Medical Aspects of Crime

Medical Aspects of Crime was published in 1936. The first third of the book, four chapters, is called ‘Medical aspects of prison administration’ and is a series of lectures given to the nursing sisters at Holloway Prison in October and November 1934. It starts with a history of English prisons from the 15th century onwards, including a significant reference to the reforming zeal of John Howard in the 18th century. East also describes the horrors of ‘garnish’ (advanced payment for ale), which encouraged drunkenness in prisons. He gives a vivid view of an appalling system, which he discusses in neutral measured terms while clearly approving of the various reforms that slowly took place. By the mid 19th century, the diseases afflicting prisoners included tuberculosis, ague (malaria), diarrhoea, fever, bronchitis, rheumatism, scurvy, ‘stricture’, imbecility, insanity and paralysis, to name a few. The reports of 19th-century prison inspectors are quoted and make fascinating reading, for example one inspector says ‘I do not think that the state of mind produced by treadmill labour is favourable to moral reformation’, a wonderful understatement.

A complete chapter is devoted to the history of prison medicine. It makes very depressing reading, outlining the use of dark dungeons and pits (black holes) deep in the earth to house prisoners right up until the beginning of the 19th century. A prison inspection of Chester city gaol in 1836 found a black hole below ground reached by a flight of steps. It was damp and without light or ventilation. The surgeon considered it an improper place of imprisonment, saying ‘the prisoners who are placed there run a very great risk. It is quite wonderful how they escape ill health’. A further inspectorate report in 1837 said ‘dark cells have the effect of hardening and brutalising those who are confined in them’. The care of ‘lunatics’ in prisons exercised the authorities considerably. The 1836 report found that lunatics had been confined to various prisons for periods up to 24 years. With an echo of modern problems, some prisoners who had been adjudged lunatic and transferred to an asylum were sent back to gaol as being of sound mind. In 1847 the surgeon at the Woolwich hulks (decommissioned ships used as floating prisons) said that it was not his duty to remove a prisoner of unsound mind to a criminal lunatic asylum unless there existed some particular reason such as violence or troublesome conduct. The prison inspector criticised this statement, saying that whether a maniac was violent or tractable he should be equally submitted to the curative treatment for which asylums were built. In 1869 Parkhurst Prison, a young boys’ prison, was converted for the reception of adult males and immediately received invalids and ‘weak minded prisoners’. East noted that in his time Parkhurst was still receiving all convicts requiring prolonged observation on account of doubtful mental conditions.

After his historical chapters East turns to more contemporary matters and the next chapters are observational studies of single criminal categories. Suicide and attempted suicide were crimes from the middle of the 13th century until 1961. In the 1930s suicide attempts were sometimes punished with a fine but many suicidal people were imprisoned. In 1913 East studied 1000 men who had been remanded in custody for attempted suicide; he identified 15 groups this way. He said that his experience left him in no doubt that to remove this offence from the list of misdemeanours would be sometimes disadvantageous. There is a discussion of the difference between cellular confinement and detention in association. East argues that plenty of association in prison, although more costly as it needs more and better trained staff, has advantages that outweigh its disadvantages, especially in respect of mental health.

A substantial chapter is included on ‘adolescent crime’. East calls this ‘mental inefficiency’. He discusses juvenile delinquency as though it were always pathological, often the result of ‘physiological imbalance’. At one point he gives a colourful, accurate description of what he calls ‘the psychopathic personality’, obviously regarding it as a legitimate psychiatric problem and noting that persecutory ideas and illusions may accompany this disorder. His later writings (e.g. East Reference East1949) introduced the idea of ‘non-sane non-insane’ individuals, an extremely useful concept that belies the nonsense of ‘no formal mental disorder’. East also regarded drunkenness and alcohol problems as a form of mental defectiveness (East Reference East1932). He clearly regarded alcohol as a toxin and emphasised its damage to a growing fetus and suggested that it is a possible cause of mental defectiveness in itself. East also notes that punitive labour is ill-advised, degrading to the prisoner and lacking in reformative effect. He notes with satisfaction that the tread-wheel and the crank were finally abolished in 1898.

