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NASAL SINUSITIS IN PHTHISIS.
1278
Correspondence. "AuJj alterarn pa,rtem."
RESPONSIBILITY OF THE CRIMINAL LUNATIC. To the Editor
of
THE LANCET.
retributive and preventive elements and more of the corrective or ameliorative element. Changes of this character will, of course, take time to become widely operative, but in the meanwhile the medical profession may think with pleasure that such changes of a scientific character are slowly but surely making their appearance, and are due almost wholly to the work of its members.-I am, Sir, yours faithfully, E. D. MACNAMARA. Harley-street, Dec. 2nd, 1923.
SIR,-The Report of the Committee upon Insanity GENERAL ELECTION: THE ENFIELD SEAT. and Crime cannot be said very appreciably to have To the Editor of THE LANCET. clarified the difficulties it was constituted to consider. Without doubt several of its members were at least SiB,—Local considerations and conditions led me sympathetically inclined to accept the medical case, to the decision not to contest the Enfield division at but unhappily this case was not presented by a united this election, thereby making a three-cornered contest ; voice. The result will probably be that a widely but I have been asked, and have agreed, to be the diffused but mild satisfaction will be felt by the of the two professions concerned ; while the general public, so far as in cold blood and uninfluenced by any immediately outstanding case in point it is at all concerned, will be indifferent. The medicopsychological world will welcome a further diminution of the field of criminal responsibility, and the legal world will, perhaps, be somewhat, though not seriously, apprehensive that " the observance of the law " may further " be gravely hindered " by the inclusion of such nebulous mental material as impulses " which the prisoner was by mental disease in substance deprived of any power to resist." In the Middle Ages insanity afforded no legal defence. In 1670 the great lawyer Hale wrote that partial insanity is no excuse, and it is really only within the last hundred years that, with the growth of humanitarianism in the administration of the law and of psychology in the practice of psychiatry, the problem of defining responsibility has become prominent. The solution of the problem certainly becomes On the one hand, no easier as the years move on. the importance of the doctrine of inescapable personal responsibility becomes clearer as the scientific investigation of ethics, law, and sociology becomes more profound. Without it even our language would have to be remodelled. On the other hand, the analytic investigation of the evolution of the mind, whether in the race or in the individual, shows more and more that growth depends upon factors over which the individual can be said to have but slight, if any, control. It is with those considerations before him that the physician so often appears to the lawyer to be unduly hesitant in the question of responsibility. Few will be found to disagree with the committee " that a person may be of unsound mind and yet be criminally responsible," but the difficulty of the physician at once arises when he attempts to disentangle the unsoundness and the responsibility. In practice he finds it impossible, and, perhaps inclining too much to the merciful and too little to the judicial aspect of the case, passes to the position that it is better to excuse any accused person who presents any symptoms of insanity than to punish one whose act has, in fact, been the result of morbid mental processes, although the connexion between the act and the processes is not obvious, or rational, or even likely. Much of our difficulty and controversy really depends on the unscientific treatment of most of our criminals and the irrevocable character of punishment. To hang a man as an act of retribution or as a warning to others for an act for which he was not responsible is clearly contrary to the ethical sense of our civilisation. To condemn him under similar circumstances to a term of imprisonment, though not so revolting, is calculated to burden the general conscience. It is likely that in the future the notion of mitigated responsibility will become more prevalent. The bald problem of whether a criminal is responsible or not will be exchanged for the problem as to how far heredity, education, and environment have qualified his responsibility, and sentences will vary with the findings of an examination of these factors. Punishments in their turn are likely to be compounded less of
prospective
mass
Liberal candidate for the next election. I am, Sir, yours faithfully, R. LESLIE RIDGE.
Enfield, Middlesex, Nov. 29th, 1923.
