243 which is the immediate result of a single clearcut episode of trauma and the plane of separation is through normal bone.’ The commonest site for osteochondritis dissecans is the knee but the elbow, ankle, and hip may be affected. The adolescent age-group are most at risk, but the lesion is found into middle age. Symptoms may be vague. There is usually pain and a history of the knee giving way. Small related effusions occur. In this early type of presentation the diagnosis is essentially made on radiographs. There is a characteristic small isolated segment of subchondral bone separated from its bed by a radiotranslucent line which represents soft tissue. In the knee the commonest site is the lateral side of the medial femoral condyle. Symptoms may become more severe owing to complete detachment of the segment, which floats around the joint producing the typical locking and discomfort of a loose body.

Treatment has been reviewed by Aichroth.2 If the symptoms are slight and the fragment remains in place, all that is necessary is advice to stop sporting activities. This may seem harsh to the patient, since the disorder commonly afflicts the vigorous and athletic. Where there is catching and locking, exploration of the joint is necessary. If the fragment is loose it must be removed. The site of origin must be carefully inspected and the crater curetted to avoid leaving segments about to break off. If the fragment has not yet separated it should be drilled with a fine drill-piece in an attempt to stimulate the blood-supply. There seems no strong case for pinning back a loose fragment that has been floating about for some time, as advocated by Smillie,3 although this is a rational procedure for the acute osteochondral fracture of moderate size. In Aichroth’s series the results of simple excision were the same as those of internal fixation, when the lesion was on the weight-bearing surface. Internal fixation has the additional disadvantages that the pins used may have to be removed at a second operation.

POLITICAL PRISONERS

Amnesty International has published a list4 of 99 doctors and other health workers detained for political reasons in 22 countries. The countries are: Argentina, Brazil, Bulgaria, Chile, Cuba, German Democratic

Republic, Haiti, Indonesia, Mali, Morocco, Namibia, Paraguay, Poland, Rhodesia, Romania, Singapore, South Africa, Spain, Taiwan, U.S.S.R., Uruguay, and Yugoslavia. Some of the prisoners are known to have been tortured; others, having been arrested, have disappeared. About three-quarters of the 99 have already been adopted by Amnesty International as prisoners of conscience, while the others are under investigation to see if they qualify as such. In many cases, the prisoners have not been charged or brought to trial, or the details of the charges and sentences have not been made known. Amnesty stresses that most of the health workers have not been arrested as -a direct result of their profes-

1 Green. J P J Bone Jt Surg. 1966, 48B, 83. 2 Aichroth, P ibid. 1971, 53B, 440. 3 Smillie, I Diseases of the Knee, p. 381. Edinburgh, 1974. 4 Medical Personnel in Pnson. Amnesty International, 53 Theobald’s Road London WC1X 851

at a particular time or place. Their propractice as incidenstatus could therefore be

sional fessional tal, but

light on

regarded is that shedding hope presumably Amnesty’s the plight of the medical prisoners may serve to

to the many other men and women also in similar circumstances. The information imprisoned given by Amnesty is, of necessity, scanty, and any attempt to assess the general situation in a country from individual cases is made doubly difficult because the offences prisoners are charged with are not necessarily the real reasons for their imprisonment. One or two of the doctors on the list are in prison as a direct result of having provided medical assistance to outlawed patients. For example, in Indonesia, Dr Mashudi Sumanto gave medical assistance to people who were in hiding after the attempted coup of October, 1965, and he surrendered in 1968 because of threats to his mother. Since then he has been in Buru Island detention camp under a presidential decree which provides for indefinite detention. He is one of thousands imprisoned under this decree in Indonesia; by 1975 over 55 000 political prisoners had spent 10 years in prison without charge or trial. Similarly, in Argentina, Brazil, Chile, Paraguay, and Singapore, doctors and others have been held in prison indefinitely, without charges, under emergency powers. Amnesty claims that the imprisonment of the health workers violates not only the United Nations Universal Declaration of Human Rights, but also two articles of the declaration adopted unanimously by the 29th World Medical Assembly in Tokyo in October, 1975-article 1, which protects a doctor’s right, in any circumstances, to refuse to have anything to do with the practice of to ’r ture or other forms of cruel, inhuman, or degrading procedures, and article 4, which grants him complete clinical independence in deciding upon the care of patients for whom he is responsible. Evidence on torture is hard to come by, but it seems clear that the case of Dr Semyon Gluzman, of the U.S.S.R., relates directly to the first point. Gluzman refused to work at the Dnepropetrovsk special psychiatric hospital because he believed that healthy people were medically "treated" for their political views there, and he subsequently issued statements exposing this practice. He was sentenced to 7 years in a strict-regime labour camp, plus 3 years’ internal exile; he has taken part in a month-long hunger strike in protest, amongst other things, at the practice of forcing political prisoners to help build punishment cells and security structures. The question of professional freedom is to a large extent bound up with that of political freedom. All but 2 of the 33 health workers listed as being political prisoners in the German Democratic Republic have been arrested on charges connected with illegal emigration. The Amnesty introduction states that political presures on doctors there are heavy, permission to specialise and promotion prospects being dependent on demonstrations of ideological conformity, and many of them have chosen to risk crossing the frontier rather than continue to practise in these conditions. Similarly, in South Africa members of the medical profession subject to banning orders have found the restrictions so oppressive as to make the practice of their profession impossible. While Amnesty’s list is short on proof and may be wrong in detail, the burden of the indictment remains. And the doctors represent only a small percentage of the world’s prisoners of conscience.

direct attention

Editorial: Political prisoners.

243 which is the immediate result of a single clearcut episode of trauma and the plane of separation is through normal bone.’ The commonest site for o...
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