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MISUSES OF PSYCHIATRY?

THE visit of British psychiatrists to an internationalconference in Moscow was bound to revive the

controversy over the alleged misuses of compulsorypsychiatric treatment in the Russian State system.Specific allegations in our correspondence columnsand elsewhere have, in our view, called for an answerbut, not yet, for condemnation. We know how"

departments of dirty tricks " can fake evidence tomislead the most sincere; and, if in other areas of life,why not in psychiatry ? Further, distortion by the massmedia cannot be doubted. When a Jewish professoris refused a visa, this makes headlines, but, until thePalestinian gunmen held up a train in Austria, howmany of us realised that 100,000 Soviet jews in 8 yearshad been released to Israel via the Schoenau Castletransit camp ? Not too much sign there of an oppres-sive and restrictive regime. We have therefore chosento believe, until proven otherwise, that our Russiancolleagues treat their patients with the same dedicationto truth and the value of the individual human beingas do we ourselves. Our Russian colleagues have,however, not helped us overmuch in this. At a pressconference at the Montreal Congress in 1961 theywere unforthcoming about the methods and safe-

guards related to compulsory detention, and, at a

similar occasion in Mexico in December, 1971, theirdenials of abuse were convincing but unsubstantiated.Now, in The Guardian of Sept. 29, no less than 21 ofthe most distinguished doctors in the U.S.S.R. haveput their names to a 1100-word letter of comment onthe whole affair.

This letter is by far the most convincing evidenceyet that something is seriously amiss with Soviet

psychiatry. Granted the linguistic problem, it is hardto believe that any scientist, dedicated to the un-emotional pursuit of truth, could lend his name tosuch a tirade of emotive rhetoric and unsubstantiatedassertion. Has The Guardian been hoaxed ? Theywrite of: " malicious concoctions ... unseemlyattempts to misinform public opinion ... the slanderingof Soviet psychiatry... only gross delusion or maliciousintent can explain allegations about any harmfulinfluence ... on patients ... slanderous concoctions... lying concoctions ... ". All true, perhaps, butthe persecutions of Russian people over the past 40years and more, freely admitted from time to time bythe Russians themselves, make us ask for the evidence.There is not much. They say: " many prominentrepresentatives of the psychiatry and jurisprudence offoreign countries ... have repeatedly assessed theactivities of [forensic, medical, and juristic] institutionshigh after visiting them ". Good, but who were they,what did they see, and where did they write theirfindings ? More to the point, perhaps, was their al-legation that the majority of people accused of offencesagainst the State and examined by forensic psychiatristswere found sane, which was " stubbornly ignored bythose who slander Soviet psychiatry ".There is a description of the paranoid personality

who may be destructive to society but of " seemingnormality". Here, perhaps, is the crunch. Anyexperienced Western psychiatrist can tell of peopleirrationally antagonistic to the prevailing regime.

Apparently they have freer reign in the more opensocieties and less potential for damage. The linebetween the nonpsychotic but destructive paranoidand the soundly motivated social reformer can be hardto draw. Presumably, if any State system is held by itsadherents to be ideal, then anyone who is against it mustbe, ipso facto, out of touch with reality and thereforepsychotic. Reading this letter from the Russians,one shifts a few degrees closer to the views of Prof,Thomas Szasz, who would remove altogether the

compulsory powers which psychiatrists now have.

THE SURGICAL APPROACH TO CONGENITALDISLOCATION OF THE HIP

IT is extraordinary how long a new but obviousidea can take to be accepted when it conflicts withconventional thought. Such is the case with themedial approach to the hip in congenital dislocation.Originally the hip-joint was approached by an anteriorroute; later posterior and lateral approaches becamepopular, though Ludloff 1 used a medial approach inolder children in whom conservative measures hadfailed. It is rash to attribute priority of any techniqueto a single person, but certainly Mizuno,2 of Osaka,at least 12 years ago was practising a medial approachto the hip-joint for the primary treatment of somepatients with congenital dislocation of the hip. Hecombines it with transfer of the psoas tendon to the

great trochanter, passing the tendon anterior to thefemur. His operation has been used intermittently bycertain surgeons in the U.K., and others have dividedthe iliopsoas without transplanting it. 3Lately, Trevor’ 4has recorded his experiences with release of the iliopsoastendon in operations for congenital dislocation of thehip. One notable feature is that, after such procedures,an initially shallow acetabulum quickly develops into anormal one-especially when the head is held deeplyinto the acetabulum by the transplanted psoas tendon.In the United States, Ferguson,5 of Pittsburgh, hasdeveloped a similar procedure independently and

reports his experience with 34 hips operated on by thisroute. Ferguson points out that the capsule in theinfero-medial aspect is tight and contracted, and thatthe tight iliopsoas muscle indents it. Release of thesestructures therefore allows the head to go back intothe acetabulum-the first prerequisite for normal

development of the hip. In short, this method enablesthe head of the femur to be fully reduced withoutany undue pressure on it. A tight inferior capsuleotherwise acts as a hinge and can lead to severe

pressure on the head after reduction.The medial approach to the hip is a logical pro-

cedure which makes preliminary traction unnecessary.Most children with lax but subluxed hips can betreated by non-operative measures, but if for anyreason there is already contracture of either the capsuleor the psoas tendon, and the femoral head is to bereplaced in the acetabulum, a medial approach may1. Ludloff, K. Z. orthop. Chir. 1908, 22, 272.2. Mizuno, S., Ono, K., Kaziura, I., Kitawaki, T., Inoue, A. J. Jer

orthop. Ass. 1967, 41, 565.3. O’Malley, A. G. Proc. IX int. Congr. orthop. Surg. 1963; Cw

Orthop. 1967, 31, 73.4. Trevor, D. Ann. R. Coll. Surg. Engl. 1972, 50, 213.5. Ferguson, A. B., Jr. J. Bone Jt Surg. 1973, 55A, 671.

