765 of a dopaminergic predominance in the system in Huntington’s chorea. Institute of
hypothalamo-pituitary
what
Pharmacology
and Pharmacognosy,
University of Calghari,
EUGENIO E. MÜLLER DANIELA COCCHI PAOLO MANTEGAZZA EUGENIO A. PARATI TOMMASO CARACENI
09100 Cagliari, Italy
Department of Pharmacology, University of Milan Instituto Neurologico "C Besta". Milan
EPIDEMIOLOGICAL TRANSITION
SIR,-Your
note
(Sept. 24,
p.
670)
on
epidemiological
theory, to which McKeown has made notable contributions,’1 glosses over some crucial points of controversy. In particular, how
are we to
explain
the increased
know what he was doing or to understand said to’him, and who-thanks to the treatment he had been receiving-was not expected to emerge from custody alive. A third possible source may have been the opinions of a certain doctor, obviously without experience of prison medicine, who has written an article containing unfounded accusations. At Wormwood Scrubs-and at all the other establishments I have worked in during 28 years as a prison medical officer-no drug of any kind has ever been administered to normal prisoners for purposes of control. Indeed, one would not so much as place a stethoscope on the chest of any individual in custody who declined to allow it. This rule also applies to every inmate who is physically or mentally ill, and who declines treatment, the sole exception being those with mental illness of such degree as to make them a danger to themselves or others. The annual number of cases of this type in an establishment such as Wormwood Scrubs is less than five; and this situation last arose 7 months ago. I have sufficient knowledge of the doctors working in three other establishments where these abuses are alleged to have occurred-and of the patients concerned, since they were subsequently transferred to Wormwood Scrubs-as to be able to say with confidence that a similar code of medical ethics is adhered to there also. It is ironic that, over a period of several years during which it has become increasingly difficult to arrange for the admission of mentally ill prisoners to N.H.S. hospitals, the Prison Medical Service should be accused of giving inadequate psychiatric help to the psychotic patients who have been left on its hands. That several of our hospital buildings have become unsuitable for this particular purpose few would deny. However, when they were built such a use could scarcely have been envisaged. Despite this, these patients receive very adequate help; and the statement made by one uninformed critic that it is very difficult, usually impossible, for a prisoner to obtain an independent medical opinion is nonsense. N.H.S. consultant psychiatrists regularly visit all our larger prison hospitals and their advice is obtainable whenever it is required. I write as an individual who wishes to do what he can to prevent the formation of a malign myth and not as an official spokesman for the Prison Department of the Home Office.
wreck,
importance
of
degenera-
tive, neoplastic, and mental illnesses? The simplest view is that these diseases have become absolutely more common, as a result of increasing exposure of the population to factors which may cause or precipitate them. Another view is that they have merely become more intrusive, partly because of the decline in the significance of diseases arising from infection and malnutrition and partly because of the changing age-structure of the population and the tendency of these diseases to be associated with advancing age. Some have attributed this age association more to genetic than to environmental causes, arguing that these diseases occur when they do precisely because evolution has determined that the disposition to acquire them when young would have exerted an unfavour-
able selection effect. An increasingly important series of arguments attributes these "modern epidemics" very substantially to social processes which redefine the nature of health and illness, and result in a substantial increase in what I have termed iatrognostic disease.2 The evidence that the objective lesions that underlie heartdisease, stroke, and mental illness have become age-specifically more common is inconclusive. The evidence that we have surrendered to our physicians-or even to their laboratories-the right to decide whether we are ill or not is distressingly and in-
creasingly convincing. Department of Community Medicine, University of Manchester
too
was
ill
to
being
H.M. Prison Hospital, Wormwood Scrubs, London W12
J. K. LOTINGA
ALWYN SMITH
Manchester M13 9PT
** Criminon,
a penal reform group sponsored by the Church Scientology, has shown us sworn statements from six exprisoners claiming abuses, including two implying forcible administration of drugs by prison staff other than medical
of PSYCHIATRY IN BRITISH PRISONS
SIR,-Your note (Sept. 10, p. 59) about the use ofpsychiatric hospitals in the U.S.S.R. for the purpose of confining certain individuals who are not mentally ill but whose views are considered by the State security authorities to be politically threatening ends, cautiously, with the remark: "... certainly in Britain charges that prisoners are subjected to unjustified drug treatment, and that mentally ill prisoners do not receive adequate psychiatric help, have still to be fully answered." What are the grounds for these charges and why do you conclude that they warrant a mention in an indictment of the abuse of psychiatry in the U.S.S.R.? Perhaps you were referring to certain spokesmen of organisations which claim to represent the cause of prisoners’ rights. Several of these spokesmen, being themselves ex-prisoners, are well-known to prison staff. Their statements to the Press on this subject are untrue. Or perhaps you were drawing on the histrionic assertions of some member of the family or close friend of a particular prison patient, now recovered, who periodically announced to the Press that he had become a physical 1 McKeown, T. The Role of Medicine: Provincial Hospitals Trust, 1976.
