them. If people demonstrate by their actions that they cannot be trusted abroad, then there are good grounds for removing them indefinitely; but the onus is ineluctably on society to manage them with compassion. We should not wring our hands if these despised outcasts become infused with rage against a society that permits this bedlam to be added to the inferno of their internal state. It is dangerous and unskilful in the extreme to imagine that some of them will not act on it. Se J. O'Sullivan, MD, LRCPI 40 London St. W Tillsonburg, Ont.
I want to express my support for the points made by Drs. McCaldon and Conacher and Ms. Clark in their article. Our system for the treatment of acutely psychotic people seems to be caught up increasingly in legal procedures. Although I strongly support a process for improving the quality and quantity of care that psychotic patients receive I believe it is not through increased legalization that this will occur. As these authors mention, the opposite may, in fact, be the case. We are already seeing some of the effects. First, many mental health professionals seem to be taking an increasing distance from these patients because of their fears of being caught up in the legal process. Common-sense decisions may be delayed because of such concerns, and this endangers patients and their families. Second, because there is a climate of economic restraint the increasing costs of review boards and the advocacy system will indirectly add to the cuts in quantity and quality of services being imposed on our health care system. Last, much has been written on how we must become more client-centred. May I suggest that 434
CAN MED ASSOC J 1992; 146 (4)
the client is being forgotten and even misidentified? The real client is the child who is growing up in a dysfunctional environment that may be violent or neglectful, who is learning to escape from reality and to dehumanize others in order to survive. Our society, our government and many professionals do not yet seem to understand or accept this. As long as our health care system and government are driven by healthy adults it is not surprising that those who benefit (in terms of job creation) from these new developments are lawyers, advocates and bureaucrats. Sooner or later the structure will become too cumbersome and expensive. The process will then have to be decentralized and judgement returned to those closer to the front line. For consumers and health care professionals I hope this will be soon.
action - with all its attendant risks - becomes essential. The open but barred cells of an old prison building are actually advantages in the safe achievement of such goals, and we believe that in this respect our record is as good as that of any modern facility dealing with a similar patient case load. We certainly dispute any comparison with bedlam. It is the lack of a workable legal framework to facilitate our therapeutic endeavour that we protest in our article. Without this, even institutions with the best resources are rendered ineffectual.
Pierre Leichner, MD Kingston, Ont.
Available tests for idiopathic intracranial hypertension
[Two authors respond:] We were well aware that in our article we were describing circumstances and procedures that might shock. We are glad to learn that we have been able to achieve a measured and dignified tone, for we share in some measure Dr. O'Sullivan's outrage that such events are allowed to occur. However, in our experience the humane management of the dangerous mentally ill offender is a complex task with many competing ethical operatives. Safe containment in isolation is well within the means of a modern facility, but it can be only one, hopefully brief, phase of a longterm management program. More important is the establishment of a therapeutic relationship with the disturbed person, preferably in the context of some form of community, however limited. To achieve this, personal inter-
G. Neil Conacher, MB, ChB, MRCPsych, FRCPC Director of psychiatric services Barba J. Clark, BA, CCHRA(A) Mental Health Act coordinator Regional Treatment Centre (Ontario) Kingston, Ont.
W M ) r agnetic resonance imaging (MRI) beautifully delineated the diagnosis and progress in the case described by Drs. Stephen Couban and Charles E. Maxner in "Cerebral venous sinus thrombosis presenting as idiopathic intracranial hypertension" (Can Med Assoc J 1991; 145: 657-659). Unfortunately, this test is not universally available. May I suggest that in a case of intracranial hypertension a nuclear medicine brain scan would also be an excellent test for evidence of significant venous thrombosis? Wamn C. Goldstein, MD, FRCPC 411-250 Harding Blvd. W Richmond Hill, Ont.
[The authors respond:] In assessing patients with idioLE 15 FEVRIER 1992
I want to express my support for the points made by Drs. McCaldon and Conacher and Ms. Clark in their article. Our system for the treatment of acutely psychotic people seems to be caught up increasingly in legal procedures. Although I strongly support a process for improving the quality and quantity of care that psychotic patients receive I believe it is not through increased legalization that this will occur. As these authors mention, the opposite may, in fact, be the case. We are already seeing some of the effects. First, many mental health professionals seem to be taking an increasing distance from these patients because of their fears of being caught up in the legal process. Common-sense decisions may be delayed because of such concerns, and this endangers patients and their families. Second, because there is a climate of economic restraint the increasing costs of review boards and the advocacy system will indirectly add to the cuts in quantity and quality of services being imposed on our health care system. Last, much has been written on how we must become more client-centred. May I suggest that 434
CAN MED ASSOC J 1992; 146 (4)
the client is being forgotten and even misidentified? The real client is the child who is growing up in a dysfunctional environment that may be violent or neglectful, who is learning to escape from reality and to dehumanize others in order to survive. Our society, our government and many professionals do not yet seem to understand or accept this. As long as our health care system and government are driven by healthy adults it is not surprising that those who benefit (in terms of job creation) from these new developments are lawyers, advocates and bureaucrats. Sooner or later the structure will become too cumbersome and expensive. The process will then have to be decentralized and judgement returned to those closer to the front line. For consumers and health care professionals I hope this will be soon.
action - with all its attendant risks - becomes essential. The open but barred cells of an old prison building are actually advantages in the safe achievement of such goals, and we believe that in this respect our record is as good as that of any modern facility dealing with a similar patient case load. We certainly dispute any comparison with bedlam. It is the lack of a workable legal framework to facilitate our therapeutic endeavour that we protest in our article. Without this, even institutions with the best resources are rendered ineffectual.
Pierre Leichner, MD Kingston, Ont.
Available tests for idiopathic intracranial hypertension
[Two authors respond:] We were well aware that in our article we were describing circumstances and procedures that might shock. We are glad to learn that we have been able to achieve a measured and dignified tone, for we share in some measure Dr. O'Sullivan's outrage that such events are allowed to occur. However, in our experience the humane management of the dangerous mentally ill offender is a complex task with many competing ethical operatives. Safe containment in isolation is well within the means of a modern facility, but it can be only one, hopefully brief, phase of a longterm management program. More important is the establishment of a therapeutic relationship with the disturbed person, preferably in the context of some form of community, however limited. To achieve this, personal inter-
G. Neil Conacher, MB, ChB, MRCPsych, FRCPC Director of psychiatric services Barba J. Clark, BA, CCHRA(A) Mental Health Act coordinator Regional Treatment Centre (Ontario) Kingston, Ont.
W M ) r agnetic resonance imaging (MRI) beautifully delineated the diagnosis and progress in the case described by Drs. Stephen Couban and Charles E. Maxner in "Cerebral venous sinus thrombosis presenting as idiopathic intracranial hypertension" (Can Med Assoc J 1991; 145: 657-659). Unfortunately, this test is not universally available. May I suggest that in a case of intracranial hypertension a nuclear medicine brain scan would also be an excellent test for evidence of significant venous thrombosis? Wamn C. Goldstein, MD, FRCPC 411-250 Harding Blvd. W Richmond Hill, Ont.
[The authors respond:] In assessing patients with idioLE 15 FEVRIER 1992
