OUGHT SUICIDE TO BE A CRIME ?

1171 in these two cases, the perisaccular connective tissue was very poorly developed, and suggested that the dilatation had been brought about, at any rate in part, by some disorder in the mechanism of fluid absorption through the saccus endolymphaticus. But, as this tissue had been found absent in two of thirteen normal cases, its absence can be no more than a predisposing anatomical variation ; the primary factor might be either a hypersecretion of the endolymph or some unknown alteration in its chemico-physical constitution. It may be that such a primary factor is common in disease of the ear, but only causes vertigo when fluid absorption is diminished by the predisposing Mr. HALLPIKE advanced anatomical variation. an interesting speculation to explain the typical intermittent character of the vertigo. It is not surprising that such investigations are rare when one considers the extreme difficulty of accurate examination of the delicate structures of the labyrinth encased in dense bone. This is not, however, the only direction from which the problem can be approached. If the relief of this condition can be obtained by operation with a reasonable degree of safety as CROWE contends4 on the basis of nearly 100 successful cases, the choice between section of the whole auditory nerve and of the vestibular portion must depend on most careful study of the symptoms and the hearing in either ear of each patient. Prof. CAIRNS pleads for a re-examination of the clinical picture of aural vertigo, and as one of the first essentials, a collection of reliable data on vertigo due to various disturbances in the external and middle ear, confirmed by continuous observation over a period of years. Only from a combination of histological, physiological, and clinical studies can progress come.

that,

THE LANCET LONDON:SATURDAY, MAY 21, 1938 8

THE PATHOLOGY OF AURAL VERTIGO THE disturbance of the labyrinth which causes vertigo may be brought about by a great variety of conditions, from wax impacted in the meatus to acute labyrinthitis. If we except the latter, in which it is continuous until the labyrinth has been destroyed, the vertigo is generally intermittent. It is usually associated with deafness of, or preponderatingly in, one ear, which may be either of the nerve or of the middle-ear type. The attacks vary much in frequency, and in severity from a mild transient giddiness to such an intense vertigo that the patient is not only unable to stand but clutches the bed for fear of being thrown out. When vertigo accompanies middle-ear disease, treatment of the latter condition often effects a cure or great improvement, and dramatic results sometimes follow catheterisation of the Eustachian tube. But, since frequent and severe attacks incapacitate the sufferer from work, drastic measures are justifiable in intractable cases. Alcohol may be used to destroy the labyrinth, injected either into the external semicircular canal, as suggested by W. M. MOLLISON,l or through the fenestra ovalis as advised by A. J. WRIGHT,2 who described his technique at the discussion reported An on another page, and by J. R. PEACOCK.3 alternative procedure is division of the auditory nerve, or of its vestibular portion, within the skull ; this operation is naturally not free from danger. Two patients who succumbed after division of the nerve with symptoms of increased intracranial pressure have provided Prof. HuGH CAIRNS and Mr. C. S. HALLPI]KE with an opportunity to study in detail the pathology of the condition. The fact that the exact mechanism by which vertigo is produced is obscure, and our lack of knowledge of the actual morbid changes within the labyrinth in these cases gives importance to their communication ; indeed their elaborate investigation of the anatomical changes in the temporal bone was hailed by their colleagues as unique. The histological preparations showed gross dilatation of the endolymph system, degeneration of Corti’s organ and the stria vascularis, and pathological elevation of the otolithic membrane of the utricle ; in both cases there was a symmetrical chronic inflammatory condition of the mucosa of the middle ear. Mr. HALLPIKE found 1 3

Mollison, W. M., J. Laryng. 1936, 51, 38. 2 Wright, A. J., Ibid, 1938, 53, 97. Peacock, J. R., Lancet, Feb. 19th, p. 421.

OUGHT SUICIDE TO BE A CRIME ? A CORRESPONDENT,

writing

to the Times last

week, made a strong case for deleting suicide and attempted suicide from the criminal code. " They belong," he declared, to the doctors." His letter "

called forth by the recent decision of the House of Lords in Beresford v. Royal Insurance Co. The facts will be familiar from the previous stages of the litigation. Major Rowlandson held life insurance policies for JE50,000. His affairs were so hopelessly involved that he could not keep up the payment of his premiums. He was allowed an extension of time until 3 o’clock on a certain afternoon in August, 1934. At a few minutes before 3 o’clock he deliberately shot himself in a taxi-cab. His sister, Mrs. Beresford, claimed the insurance money as his administratrix. The company refused to pay. Suicide is a crime. Sir John Jervis, in the first edition of his book on the office and duties of coroners, observed that self-murder was " wisely and religiously considered by the English law as the most heinous description of felonious homicide." A man cannot commit a crime and make a profit out of it. He cannot was

4

Medicine, February, 1938, p. 1.