2 Smith.A Lancet, 1976, ii, 973.
Dream, Mirage
or
Nemesis. Nuffield
officers. These
far from clear-cut; nevertheless, collecfuller from the Home Office than a restatement of the medical-ethical position.-ED.L.
tively, they
cases are
warrant
something
ABORTION REGARDED AS CONTRACEPTION
SIR,-Whilst it would be easy to criticise Michele Beaconsfield’s method of data collection, it is perhaps her conclusions which are the more worrying (Sept. 24, p. 666). She twice describes the 28 women she talked to as being "perfectly aware", but to be perfectly aware of certain biological facts about pregnancy is not an effective contraceptive. To understand why these women have become pregnant against their wishes and despite the family-planning services available demands a much more thorough analysis followed by evaluated intervention studies. Individual culpability is only one way of explaining the gap between those who need contraceptive advice and those who provide it. Another tenable hypothesis is that the N.H.S. either fails to appreciate the particular problems which some women have in planning their pregnancies or, even if these problems are un-
hypothalamo-pituitary
what
Pharmacology
and Pharmacognosy,
University of Calghari,
EUGENIO E. MÜLLER DANIELA COCCHI PAOLO MANTEGAZZA EUGENIO A. PARATI TOMMASO CARACENI
09100 Cagliari, Italy
Department of Pharmacology, University of Milan Instituto Neurologico "C Besta". Milan
EPIDEMIOLOGICAL TRANSITION
SIR,-Your
note
(Sept. 24,
p.
670)
on
epidemiological
theory, to which McKeown has made notable contributions,’1 glosses over some crucial points of controversy. In particular, how
are we to
explain
the increased
know what he was doing or to understand said to’him, and who-thanks to the treatment he had been receiving-was not expected to emerge from custody alive. A third possible source may have been the opinions of a certain doctor, obviously without experience of prison medicine, who has written an article containing unfounded accusations. At Wormwood Scrubs-and at all the other establishments I have worked in during 28 years as a prison medical officer-no drug of any kind has ever been administered to normal prisoners for purposes of control. Indeed, one would not so much as place a stethoscope on the chest of any individual in custody who declined to allow it. This rule also applies to every inmate who is physically or mentally ill, and who declines treatment, the sole exception being those with mental illness of such degree as to make them a danger to themselves or others. The annual number of cases of this type in an establishment such as Wormwood Scrubs is less than five; and this situation last arose 7 months ago. I have sufficient knowledge of the doctors working in three other establishments where these abuses are alleged to have occurred-and of the patients concerned, since they were subsequently transferred to Wormwood Scrubs-as to be able to say with confidence that a similar code of medical ethics is adhered to there also. It is ironic that, over a period of several years during which it has become increasingly difficult to arrange for the admission of mentally ill prisoners to N.H.S. hospitals, the Prison Medical Service should be accused of giving inadequate psychiatric help to the psychotic patients who have been left on its hands. That several of our hospital buildings have become unsuitable for this particular purpose few would deny. However, when they were built such a use could scarcely have been envisaged. Despite this, these patients receive very adequate help; and the statement made by one uninformed critic that it is very difficult, usually impossible, for a prisoner to obtain an independent medical opinion is nonsense. N.H.S. consultant psychiatrists regularly visit all our larger prison hospitals and their advice is obtainable whenever it is required. I write as an individual who wishes to do what he can to prevent the formation of a malign myth and not as an official spokesman for the Prison Department of the Home Office.
