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imaging22 are encouraging, studies have not

incorporated the appropriate control-an atrophictestis from a cause other than in-situ carcinoma. The

gold standard is testicular biopsy. In most institutionsthis procedure is carried out under generalanaesthesia, making it unsuitable for routine

screening.Bruun et aF3 reviewed

their experienceof

outpatient testicular biopsies under local anaesthesiaand found that 28 % ofpatients thought the procedurewas unacceptably uncomfortable and 1-5% hadinfectious complications. These problems, and the

difficulty of excluding malignancy in a testis once ithas a biopsy scar, are the major reasons that screeningof risk groups has not been undertaken as

enthusiastically in the UK or elsewhere as inDenmark. Another factor was the course of action to

be taken once the diagnosis is made: until latelyorchidectomy was the only therapeutic option. Sincethis procedure was also the recommended treatmentfor invasive tumours, with a cure rate exceeding90%, orchidectomy for in-situ carcinomas hardlyseems a major gain. However, attitudes are beginningto change as it is now possible to eliminate in-situdisease without surgery.25 Low-dose radiation (20cGy in ten fractions) has the disadvantage ofinducinginfertility,but chemotherapy is equally effective in theshort term, although with greater acute toxicity. Since

recovery of spermatogenesis after chemotherapy forestablished metastatic tumours has been well

documented,26 this approach might be preferable for

patients who wish to remain fertile. However,

it is unclear whether a blood-testis barrier willdiminish the long-term effectiveness of chemo-

therapy. 27In this issue (p 528) Dr Daugaard and colleagues

take the study of in-situ carcinoma into a new areawhich was not addressed at last years meeting. Theyprovide evidence for in-situ carcinoma in testicular

biopsies from 8 of 15 patients thought to have an

extragonadal primary germ-cell tumour, particularlythose with predominantly retroperitoneal disease.These findings indicate that such cells may progressdirectly to demonstrate the fourth property of

malignant cells-metastasis without obvious localinvasion. Azzopardi and Hoffbrand 211 had previouslysuggested that spontaneous regression of anestablished primary tumour might be due to an

22. Thomsen C, Jensen KE, Giwercman A, et al. Magnetic resonance: in vivo tissuecharacterization of the testes in patients with carcinoma-in-situ of the testis and

healthy subjects. Int J Androl 1987; 10: 191-98.23. Bruun E, Frimodt-Moller C, Giwercman A, et al. Testicular biopsy as an outpatient

procedure in screening for carinoma-in-situ: complications and the patientsacceptance. Int J Androl 1987; 10: 199-202.

24. Oliver RTD. Rare cancers and specialist centres. Br Med J 1986; 292: 641-42.25. VonderMaase H, Giwercman A, Muller J. Management ofcarcinoma-in-situ ofthe

testis. Int J Androl 1987; 10: 209-20.

26. Oliver RTD. Fertility ofpatients with germ cell tumours ofthe testis before and after

treatment with platinum and etoposide containing combination chemotherapy

regimens. In: JonesWG, Milford WardA, AndersonCK, eds. Germ celltumoursII. Pergamon, Oxford: 1986. 467-70.

27. Fowler JE Jr, WhitmoreWF Jr. Intratesncular germ cell tumors: observations on the

effect of chemotherapy J Urol 1981; 126: 412-14.28. Azzopardi JG, Hoffbrand AV. Retrogression m testicular seminoma with viable

metastases. J Clin Pathol 1965; 18: 135-41.

immune mechanism whereas seeded metastases

continue to grow. Preliminary anecdotal evidence of a

possible autoimmune reaction against in-situcarcinoma of the testis29 was an important new

development reported in Copenhagen, and provides anewdirection for research. Given Kleins contention30

that ifimmune surveillance is

importantin resistance

to cancer, then terminal tumours must inevitably havethe most efficient systems for evasion of host response,

investigation ofthe immunology ofin-situ carcinoma

might be a profitable avenue for future research. The

high cure rate of in-situ carcinoma of the bladderachieved with intravesical BCG would support that

concept.""Since testicular cancer has such a high cure rate,

study of in-situ change might seem largely irrelevant

by comparison with the more common drug-resistantadult solid cancers. However, the greater range of

biological markers for in-situ carcinoma of the testis

provides important insights into cancer biology in

general. These findings may aid understanding of thenatural history and contribute to better managementof all common adult tumours, particularly cervix,

lung, and bladder which also have well defined, andmore readily detectable, in-situ stages.

