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in cancer mortality, let alone causes it. All the evidenceis publicly available, and none is protected by the Offi-cial Secrets Act.We acknowledge secretarial and computing assistance from the staff

of the D.H.S.S. Cancer Epidemiology and Clinical Trials Unit. L.K.is a Gibb fellow of the Cancer Research Campaign.

Requests for reprints should be addressed to L.J.K.

REFERENCES

1. Fluoride, Teeth and Health. Report of Royal College of Physicians. London:Pitmans. 1976.

2. Burk, D., Yiamouyiannis, J. Congressional Record, 191, H7172-7176, July21,1975.

3. Yiamouyiannis, J., Burk, D. ibid. H12731-12734, Dec. 16, 1975.4. Fredrickson, D. S. Letter to J. J. Delaney, dated Feb. 6 and March 24, 1976.5. Hoover, R. N., McKay, F. W., Fraumeni, J. R. J. natn. Cancer Inst. 1976,

57, 757.6. Taves, D. R. in Origins of Human Cancer (Cold Spring Harbor Symp.) (In

the press.)7. Lewis, A. W. J. Doctor, Oct. 28, 1976.8. U.S. Bureau of the Census. U.S. Census of Population: vol. I for 1950, 1960,

and 1970. U.S. Government Printing Office, Washington, D.C., 1951,1963, 1973.

9. U.S. Dept. of Health, Education and Welfare. Vital Statistics of the U.S.:mortality 1950, 1960 and 1970. Washington, D.C. 1954, 1963,1974.

10. Burk, D. Personal communication.11. Kinlen, L. J. Br. dent. J. 1975, 138, 221.

Mental Health

THE PSYCHIATRICALLY ILL PRISONER

R. A. H. WASHBROOK

H.M. Prison, Winson Green Road, Birmingham 18

AMONG the prison population of what is termed a"local" prison are many inmates who require inpatientpsychiatric care. A large percentage, however, are

refused admission to psychiatric hospitals. The mainreason is that a total open-door policy is considered tobe progressive; but in practice it means that mentally illpeople who lack insight and are troublesome, uncooper-ative, and likely to abscond from the hospital cannot becontained there tor treatment. Over the past two yearsthe difficulties in dealing with offenders who are receivedinto the prison but who ought to be in a psychiatric hos-pital has become an organisational nightmare. In orderto assess the size of the problem three surveys were madeat intervals of 6-7 months among the inmates of WinsonGreen Prison in Birmingham. This article is based onthe findirigs.

SURVEY RESULTS

The subjects interviewed were all sentenced men whowere resident in the prison during a specific 6-day per-iod. 600 prisoners were seen during each of the threesurveys. Background information was obtained wherepossible, and any other reports-e.g., documents fromother practitioners-were also studied. The results forthe three separate survey periods showed that 11-6’%),7 5 ‘.%, and 8.6% respectively were in need of psychiatriccare-an average of 9-23’/. the subjects could beclassified broadly into five groups:

1. Offenders whose psychiatric state was noted before sen-tence-i.e., on remand in the prison. These men were mentallyill, and the diagnosis was agreed between the prison doctor andthe psychiatrist called in for possible endorsement of a Sectionof the Mental Health Act. Nevertheless, these men wererefused admission to their area psychiatric hospital or unit."It’s not our policy, we have only open doors" and "We can’ttake Section 60s" are examples of the reasons given tor reJect-ing these men, but the most common reason was lack of secur-ity. This particular group of offenders accounted for roughly19’ of the prisoners considered to be mentally ill. This meansthat at any one time about 15 men in Birmingham prison werethere because they were not wanted by the psychiatric services.Nearly all of the group gave a history of previous inpatientpsychiatric care and were known to be a "nuisance". Gener-ally, as a group, they had been uncooperative, tended to abs-cond from, the hospital, and had caused problems for bothmedical and nursing staff. The Courts had passed a sentenceon these men because there was no alternative and invariablyadded a rider in their summing-up comments that "you willreceive treatment in prison during your sentence".

2. Subnormal prisoners.-Each year about 6 subnormalmen found themselves in prison because the subnormality hos-pitals (from which most of them came) could no longer copewith their childishly antisocial and cantankerous behaviour.Most of their offences were fire-setting or comparatively minorsexual misdemeanours.

3. Chronic alcoholic offenders.-Most of these were drop-.outs of no fixed abode, serving short sentences for trivialoffences related to excessive alcohol consumption. If referred toa hospital or alcoholic unit they tended to default early. Froma previous study I believe that the chronic alcoholic offenderis a special-category alcoholic whose malady is a defenceagainst an established mental disorder. Initially he needs inpa-tient care, with long-term follow-up, social support, diagnosis,and rehabilitation. Some 83 new cases appear each year (or1.6/wk).

4. Brain-damaged prisoners.-This group consisted of menwho, because of operative brain interference (e.g., leucotomyor excision of a space-occupying lesion) or organic dementia,lacked insight and were unable to comprehend social demands.Such men regularly appear before the Courts and receive shortsentences for trivial offences. They are psychiatric crippleswho have had long associations with psychiatric and neurosur-gical departments. However, their lack of insight and theirgeneral demeanour make them unacceptable to psychiatrichospitals. they need long-term rehabilitation and psychiatricsupervision.

5. Mixed group.-This group ranged wider in its spectrumof psychiatric labelling. In the survey, 72% of the men in thisgroup had a history of mental illness. They included neurotics,simple schizophrenics, obsessive compulsives, and severely in-adequate men-all of whom should have been having long-term psychiatric treatment. Offenders in this category areusually sent to prison because they are not disturbed enoughto be pronouncea "under disability" and admitted to a psychi-atric hospital under a Section of the Mental Health Act. Inretrospect, and at times during their sentence, their admissionto a psychiatric hospital would have been more appropriatethan a period of imprisonment. Many of these subjectsbelonged to the rather sad group of "burnt out" psychotics.Their personalities showed a defect which in the majoritymade their adaptation to social requirements difficult and inmany cases impossible.The above list does not include those persons who are

serving a sentence for offences connected with antisocialsexual behaviour.