A chapter reprinting a paper published in the Proceedings of the Royal Society of Medicine in 1934 gives East's view on the ‘medical aspects of crime’. He rejects the general notion that crime is a disease in itself. In his view crime is essentially a social problem, and not altogether a medical one. He scoffs somewhat at a proposal made by the psychotherapist Grace Pailthorpe that offenders should be sent to hospitals rather than prisons for different kinds of psychological treatment. He says that he much prefers that, where possible, offenders should be entrusted to probation officers, perhaps for 5 years at a time. East believed that the prevention of crime is as important as the punishment of the criminal, and all relevant facts may require consideration to effect either purpose and ‘it is certain that cooperation between the courts, the police and prison alienists is essential if we are to achieve our common aim: the pursuit of truth as servants of justice’.

A chapter on sterilisation of criminals, which was a paper given to the International Penal and Penitentiary Congress in Berlin 1935, is somewhat chilling now that we know the direction Germany was facing. It is clear that East was not an enthusiast for such activities; indeed, he tells us that such operations may be harmful and lead to a false sense of security in the public mind, but nowhere does he discuss the morality or ethics of such ideas. It is striking that throughout the book ethics are never mentioned. A chapter on homicide gives some insight into his thinking about the role of the doctor in courts and prisons. He says that ‘although the law in this country in regard to criminal responsibility is illogical, justice is done, and the manner in which it is done compels the admiration of the world. It is the privilege as well as the duty of the psychiatrist to assist the state to effect this purpose’. Later he argues that in some cases imprisonment improves physical health. However, he does accept that some depressive and paranoid states occur in prisons, but says that delusions of persecution and hallucinations are more frequently due to malingering. His final paragraph urges us to remember that it is often necessary for the law to consider the interests of the public as well as of the offender, and that moral and social obligations must be upheld ‘if civilization is to endure’.

W. Norwood East and his legacy

Norwood East was a prison doctor for the whole of his career. However, as Bowden (Reference Bowden1991) tells us, ‘He was responsible for making general surgery available at Wormwood Scrubs Prison and he started a prison nursing service with state registered nurses’. Apart from his medical degree he was largely self-taught: there was no training available in psychiatry when he qualified in 1897. He devoted himself to the prison system, always trying to make it more humane and rational. In one of his later books, Society and the Criminal, he made his approach to forensic psychiatry explicit: ‘The training of the physician generally leads him to put the interests of his patient before other considerations. But in a criminal case the wider interests of society cannot be impoverished in favour of the offender’ (East Reference East1949: p. 10). This approach is quite apparent in the book reviewed here: he clearly thought of himself as a civil servant first and foremost.

Medical Aspects of Crime is mainly of historical interest and the first four chapters give a fascinating account of the development of English prisons. Today, I hope we can put the patient at the centre of our endeavours but we should not neglect the patient's environment, whatever it is, and our prisons are dreadful places in which to house large numbers of mentally disordered people in the way we do at present.

Norwood East's legacy is threefold. First, he took an unusual and detailed interest in our prisons and prisoners: I can think of no other prison doctor who has made such a remarkable contribution. Second, he emphasised the importance of research and science; he was clearly the first academic forensic psychiatrist and this legacy was built on by Sir Aubrey Lewis when he developed a unique section of forensic psychiatry at the Maudsley Hospital in London, with its first chair to be held by Dr Trevor Gibbens. The third legacy is paradoxical and could not be discerned from this book alone: East did not see himself as a therapist and he was critical of psychotherapy for criminals, yet Grendon Prison, the direct result of the East–Hubert Report (East Reference East and Hubert1939), provides effective psychotherapy for selected prisoners (see Gunn Reference Gunn, Robertson and Dell1978; Lees Reference Lees, Manning and Rawlings2004) and is a model which should be built upon.

Paul Bowden was right: Sir William Norwood East was a pioneer of forensic psychiatry.