THE NEED FOR ASYLUM FOR THE MENTALLY

ILL

A CONSENSUS statement from a Kings Fund forum1 isthe second2 recent declaration that asylum should remainone ofthe functions ofmental illness services. Theproposals- merit analysis since this is an area in which good intentionsare clearly not sufficient.

The statement tends to deal with the darker aspects of

asylum by splitting them off into the large institutions ofa

past era ("symbols of the outdated"), leaving the more

benign connotations unsullied for the community services ofthe future. This approach may increase the risk of repeatingpast mistakes by denying the institutional era the open-minded scrutiny that is still so badly needed before it ends. It

certainly confuses what isandwhat ought to be-a perennial

failing of mental illness service ideologies. To state that"Large wards in large institutions cannot and should not be

regarded as home for anyone" devalues the experience of thetens of thousands of long-stay patients for whom this hasbeen the reality for decades, andmakes it easier to gloss overtheir present feelings.

29. Lehmann D, Muller HJ. Analysis of the autoimmune response in an "in-situ"

carcinoma ofthe testis. Int J Androl 1987; 10: 163-68.

30. Klein G. Immune and non-immune control ofneoplastic development: contrastingeffects of host and tumour evolution. In: Former JG, Rhoads JE, eds.

Accomplishments in Cancer Research 1979. Philadelphia: Lippincott, 1979:

123-46.

31. Pinsky CM, Camacho FJ, Kerr D, et al. Intravesical administration of BacillusCalmette-Guerin in patients with recurrent superficial carcinoma ofthe urinary

bladder: report of a prospective, randomized trial. Cancer Treat Rep 1985; 69:47-53.

1. The need for asylum in society for the mentally ill or infirm. Consensus statement, thethird Kings Fund Forum. London: Kings Fund Centre, April, 1987.

2. Community care. Second report from the House of Commons Social Services

Committee. London: HMSO, 1985; paras 25-26.

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The consensus panel might instead have challenged theconventional assumption that unwillingness to opt for anuncertain future on other peoples terms is merely evidence

of "institutionalisation", and have taken seriously patientsactual views. It is clear that, given adequate information,

preparation, and choice, long-stay patients are sufficientlyrealistic and indeed

courageous

in

facing change3for it to be

inexcusable that they are still so widely excluded from

planning for their own futures. This is important for the

mental illness service as a whole. To bring the institutionalera to an ugly end by sacrificing the remaining patientsrights is likely to be the worst possible basis for anew serviceintended to be founded on respect for the needs and wishes

of its consumers. The panels approach contrasts with themore forthright recommendation of the House ofCommons Social Services Committee that "The

Department lays an obligationon Authorities to ascertain asfar as practicable, and give consideration to, the wishes and

feelings of mentally disabled individuals ... in particularwhere closure of a long-stay facility is contemplated".4There are several other reasons whythe past should not be

lightly brushed aside. The overridingimage ofasylum is ofa

place of safety for those sheltered within, but the publicswillingness to sanction necessary resources may still hingeon expectation of protection for themselves. Lack of clarityabout which interest was being served contributed to someof the malign developments of the institutional era,5 and

community caremay be similarly distorted. Comprehensivedistrict services-the model supported by the consensuspanel-aim to reverse the segregation of the post bydispersing long-term patients in small groups. Theostensible purpose is to normalise their lives, but there is

clearly also the hope of defusing public anxieties. Failure to

separate assumptions may lead to confusion betweenunobstructiveness and integration, to denial of the reality of

psychiatric disabilities, and even to the view that the veryterm "special needs" is stigmatising.6 It also leads to

acceptance of discriminatory zoning that would lead to an

outcry ifapplied to other groups.The evidence is that the social networks of long-term

mentally ill persons are mainly composed of other patients,ex-patients and staff, and their own families.7 This seems to

be the case not only for those discharged after long stays in

hospital, but also formanywho havespentmostoftheir livesin "the community". There is thus a danger of progressivesocial isolation if such ties are broken by too widespread

dispersal, and wider relationships remain a pious hope.Under such circumstances emotional tensions within small

groups in daily close contact, to which schizophrenicpatients are particularly vulnerable, are likely to be inimicalto genuine asylum. Patients have a right to relationshipsboth with other patients and with "normal" people: theseare not reciprocal,8 as sometimes assumed, and may fulfildifferent functions.9 Community care should not merely

3.Abrahamson D, BrennerD. Do long-stay psychiatric patients want to leave hospital?Health Trends 1982, 14: 95-97.