1172 insure his house, set fire to the premises, and claim the money. Public policy forbids. Major Rowlandson’s contract of insurance contained a clause that it should become void if he committed suicide, whether sane or insane, within the first twelve months. Lord Atkin holds that the clause meant that the company would pay if Major Rowlandson deliberately committed suicide after the twelve months were over. If, however, this is what the company undertook to do, the House of Lords has now decided that the company cannot do it. Neither the assured nor his estate may profit by his crime. The decision, irreproachable as it may be on legal grounds, is causing disquiet among laymen. The company, they say, was willing to pay ; it calculated its rates of premium with knowledge of the risk ; it accepted Major Rowlandson’s premiums and it ought to carry out its own side of the agreement. A man insures his life for the sake of his dependents. They get no benefit till he dies. They need to be provided for whatever the cause of death. Why should they suffer if he has been so hardly driven by circumstance that he makes an end of himself ? The simplest way to avoid the unfortunate effects of the decision in the Beresford case is to enact that suicide and attempted suicide shall cease to be a crime. The law has been tending towards this greater leniency for many generations. Ancient.ly if a coroner’s jury found a verdict of felo-de-se, the goods of the deceased were forfeited to the Crown and the corpse was, under warrant from the coroner, buried at midnight in a highway (usually at the cross-roads) with a stake thrust through it and without Christian rites. The barbarous method of burial was altered in 1823 and again in 1882. The forfeiture of goods was More significant still, the abolished in 1870. annual volumes of criminal statistics have officially stated that it is no longer the practice of the police to institute a prosecution for attempted suicide unless this course is made desirable to ensure that the defendant can be adequately looked after for the future. The sole question, in other words, is the physical and mental welfare of the unfortunate creature for whom circumstances have proved too much. Major Rowlandson has furnished what a jury has found to be an unmistakable instance of a man committing suicide while in full possession of his Mr. H. R. Fedden1 has recently expressed senses. the view, in a study of suicide throughout the ages, that deliberate self-slaughter is more common than is generally admitted. The public, nevertheless, is likely to remain convinced that nobody who commits- or attempts to commit suicide is entirely normal. One by one the vestigial survivals in our legal system are being eliminated by a policy of progress and reform. Suicide has Are we ready lost its old evidently significance. to be realists-to tear another tattered page out of the criminal code and " leave suicide to the doctors " ? 1 Suicide. By Henry Romilly Davies. 1938. Pp. 351. 12s. 6d.

Fedden.

London:

Peter

DIABETES AND THE ANTERIOR PITUITARY SiNcE the time of vorr MERING and MINKOWSKI there has been little doubt that the pancreas is intimately concerned in carbohydrate metabolism. The isolation of insulin from the pancreas by BANTING and BEST, and the successful treatment of diabetes with this hormone, apparently provided proof that the cause of diabetes mellitus lies in deficient secretion of insulin by the islets of Langerhans. But in medicine, as in other subjects, things are seldom what they seem, and the experiments of the last eight years, initiated by HousSAY in the Argentine, have shown that the anterior lobe of the pituitary gland plays an important, if not dominant, part in controlling the metabolism of carbohydrate. Two facts of great importance emerge from these experiments : the first is that removal of the pituitary gland diminishes the severity of the diabetes that ordinarily follows extirpation of the pancreas ; the second is that daily administration of an anterior-pituitary extract to normal animals may produce a condition resembling diabetes. This diabetic condition may become permanent after quite a short period of treatment with anterior-pituitary extract. It is generally accepted that insulin can stimulate the oxidation of carbohydrate in the body, and repress the formation of sugar from non-carbohydrate sources. Evidence is now accumulating that secretions of the anterior lobe catalyse the reverse processes-i.e., they inhibit the oxidation of carbohydrate and stimulate the formation of sugar from protein and possibly from other noncarbohydrate sources. These observations are the basis of the conception that the production and oxidation of sugar are regulated by the balanced, mutually antagonistic, actions of the internal secretions of the pancreas and of the anterior lobe of the pituitary. According to this theory diabetes results from faulty regulation of the relative intensities of the pancreatic and the pituitary factors, and may be caused by excessive pituitary action just as well as by deficiency of insulin secretion. The precise way in which the pituitary directly influences carbohydrate metabolism is not easily explained, and those who seek an account of recent investigations will do well to study the review presented a fortnight ago to the Royal Society of Medicine by Mr. F. G. YOUNG, Ph.D., of the National Institute of Medical Research. It may be noted here however that anterior-lobe preparations can now be obtained which abolish the hypoglycsemic action of insulin without raising the blood-sugar level, which induce the accumulation in the liver of abnormal amounts of glycogen and fat, and which give rise to ketosis in normal animals. If one function of the anterior pituitary is to stimulate those processes which, pushed to excess, lead to diabetes, then one would expect to find signs of pituitary hyperfunction in some cases of diabetes mellitus. This expectation is realised: the association of diabetes and acromegaly has long been recognised, and substances with a