NASAL SINUSITIS IN PHTHISIS. To the Editor of THE LANCET. do not think the citation of Skillern by Dr, SiB,—I A. L. Yates (THE LANCET, Dec. 1st, p. 1211) tells for his contention that frontal and ethmoidal sinusitis do not complicate the diagnosis of chest affections-, for Skillern’s conclusion was that ordinary maxillary sinusitis was not over-common in tuberculosis. Moure’s conception of nasal defect in phthisis I mentioned deprecatingly in my letter as well as in my book ; but also with the implication that it was far nearer the truth than the proposition that these nasal changes are the result of tuberculosis, which is what Dr.Yates had advanced. As to packing the nose of ozaenatous consumptives with cyanide gauze, that was " merely on a single occasion, for an hour or so," to and abate the nuisance to remove crusts, deodorise, The above indicate fellow sanatorium patients. differences real enough, but such as will diminish. If Dr. Yates publishes his protocol, he will add to the
scanty
exact
record, and thereby to our knowledge. I am, Sir, yours faithfully,
Dec. 2nd, 1923.
W. C.
RIVERS.
MATERNITY NURSING HOMES. To the Editor of THE LANCET. connexion with the efforts of the medical SiR,-In profession to lower both the present existing high mortality and illness from puerperal sepsis, may I call attention to one of the types of maternity home which are springing up like mushrooms throughout the country, especially in the poorer areas of the large cities. The public, in response to the teaching of the profession, is beginning to appreciate the advantages that accrue when a confinement is properly conducted in a well-equipped institution or nursing home. With the demand the supply has naturally increased, but it behoves the profession to watch carefully that the good is not undone by new evils arising in its midst. I refer to the small dirty house, owned and presided over by a woman frequently covered by the diploma of the C.M.B., into which patients are taken for the purpose of their confinement. Houses of this type are popular with the masses, and apparently are a financial success to the owner. No medical man enters unless something goes wrong, and then it is often too late. The midwife, however, is " covered because she has called in medical help. It is no uncommon thing in the out-patient depart,ment of a hospital to trace many cases of pelvic inflammation to the " care " bestowed upon the patients in houses of this type. It is one thing to train a woman for the diploma of the Central Midwives Board. It is another to train her, without long and detailed hospital experience, to equip and manage a maternity home. As often as not it is the uneducated type of the C.M.B. diplomée who appears to fall into the error of attempting such a proposition.
Correspondence. "AuJj alterarn pa,rtem."
RESPONSIBILITY OF THE CRIMINAL LUNATIC. To the Editor
of
THE LANCET.
retributive and preventive elements and more of the corrective or ameliorative element. Changes of this character will, of course, take time to become widely operative, but in the meanwhile the medical profession may think with pleasure that such changes of a scientific character are slowly but surely making their appearance, and are due almost wholly to the work of its members.-I am, Sir, yours faithfully, E. D. MACNAMARA. Harley-street, Dec. 2nd, 1923.
SIR,-The Report of the Committee upon Insanity GENERAL ELECTION: THE ENFIELD SEAT. and Crime cannot be said very appreciably to have To the Editor of THE LANCET. clarified the difficulties it was constituted to consider. Without doubt several of its members were at least SiB,—Local considerations and conditions led me sympathetically inclined to accept the medical case, to the decision not to contest the Enfield division at but unhappily this case was not presented by a united this election, thereby making a three-cornered contest ; voice. The result will probably be that a widely but I have been asked, and have agreed, to be the diffused but mild satisfaction will be felt by the of the two professions concerned ; while the general public, so far as in cold blood and uninfluenced by any immediately outstanding case in point it is at all concerned, will be indifferent. The medicopsychological world will welcome a further diminution of the field of criminal responsibility, and the legal world will, perhaps, be somewhat, though not seriously, apprehensive that " the observance of the law " may further " be gravely hindered " by the inclusion of such nebulous mental material as impulses " which the prisoner was by mental disease in substance deprived of any power to resist." In the Middle Ages insanity afforded no legal defence. In 1670 the great lawyer Hale wrote that partial insanity is no excuse, and it is really only within the last hundred years that, with the growth of humanitarianism in the administration of the law and of psychology in the practice of psychiatry, the problem of defining responsibility has become prominent. The solution of the problem certainly becomes On the one hand, no easier as the years move on. the