medical

1132 SOCIETY OF M.O.H.’S : MATERNITY AND CHILD WELFARE.

treatment the first thing was to ensure that suchtreatment was obtainable, and the general practitionerought to be trained to deal with these cases.

, Dr. E. SLOAN CHESSER emphasised the importanceof motive, of the mother, and of decent housing.

Dr. WEATHERLY briefly replied.

SOCIETY OF MEDICAL OFFICERS OFHEALTH.

MATERNITY AND CHILD WELFARE GROUP.

THIS group held a meeting at the Royal FreeHospital on Nov. 23rd, Prof. LOUISE MCILROY, thePresident, being in the chair. A discussion on

ANTENATAL METHODS WITH SPECIAL REGARD TODISPROPORTION

was opened by Mr. EARDLEY HOLLAND, who said thata weak point about the municipal antenatal clinic wasthat no beds were attached to it, and the doctor incharge did not look after the women during theirconfinement, so that an element of irresponsibilitycrept in. Publit health authorities had given greatprominence to antenatal work, but far more womenlost their lives through lack of care during labour thanthrough lack of antenatal care. The only way toestablish a new standard in midwifery was to startwith the medical profession, and the only way to dothat was to set up more large maternity hospitals.Pelvic measurements had been decried, but they werevaluable in giving an early idea of what sort oflabour the patient was likely to have, so that everyonecould be prepared, if necessary, for induction,Caesarean section or hospital treatment. Vaginalexamination had also been decried, but was importantin that it enabled the practitioner to measure thediagonal conjugate and get some idea of the shape ofthe pelvic outlet. The importance of engagement ofthe head, on the other hand, had been exaggerated.In some 20 per cent. of primiparae who had normallabours the head remained floating until the last weekor even until the onset of labour. The mere fact offailure to engage was not sufficient evidence of dis-proportion or difficult labour. Disproportion couldnot be standardised ; it was a matter of personalestimation, depending on an exact mental impressionof what was right proportion. The reserve capacityof the pelvis played an important part. The normalpelvis was designed to take a 7t lb. baby, but in factit frequently managed a 10 or 11 lb. child by callingup its reserve capacity. Therefore the slightlycontracted pelvis might reasonably be expected tomanage the 7 lb. baby.The treatment of severe disproportion was inevitably

Caesarean section, but for the milder forms two alterna-tive lines might be adopted ; induction of prematurelabour, or test-labour at term and early Caesareansection if it was apparent that natural delivery wasunlikely. Induction was time-honoured, but thespeaker said he had come to the conclusion that itwas being done too often, since 80 per cent. of induced

labours were far too easy. Induction was playing forsafety ; there were many unknown factors which, iffavourable, might allow spontaneous delivery. Ifthe foetus were premature the doctor must play forsafety because the child would not stand difficultlabour. Caesarean section or craniotomy after induc-tion was most dangerous.

Treatment by Test Labour.In cases of genuine disproportion with a pelvis

really contracted the decision was made at the thirty-sixth week, if necessary with the aid of a generalanaesthetic. If there seemed a reasonable chance ofspontaneous or forceps delivery at term the patientwas allowed to go into labour and watched almostevery hour. If after a few hours the head began to

’ sink into the pelvis it would pass through ; if not,Csesarean section was performed. The decision

’ required the highest skill and the method was only I’suitable for institutions with a resident accoucheur of I

experience. Several secondary factors influenced thedecision-e.g., premature rupture, posterior presenta-tion, weak pains, and a nervous or unfit patient wouldindicate operation. Out of about 2000 deliveries atthe London Hospital during the year there had been17 cases of contracted pelvis, of whom 16 had had testlabours. Eleven of these had had spontaneousdelivery ; three had had easy forceps and two earlyCaesarean section. Only one baby had died. There hadbeen no inductions at this hospital for two or threeyears. = Reducing the Size of the Head.

Dr. ANNIE MCCALL agreed that too many operationswere done. She emphasised the fact that disproportionwas between two things and there was a tendency toleave the second factor-the head-out of considera-tion. The size of the head could be altered by dietingthe mother. Mothers who had received the advice theyought to have received during pregnancy did not havethese enormous babies. During the last month-andpreferably two months-the mother should have noprotein-i.e., meat, egg, and milk should be forbidden.Milk made fat babies. She should be allowed as muchfruit as she liked and should take plenty of hot water,sipping it by the half-pint. Equally important withdiet was exercise during the same period. The womanought to do three or four miles walking uphill daily.Erratic exercise was no good, and hill-climbingbrought into play the muscles concerned in labour,which ordinary walking did not touch. Hot bathsshould be taken on alternate days during the eighthmonth and daily during the last month. They shouldbe as hot as the patient could bear, and she should sitin them for 13 or 15 minutes. This softened the pelvicfloor. Chloral hydrate, with or without bromide ofpotassium, was invaluable for softening the cervixand shortening the first stage of labour. Dr. McCallpreferred to give it every other night for the last tendays before labour, and thought midwives ought mostcertainly to be allowed to carry the drug, as it saveduntold suffering. She quoted statistics from theClapton Maternity Hospital to show how effectivethese methods had been, and cited the "hymn"

"

which was given to all the patients there :In later months of pregnancy dispense with eggs and meat,

t. Then drink hot water freely ; take fruit-all you can eat.Hot baths are very useful, their value is untold ;These rules, with daily exercise, are worth their weight in gold.Prof. F. J. BROWNE agreed that nothing required

so much experience as the estimation of proportionand that the head might float without any pelviccontraction, but thought there was usually someother cause for the floating head-for instance, a

posterior presentation or hydramnios. Constipationalone would keep the head out of the pelvis. Hewas at present quite satisfied with the method ofinduction ; trial labour was not the practice atUniversity College Hospital. He thought that thebabies of premature labour often did not survive thefirst two or three years of life. " Playing for safety

"

seemed the one thing desirable in conducting a labour.Trial labour was impossible in private practice, butinduction caused the doctor, the patient, and therelatives no anxiety and-provided it was not donebefore the thirty-sixth week-was perfectly safe forthe baby. Treatment should never be determinedbefore that week, but by then the head was hardenough to pass without injury through the maternaltissues. Since the date could not be ascertained withaccuracy, the accoucheur should estimate the age byvaginal palpation of the head-the width and mobilityof the sutures and the general hardness. There weretwo degrees of disproportion : first, where the headwas just flush with the outer margin of the pelvicbrim-it would then mould through well-andsecondly, when there was definite overlapping, whichcontra-indicated induction ; the case should then go toCsesarean section at term.

The Significance of the Shape of the Pelvis.Mr. ALECK BouRNE said that disproportion could

only be defined after the baby was born. A case ofdisproportion produced a white, limp, toneless,