1152

Another experiment in community care for the

physically disabled is reported from Denmark. MissENGBERG 10 describes a scheme by which severely para-lysed patients live in subsidised family flats, with a com-munal nursing annexe. The National Fund for Researchinto Poliomyelitis has proposed building a similar blockof flats in this country, and we understand that twoLondon local authorities are considering possibilities.But so far it is, of course, in the mental-health services

that we have had most experience of community care.Often it was introduced as a slightly desperate expedientto relieve the overcrowded mental hospitals; but thesuccess of early schemes, such as those at Nottingham,Worthing, Bolton, and Oldham, soon proved that com-munity care could be an active principle in therapeutics.Its acceptance was favoured by simultaneous advancesin other forms of psychiatric treatment and by thepublic’s changing attitude, and the Mental Health Actconfidently shifts much of the responsibility for thementally ill from the hospital to the community. Clearly,a method which has proved so helpful should be de-veloped. At the same time, pioneer schemes run byenthusiasts are, perhaps fortunately, more apt to provemerits than to demonstrate difficulties. The comprehen-sive and routine community service will probably faceproblems which did not affect the small, the experimen-tal, and the novel. As a start, from the therapeutic pointof view, Dr. MAY 11 warns against the temptation ofoverprescribing community care. It throws a consider-able burden on the patient, his relatives, and his generalpractitioner, and to use it for unsuitable patients in anunsuitable environment may disrupt a whole familywithout benefiting the patient. Dr. FERGUSON 12 suggeststhat there is now a tendency to overcompensate for pastsins of hospitalisation and to see who can admit fewerpatients and discharge more patients. He wonderswhether some patients are not in fact better off in thesheltered leisure of a mental hospital than in the hurly-burly of the overbusy outpatient clinic. An inpatientwho becomes an outpatient still needs a doctor’s support,and EGAN’s observation 13 that local-authority servicesinterpret their obligation to the handicapped as the pro-vision of " care "-which may imply the exclusion oftreatment-reinforces Dr. FERGUSON’S opinion that thecommunity services are already showing the need formore psychiatrists and more psychiatric time.

For many patients a short intensive course of treatmentin hospital is an essential part of community care. Fortheir stay many prefer a psychiatric unit at a generalhospital to a mental hospital, and Dr. SMITH 14 hasdescribed the network of units which now covers theManchester area pretty completely. Again, selected

patients, as Dr. BROOK and Dr. STAFFORD-CLARK 15

show, can be treated successfully in one of the ordinarywards of a general hospital.

Sitting exposed to all these winds of change, the10. Engberg, E. ibid. May 20, 1961, p. 1106.11. May, A. R. ibid. April 8, 1961, p. 760.12. Ferguson, R. S. ibid. April 29, 1961, p. 931.13. See ibid. May 20, 1961, p. 1123.14. Smith, S. ibid. May 27, 1961, p. 1158.15. Brook, C. P. B., Stafford-Clark, D. ibid. p. 1159.

mental hospitals themselves are beginning to feel a

shade chilly. The impetus for many of these reformscame from their staffs, but now they are beginning towonder what their own future is to be. Uncertainty anddespondency (aggravated by the Minister’s prophecythat half our mental-hospital beds will be closed withinfifteen years) has already affected nursing recruitment,and nurses without a general training fear that smallpsychiatric units in general hospitals will offer them fewchances of promotion. Yet, as the Minister has alreadypointed out,16 though there will probably be fewermental-hospital beds in the future,

" the total effort

needing to be devoted to mental treatment " will notlessen. Indeed it may grow, for community care mayprove more expensive in skilled labour than anyone yetsupposes. More people, and not fewer, will probably berequired, and it would be a pity if, through a mis-understanding, trained people were lost or suitablecandidates discouraged.The staffs of mental hospitals are uneasy also about the

patients who will fill their beds. They fear that soonnone of the more hopeful and interesting cases will reachthem and that they will be left with a smaller, but harder,core of long-stay patients. These apprehensions are nodoubt too gloomy, but they are far from unreasonable.If, for instance, money should run short and the presentprogramme of building and reform were curtailed, it iseasy to picture the mental hospitals relapsing into under-staffed, isolated dumping-grounds, in a worse plight thanbefore the present renaissance. Even if all goes smoothly,there will probably always have to be beds for some long-stay patients, whether they are physically or mentally ill.But if, as we all hope, the community services can reducethe number, the smaller long-stay hospital could take itsplace as a unit of a balanced comprehensive hospitalcommunity, such as McKEOWN has proposed 1’ Thecare of the long-stay patient is an exacting specialty, andthose who practise it too often lack the stimulus of con-tact with their colleagues and the diversity of medicine.In a comprehensive hospital community ideas and dutiescould be readily shared, and propinquity would ensurethat their needs were not overlooked and that standardswere not lowered for lack of equipment, staff, or

encouragement.

16. See ibid. May 6, 1961, p. 996.17. McKeown, T. ibid. 1958, i, 701.18. MacArthur, W. P. Trans. R. Soc. trop. Med. Hyg. 1933, 26, 525.19. MacArthur, W. P. ibid. 1934, 27, 343.20. Bickerstaff, E. R. Lancet, 1955, i, 1055.