wreck,
importance
of
degenera-
tive, neoplastic, and mental illnesses? The simplest view is that these diseases have become absolutely more common, as a result of increasing exposure of the population to factors which may cause or precipitate them. Another view is that they have merely become more intrusive, partly because of the decline in the significance of diseases arising from infection and malnutrition and partly because of the changing age-structure of the population and the tendency of these diseases to be associated with advancing age. Some have attributed this age association more to genetic than to environmental causes, arguing that these diseases occur when they do precisely because evolution has determined that the disposition to acquire them when young would have exerted an unfavour-
able selection effect. An increasingly important series of arguments attributes these "modern epidemics" very substantially to social processes which redefine the nature of health and illness, and result in a substantial increase in what I have termed iatrognostic disease.2 The evidence that the objective lesions that underlie heartdisease, stroke, and mental illness have become age-specifically more common is inconclusive. The evidence that we have surrendered to our physicians-or even to their laboratories-the right to decide whether we are ill or not is distressingly and in-
creasingly convincing. Department of Community Medicine, University of Manchester
too
was
ill
to
being
H.M. Prison Hospital, Wormwood Scrubs, London W12
J. K. LOTINGA
ALWYN SMITH
Manchester M13 9PT
** Criminon,
a penal reform group sponsored by the Church Scientology, has shown us sworn statements from six exprisoners claiming abuses, including two implying forcible administration of drugs by prison staff other than medical
of PSYCHIATRY IN BRITISH PRISONS
SIR,-Your note (Sept. 10, p. 59) about the use ofpsychiatric hospitals in the U.S.S.R. for the purpose of confining certain individuals who are not mentally ill but whose views are considered by the State security authorities to be politically threatening ends, cautiously, with the remark: "... certainly in Britain charges that prisoners are subjected to unjustified drug treatment, and that mentally ill prisoners do not receive adequate psychiatric help, have still to be fully answered." What are the grounds for these charges and why do you conclude that they warrant a mention in an indictment of the abuse of psychiatry in the U.S.S.R.? Perhaps you were referring to certain spokesmen of organisations which claim to represent the cause of prisoners’ rights. Several of these spokesmen, being themselves ex-prisoners, are well-known to prison staff. Their statements to the Press on this subject are untrue. Or perhaps you were drawing on the histrionic assertions of some member of the family or close friend of a particular prison patient, now recovered, who periodically announced to the Press that he had become a physical 1 McKeown, T. The Role of Medicine: Provincial Hospitals Trust, 1976.
2 Smith.A Lancet, 1976, ii, 973.
Dream, Mirage
or
Nemesis. Nuffield
officers. These
far from clear-cut; nevertheless, collecfuller from the Home Office than a restatement of the medical-ethical position.-ED.L.
tively, they
cases are
warrant
something
ABORTION REGARDED AS CONTRACEPTION
SIR,-Whilst it would be easy to criticise Michele Beaconsfield’s method of data collection, it is perhaps her conclusions which are the more worrying (Sept. 24, p. 666). She twice describes the 28 women she talked to as being "perfectly aware", but to be perfectly aware of certain biological facts about pregnancy is not an effective contraceptive. To understand why these women have become pregnant against their wishes and despite the family-planning services available demands a much more thorough analysis followed by evaluated intervention studies. Individual culpability is only one way of explaining the gap between those who need contraceptive advice and those who provide it. Another tenable hypothesis is that the N.H.S. either fails to appreciate the particular problems which some women have in planning their pregnancies or, even if these problems are un-