importance of the doctrine of inescapable personal responsibility becomes clearer as the scientific investigation of ethics, law, and sociology becomes more profound. Without it even our language would have to be remodelled. On the other hand, the analytic investigation of the evolution of the mind, whether in the race or in the individual, shows more and more that growth depends upon factors over which the individual can be said to have but slight, if any, control. It is with those considerations before him that the physician so often appears to the lawyer to be unduly hesitant in the question of responsibility. Few will be found to disagree with the committee " that a person may be of unsound mind and yet be criminally responsible," but the difficulty of the physician at once arises when he attempts to disentangle the unsoundness and the responsibility. In practice he finds it impossible, and, perhaps inclining too much to the merciful and too little to the judicial aspect of the case, passes to the position that it is better to excuse any accused person who presents any symptoms of insanity than to punish one whose act has, in fact, been the result of morbid mental processes, although the connexion between the act and the processes is not obvious, or rational, or even likely. Much of our difficulty and controversy really depends on the unscientific treatment of most of our criminals and the irrevocable character of punishment. To hang a man as an act of retribution or as a warning to others for an act for which he was not responsible is clearly contrary to the ethical sense of our civilisation. To condemn him under similar circumstances to a term of imprisonment, though not so revolting, is calculated to burden the general conscience. It is likely that in the future the notion of mitigated responsibility will become more prevalent. The bald problem of whether a criminal is responsible or not will be exchanged for the problem as to how far heredity, education, and environment have qualified his responsibility, and sentences will vary with the findings of an examination of these factors. Punishments in their turn are likely to be compounded less of
prospective
mass
Liberal candidate for the next election. I am, Sir, yours faithfully, R. LESLIE RIDGE.
Enfield, Middlesex, Nov. 29th, 1923.
NASAL SINUSITIS IN PHTHISIS. To the Editor of THE LANCET. do not think the citation of Skillern by Dr, SiB,—I A. L. Yates (THE LANCET, Dec. 1st, p. 1211) tells for his contention that frontal and ethmoidal sinusitis do not complicate the diagnosis of chest affections-, for Skillern’s conclusion was that ordinary maxillary sinusitis was not over-common in tuberculosis. Moure’s conception of nasal defect in phthisis I mentioned deprecatingly in my letter as well as in my book ; but also with the implication that it was far nearer the truth than the proposition that these nasal changes are the result of tuberculosis, which is what Dr.Yates had advanced. As to packing the nose of ozaenatous consumptives with cyanide gauze, that was " merely on a single occasion, for an hour or so," to and abate the nuisance to remove crusts, deodorise, The above indicate fellow sanatorium patients. differences real enough, but such as will diminish. If Dr. Yates publishes his protocol, he will add to the
scanty
exact
record, and thereby to our knowledge. I am, Sir, yours faithfully,
Dec. 2nd, 1923.
W. C.
RIVERS.
MATERNITY NURSING HOMES. To the Editor of THE LANCET. connexion with the efforts of the medical SiR,-In profession to lower both the present existing high mortality and illness from puerperal sepsis, may I call attention to one of the types of maternity home which are springing up like mushrooms throughout the country, especially in the poorer areas of the large cities. The public, in response to the teaching of the profession, is beginning to appreciate the advantages that accrue when a confinement is properly conducted in a well-equipped institution or nursing home. With the demand the supply has naturally increased, but it behoves the profession to watch carefully that the good is not undone by new evils arising in its midst. I refer to the small dirty house, owned and presided over by a woman frequently covered by the diploma of the C.M.B., into which patients are taken for the purpose of their confinement. Houses of this type are popular with the masses, and apparently are a financial success to the owner. No medical man enters unless something goes wrong, and then it is often too late. The midwife, however, is " covered because she has called in medical help. It is no uncommon thing in the out-patient depart,ment of a hospital to trace many cases of pelvic inflammation to the " care " bestowed upon the patients in houses of this type. It is one thing to train a woman for the diploma of the Central Midwives Board. It is another to train her, without long and detailed hospital experience, to equip and manage a maternity home. As often as not it is the uneducated type of the C.M.B. diplomée who appears to fall into the error of attempting such a proposition.