REAPPRAISAL AND REALISM

Prisons are having to accept an increasing number of

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mentally disturbed offenders, and this enforced shift infunction has gradually obscured both the definition ofprison and the philosophy behind imprisonment. Mostpsychiatrically disturbed prisoners are put behind barsbecause there they will be conveniently out of the way;a few are told they are to be sent to prison "where youwill receive treatment". Both these attitudes are wrong.Prison is not merely a dumping ground for criminalsand social misfits. Treatment is an important part of itsfunction, but the emphasis in this is on correction, learn-ing, and the encouragement of maturation. Prison man-agement and staff training are rightly geared to dealingwith criminals, and although prison staff" have to betrained to cope with the personality disorders and inade-quacies which plague the majority of prisoners, they arenot-nor should they be—equipped to treat people withformal mental illness. The medical approach to crimi-nality is just as specialised as the treatment of psychoticor severely neurotic individuals; but it is neverthelessdifferent.Neither is the prison hospital the place to treat men-

tally sick patients. Prison hospitals are generally nomore than sick bays, and all medical problems have tobe dealt with in this one area, including postoperativecases, hxmodialysis-and, unfortunately, the most

bizarre mental states. The work-load of the prison hospi-tal has increased considerably in recent years, but thefacilities have improved little. The management of thementally ill offender is even more difficult if the prisonerrefuses treatment; for the prison doctor, whatever hisqualifications, has no legal powers to take upon himselfthe role of "responsible medical officer", even if the pris-oner concerned is unable to be responsible for himself.

THE MENTAL HEALTH ACT

The architects of the Mental Health Act obviously un-derstood mental illness. The Act was designed to encour-age the restoration and healing of the disordered mind.Certain parts of the Act, particularly Sections 60, 65,72, and 73 required for their ultimate success a compre-hensive psychiatric hospital service. This marriage ofAct and hospital was the very essence of the contract.Neither could operate without the other. With the pass-ing of time the marriage alas has become turbulent. Atotal open-door policy has been established, under theguise of progress. This change, however, has made theimplementation of the above Sections of the Act un-workable and has also considerably increased the work-load of the prison medical service. There also seems tohave been a gradual increase in disillusionment amongpractising hospital psychiatrists. This changing attitudewas shown in the answers to a questionnaire I sent tofull-time or maximum part-time consultant psychiatristsworking for the D.H.S.S. From the 35 who completedand returned the questionnaire, 28 were dissatisfied withtheir posts and thought that the standards of psychiatrictreatment and care had generally deteriorated. Morethan half of these practitioners had considered leavingthe country but were for various reasons, personal orotherwise, unable to do so.

In the asylums of 100 years ago all wards were locked.Since that time tremendous improvements haveoccurred. Limited open-door policies, matched to the

true nature of mental illness, have encouraged rehabili-tation. 10 years ago the so-called "locked ward" was

thought to be essential for very acute cases and certainunstable chronic patients. With care and persistencemany of these patients were later able to be transferredto make room for new patients in a continuum based ontreatment. The subnormal hospitals likewise felt that, inthe interest of patients and society, a certain restrictivearea was necessary. For the past 5-6 years, however, allwards have been open. Unfortunately, this policy hascreated difficulties and has helped to fill places in prisonswith people who should be in hospital. It is a travesty ofjustice that a man can be committed to serve a periodof imprisonment because no hospital will take him. Thisaccount, of course, does not include the "special hospi-tals", which continue to maintain a very high standardof caring for people with mental disorder associated withsevere criminal or violent propensities.

SECURITY: A NEW MEANING

A person whose mind is damaged by mental illnesscan act strangely and lose insight. Some patients recoverfully, but others have lasting effects which can never betotally erased. I believe that it is some of these chronicpatients, together with a comparatively small number ofacutely disturbed patients, who for their own good, needto be nursed and treated in secure conditions. Securityhas come to suggest bars and bolts. However, my definit-ion of "security" would mean treatment and care and,perhaps, a ward with a locked door. The last may notbe necessary if a high staff/patient ratio can be provided.Most patients, after treatment, recover well enough tomove to an open ward with a lower staff/patient ratio.Some patients, however, do not recover so readily andbecome both chronic and dementing. This group wouldalso include a small number of subnormal persons who

require long-term security care. There is nothing sadderthan a chronic psychiatrically ill person wandering thestreets, unkempt and purposeless. The reintroduction oflocked wards in pscyhiatric hospitals need not be retro-gressive. They would, I believe, indicate an understand-ing of mental illness and could accommodate many men-tally ill people who are now in prison.

Secure units as envisaged by the Butler Committeereport would, I think, encourage the attachment of stig-mata to the patients contained therein. Although we liketo think that the public are now better informed aboutmental illness, it is remarkable how poorly this aspect isreally grasped. With a true understanding of the naturalhistory of mental illness, the prejudice of psychiatristsagainst the locked ward should disappear. Misunder-standing could be reduced if each psychiatric hospitalwere to come under the domain of the general hospitalconurbation and if the secure units were to be estab-lished within the hospital perimeter. Instead of referringto "special units" we should give these secure placesnames in keeping with the rest of the wards.

Finally, I suggest that the posts of medical superinten-dent and his deputy should be re-established as the over-all authority of the hosptial. We know from studies ofmanagement that this type of organisational system isthe most efficient. 31 of the 35 respondents to my ques-tionnaire said they would welcome the reintroduction ofthese two posts.