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well be best. Clearly, if reconstruction of the aceta-bulum is to be carried out this approach is by itselfinadequate, though it may still be a useful preliminarymeasure.

How often is this procedure indicated ? In Fer-

guson’s series the age-range was from two weeks totwo years. The children remained in a plasterspica for at least four months. If these were childrenin whom a satisfactory (i.e., virtually normal) hipwould not have been achieved by conservativetreatment, his good results represent a considerableadvance. Equally there may be a place for operationin cases where it will substantially reduce the durationof treatment.

WHAT DO THE ELDERLY NEED?

IT has become a truism to say that the medical

problems of an elderly patient cannot be treated withouthaving regard to such things as housing, mobility,and social isolation. Frequently the kind of help thatthe elderly need can be expressed in terms of the kindof accommodation required-independent, geriatric orpsychiatric hospital, residential home, or sheltered

housing. The fairly wide choice of facilities availablefor the care of the elderly does not, however, neces-sarily mean that different kinds of care are providedin different kinds of accommodation, or that the

elderly end up in the accommodation best suited totheir needs. If one takes into account the fact that the

problems of the elderly are usually manifold, it is nothard to see why the difficulties of assessing the levelof need (expressed and unexpressed), and of discover-ing whether the care that is given is effective, are lesseasy to overcome for the elderly than for most othergroups of people. 31 % of the National Health Serviceexpenditure goes on the elderly, but there is verylittle evaluation as to the outcome of this expenditure.The operational research division of the Institute ofBiometry and Community Medicine is at presentdeveloping a model for planning and predictive pur-poses with the object of improving the provision ofhealth, welfare, and care services for the elderly. Theproject study area is the Exeter and Mid-Devonhospital group, and at a seminar held at the Universityof Exeter last year a number of papers were given,and have now been published, which sought to

define the needs of the elderly.One of the themes that emerges from a reading of

the seminar papers is the desire among all the profes-sions caring for the elderly, along with those doing theoperational research on them, to get together to estab-lish the levels of need for old people which societyin its collective responsibility will wish to reduceas far as possible. A means of classifying the prob-lems of the elderly was also felt to be an urgentrequirement, and not only by those engaged in research.Prof. A. L. Cochrane said that he would like to see thedevelopment of a simple, reproducible classificationof the elderly which could be carried out by a socialworker or health visitor in the home and which would

Needs of the Elderly for Health and Welfare Services. Edited byR. W. Canvin and N. G. Pearson. Institute of Biometry andCommunity Medicine, Publication no. 2. University of Exeter,The Queen’s Drive, Exeter EX4 4QJ. £2.

be closely related to the type of housing required.Prof. Peter Townsend described an index of incapacitythat he had devised whereby a score was allocated onthe elderly person’s ability to carry out a number ofkey activities in personal care (such as dressing, cuttingtoenails, getting about the house) and in householdcare (such as doing light housework, preparing a hotmeal).The question of alternatives of care was pursued by

Dr Thomas Arie, who pointed out that, while theelderly form an increasing proportion of inmates ofpsychiatric hospitals, and though patients withdementia also form a high proportion of the residentsin geriatric hospitals and local-authority homes, theoverwhelming majority of the elderly mentally ill areat home, and the number is likely to increase greatlyover the next 20 years. We can no longer, Dr Ariewarned, take it for granted that the fine balance be-tween home and institutional care on which servicesnow depend will endure. But, on the other hand, themajority of the elderly who actually become long-staypsychiatric patients not only could but ought to belooked after not in hospital but in hostels, which donot function on the medical model at all. Dr Ariealso urged that the whole range of facilities must bemade available according to need, rather than accord-ing to the component of the service with which theelderly person happened, often by the merest chance,to have first engaged.

Professor Townsend, using data collected in

parallel national surveys of people aged 65 and overliving at home and living in three different types oflong-stay institution (residential homes, geriatrichospitals, and psychiatric hospitals), questionedwhether institutions actually carried out the functionthey purported to fulfil, and whether, on the contrary,they carried out a different function which would infact be better fulfilled elsewhere. Old people areusually admitted to institutions because they requirecare and attention which is not available or cannot beprovided at home. Professor Townsend had carried outa comparative study of the incapacity of the elderly athome and in institutions, and he found that altogetherthere were more than twice as many severely in-capacitated and bedfast elderly people living at homeas there are in all institutions. He also discovered thatto a considerable extent the three different kinds ofinstitution catered for patients with similar problems,and that the elderly living at home frequently receivedbetter care and attention, were less lonely, and livedin better physical surroundings than those in institu-tions, especially if those at home had the advantageof attending a day hospital or day centre.

Professor Townsend also found that the expectationsof old people were not very high and that, perhapsthrough fear or ignorance, they did not like to complainabout their treatment or claim anything as a right.Prof. W. Ferguson Anderson made the point that theelderly often attribute their symptoms simply to theprocess of ageing and therefore do not report them tothe doctor. The utmost vigilance on the part of thosecaring for the elderly is obviously required if their

unexpressed needs are to be met. The situation was

aptly summed up by Professor Cochrane, who saidthat in attempting to discover whether screening the