Cerebral CysticercosisSINCE Sir WILLIAM MACARTHUR’S 18 19 convincing

demonstration of cerebral cysticercosis as a cause ofepilepsy and other neurological disturbances, the condi-tion has attracted considerable interest; and indeed thisdisorder is sometimes diagnosed without adequatejustification in people who have lived in India andsubsequently developed epilepsy. Although most

patients seen in this country have been infected in Indiathe disease is not uncommon in parts of Eastern Europeand South America, and cases have been recorded inPoles living in England.2o

1153

A Medical Research Council report by DIXON andLIPSCOMB 11 describes a study of 450 cases, the greatmajority being soldiers who had served in India. Theseworkers have tried to estimate the frequency of thedisease in such patients; and, on the basis of the numberof patients apparently infected between 1921 and 1937and of the figures for British soldiers and airmen servingin India during this period, they conclude that clinicalevidence of the disease occurred in between 1-2 and2-0 per 1000. They note that of the troops who servedin or passed through India in the late war, only 45 areknown to have contracted cysticercosis. Of the provedcases 21-6% had a history of an intestinal tapeworm,which is approximately eight times the frequency in thepopulation from which the patients were drawn.DIXON and LIPSCOMB found considerable difficulty in

estimating the time between infection and the inset ofsymptoms except in a few cases; but when they arbit-rarily selected the midpoint of a man’s service in Indiaas the time of infection they found that symptoms mightstart one to thirty years after infection, the average beingabout four and a half years. In 83% of patients symptomsstarted within seven years of infection-which is dis-

tinctly encouraging for those who served in India duringthe war, as it seems unlikely that they will now developthe disease. As was to be expected, the commonestneurological manifestation proved to be epilepsy, whichoccurred in 92% and was the only symptom in 31%;the epilepsy may be of any type, and indeed it is rathercharacteristic for more than one type to occur in a singlepatient. Other neurological disorders may arise, oftenin combination with epilepsy; of the 450 patients, 13had focal neurological signs, most commonly hemi-paresis, and 1 had progressive tetraparesis and at opera-tion was found to have cysticercosis in the cervical

enlargement of the spinal cord. In 29% intracranialhypertension developed. This fell into three distinctclinical groups. In the first it developed fairly soon afterinfection and was associated with fever. In the secondit occurred later in the course of the disease, in associa-tion with epilepsy. Of 14 patients in this group 2recovered without operation and 6 recovered after

operation; postmortem examination in the fatal cases

apparently showed multiple intracerebral cysticercosisbut no evidence of obstruction of the cerebrospinal-fluid pathways, and the reason for the intracranial

hypertension seems uncertain. In the third group therewas obstructive hydrocephalus due to a racemose

cysticercus or a single cyst or arachnoid adhesionsassociated with a cyst. In this group the prognosisseems to be very poor even after operation, for, of the 9patients, 8 died within three years; the 9th improvedfor a time but then relapsed and was finally killed in anaccident. Mental symptoms occurred in 39 patients.In 19 of these there was organic mental deterioration;5 had progressive dementia, while 11 had a severe

affective disorder, but in these patients the relationbetween the cysticercosis and the psychiatric disorderwas difficult to evaluate.21. Dixon, H. B. F., Lipscomb, F. M. Spec. Rep. Ser. med. Res. Coun.,

Lond. 1961, no. 299. Pp. 58. 6s. 8d.

DIXON and LIPSCOMB consider in detail the sub-cuticular nodules which are so characteristic of thedisease and which, by providing material for biopsy, aremost important for diagnosis. These nodules are pri-marily in the muscles and appear when the larvar dieand the fluid content of the cysts increases. They com-monly vary in size from time to time, and thoroughinspection and palpation of the whole body may beneeded to find them. They were detected in 54% of theseries. They are often the first sign, or they may appearat about the same time as epilepsy develops. New onesmay continue to appear for months or years after theirfirst appearance. In only occasional cases is muscle paincomplained of; but in extremely uncommon cases

where the muscles are massively invaded, there may bepain with swelling and weakness of the muscles re-

sembling a myopathy or myositis.22 23The most certain method of diagnosis is by biopsy and

histological examination of a nodule, but many caseshave been diagnosed by radiographic examination of themuscles. The cysts in the muscles usually become cal-cified within about five years of infection; but there aremany exceptions, and in 3 patients cysts were only seenafter nineteen years. Calcification of the intracranial

cysts is much more rare, and, when it does take place,the cysts appear as small rounded opacities and do nothave the elliptical shape so characteristic of the musclecysts. Of the 256 cases where X-rays of skull andmuscles were available, there was only 1 where calcifi-cation in cysts could be seen in the brain and not in themuscles.The 450 patients were followed up till the end of 1958,

when 42 had died of the disease, 5 had died partly fromthe disease, and 47 had died from other disorders. Thecommonest causes of death from cysticercosis werestatus epilepticus and intracranial hypertension. DIXONand LiPSCOMB found that in many cases fits could becontrolled by anticonvulsant drugs, and that the prog-nosis for those with epilepsy was less unfavourable thanhad previously been supposed. Surgical removal ofcysts for the relief of focal epilepsy was seldom of value.In the treatment of intracranial hypertension withoutobstructive hydrocephalus, decompression might be

helpful; but the results of operative treatment ofobstructive hydrocephalus had been disappointing.

22. McRobert, G. R. Indian med. Gaz. 1944, 79, 399.23. McGill, R. G. Indian J. Med. Surg. 1947, 1, 109.24. Ministry of Health, Department of Health for Scotland. Drug Addiction.

Report of the Interdepartmental Committee. H.M. Stationery Office:1961. 1s. 3d.

Drug AddictionTHE interdepartmental committee appointed, under

Sir RussELL BRAIN’S chairmanship, to review drugaddiction in this country has now reported.24 Since 1926when the Rolleston committee reported on morphineand heroin addiction many new drugs liable to produceaddiction or to be habit-forming have been introduced.After careful examination the committee concluded thatthe prevalence of addiction to dangerous drugs-boththe older ones such as morphine and heroin and thenewer synthetic agents such as pethidine and methodone