4 Community care. Second report from the House of Commons Social ServicesCommittee.London:

HMSO,1985:

para149.

5 Scull AT Museums ofmadness. London: Penguin, 1982.6 Heginbotham C. Good practices in housing for people with long-term mental illnesses.

In Good practices in mental health.London: 1985.

7 Abrahamson D, Ezekiel A. Social networks of psychiatric patients. Paper tosymposium, Kings Fund Centre, London, June, 1985.

8 Segal SP, Aviram U.The mentally ill in community based sheltered care.New York:

Wiley, 19789 Estroff SE.Making it crazy.London: University of California Press, 1981.

reverse the one-sidedness ofinstitutional lifeespeciallynotfor those who will experience both.One approach to achieving a balance is to bring the

community to the patients, as well as the reverse. "New

community"1 or "haven"" projects propose using the

major resources of space, public acceptance, and in somecases buildings, ofmental hospital sites to develop a range ofresources for the long-term mentally ill. Their economic

potential is such that a variety of supported accommodationand occupational and leisure facilities could be funded-mixed and to some extent combined with public provisionincluding up-market housing, shops, and parks. The

utopian ring of some descriptions should not deflect

attentionfrom the practicalityofthe concept: schemescouldbe developed on varying scales appropriate to local

circumstances, as one component of comprehensiveservices. At the most modest level they would add to the

range of choices open to long-stay patients and mitigate thePoorLaw flavour produced by dispersal to district of originirrespective of present loyalties. It is difficult to understand

why this aproach was ignored by the consensus panel-again in contrast to the Social Services Committeesrecommendationsthatno mental-handicap or mental illness

hospital site should be disposed of without it beingconsidered. 12 Urgent action is needed as wards deteriorate,whilst dispersed schemes meet planning obstructions thatrestrict both their number and their ability to cater for themore disturbed patients.

These schemes are also needed to increase resources forfuture generations of long-term patients, who mayotherwise lack opportunities for asylum even in its most

primitive sense of shelter. More intangibly, these patientswill benefit from the signal that their special needs are to be

taken seriously in the new service. Developments inunderstanding13 and treatrnent14 make it no longer tolerablefor interest in long-term schizophrenic illnesses to be

regarded as evidence of nostalgia for the mental hospital,unfitting for the would-be community psychiatrist. IS

STEROIDS IN HAEMORRHAGIC STROKE

CLINICAL trials of stroke treatment have tended to

concentrate on infarction rather than haemorrhage-wherethe two have been

adequately distinguishedand ifwe leave

aside primary subarachnoid haemorrhage. This is not to saythat we are now much better at treating infarction. The

probable reason is that rationales have been more easilyconceived for drug therapy of cerebral infarction-even if

wrong. A prominent target for drug activity has beenoedema formation, and dexamethasone has been one ofthe

10. Jones K. Mental hospital closures-the way forward? York: University of York

Institute of Advanced Architectural Studies, 1987.

11.Wing JK, Furlong R. A haven for the severely disabled within the context of a

comprehensivepsychiatric community service. Br J Psychiatry 1986; 149: 449-57.12. Community careSecond report of the House of Commons Social Services

Committee. London:

HMSO,1985:

para208.

13.Bleuler M. The schizophrenic disorders: long-term patient and family studies. New

Haven: Yale University Press, 1978.14. Steinglass P. Psychoeducational family therapy for schizophrenia: a review essay.

Psychiatry 1987; 50: 14-23.15. Sturt J, Waters H. Role of the psychiatrist in community-based mental health care.

Lancet 1985; i: 507-08.

1. Ng LKY, Nimmannitya J.Massive cerebral infarction with severe brain swelling: a

clinicopathological study. Stroke 1970; 1: 158-63.