- Email: [email protected]
TREATMENT OF STROKES
268 the expressions: patient-doctor contract, collective medicine, and the leadership role of the doctor. Perhaps the major difficulty to be overcome arising from these differences is that of the conflicting requirements of highquality medicine and of gross quantitative delivery of service. Stages of progress in the Odyssey from underdevelopment to development are evident, and it is possible that no one solution has universal application. But at present many doctors are prevented from utilising to the full the learning which they have acquired by the two factors of excessive demand and poor
facilities. The latter result from economic and educational resources that are strictly limited, and likely to be so for many years to come. Planning for the future must take cognisance of this. There are three possible solutions: to maintain an inadequate flow of high-quality doctors; to substantially lower the standard of doctors and increase output; or to screen the high-quality doctors with auxiliaries. No doubt each method will in the end achieve the same endpoint-namely, the application of the best medicine to the greatest number of people for most of the time. What is at issue is how best to supply the needs of the majority during this somewhat lengthy interim period. Until a decision is made on this point much of the discussion on reform of medical education will be sterile. The last alternative, which is not a compromise, offers the opportunity of affording those in most dire need the best that medicine can offer, whilst offering to the many with lower needs a more modest but adequate service. It offers the doctors and the auxiliaries an opportunity to practise their skills in circumstances more befitting their respective degrees of learning: and thus produces job-satisfaction and a solution to maldistribution. If this is accepted, then the need for quality in the doctor becomes more evident, and his education requires revision accordingly, with a stronger bias towards social responsibilities. As the economic and educational resources improve, so the emphasis on quantitative production will shift from the auxiliary to the professional: but at all times the gap between the two should be clear and distinct. You rightly emphasise two important aspects in your leaderinternational schools, whose possibilities have yet to be fully explored and exploited, and education in the local milieu. The latter, I think, needs clarification. The multiplication of medical schools is limited by economic and educational resources, and there is little prospect of achieving one school for every two and a half million people. More emphatically, there is little hope of achieving a sufficiency of teaching at the basic-medical-science level. At the basic-science level there is the prospect of concentrating resources in a pre-university school. At the clinical level there are many excellent hospitals in the main urban centres of the underdeveloped territories, which could with a little assistance become clinical teaching centres. The main bottle-neck at the basic-medical-science level could be widened by developing courses in social and biological sciences at international centres. The siting of such international centres would require the prior and careful consideration of selection criteria, such as political stability, social and economic status, and source of funds. Moreover, such a proposition would not deprive individual countries of their natural desire to train their own doctors, whilst concentrating resources where the deficiency is greatest. The encouragement of clinical teaching centres in a country is a sure way of maintaining local standards. The expansion of existing medical schools overseas on a regional international basis is a second but less satisfactory solution. Undergraduate training in the schools of industrialised countries IS the least happy solution. How does a medical student. educated under such optimal circumstances, and possibly having had postgraduate education as well, react and adiust to the minimal conditions of his own country ? Does aggravate maldistribution ? At postgraduate level, there should be a reasonable chance of readjustment. but the difficulties even at this level are illustrated by your quotation from Dr. Lenrie Peters. How many come to be educated and how many to acquire a certificate ? this
not
At this level there might well be a two-stage programme combining the bulk of the teaching locally with the final " polishing " prior to examination overseas. A necessary prerequisite to acceptance at overseas postgraduate centres could be the acquisition of a local degreee.g., M.M. (master of medicine)-which could be recognised for all but the most exacting of consultative posts. These two proposals, on the delivery of services and on
education,are complementary. They are put forward, also, on the understanding that comparability of standards does not necessarily imply comparability of content. N. R. E. FENDALL. WHY DO WE STILL NOT TELL?
SIR,-The need
improve communication between which doctor and patient, your leading article (Jan. 9) draws attention, is important not only for the reasons which you outlined, but also because it is essential to the flourishing of medical research in Britain. to
to
The ominously increasing influence of an uninformed climate of opinion is restricting the use of patients for research purposes. It is surely no accident that the move to thwart research activity has sprung from the laudable efforts of the general public to form " patient protection societies "-which themselves originated in part from a desperate effort to force the doctors to communicate more fully with their patients. If the attitude of British doctors continues to make medicine " a mystery ", the public will remain ignorant of the imperative need to use the patient as a tool in research. One can quite well imagine Joe Bloggs saying: " Well, the doctor won’t tell me what is going wrong, and why, and what he’s going to do about it, and what my chances are, even when he’s doing his best job in the ordinary way. So why should I let him muck about with me just so that he can do his bit of interesting research?" But let Joe Bloggs and his wife know what problems are to be faced, and an army of enthusiastic helpers in research activities will rapidly be gathered, for the public will then understand that they are indeed coworkers in the struggle to advance the health of the nation.
An informed public, accustomed in its role as patient to confident communication with the doctor, will agree with surprising, often moving, eagerness to cooperate in research projects designed to raise the level of medical care and understanding. These are the facts of life as I have seen them in the United States. I am sure that if the doctors in Britain continue to hold aloof from sympathetic communication with their patients, research will wither, for the days when penurious patients could be dragooned into providing " warm bodies " have gone for ever. Section of Anesthesiology,
Department of Surgery, University of Chicago, Chicago, 37, Illinois.
J. SELWYN CRAWFORD.
TREATMENT OF STROKES
SIR,-While welcoming the new venture in postgraduate medical education by television, one must deplore several things which were said about strokes in the opening programme. The programme was concerned with rehabilitation but it opened with remarks which gave the impression there is nothing to be done about strokes before the stage of rehabilitation. was said, for instance, that since strokes are largely due degenerative vascular disease prevention will not be possible until we discover the cause. This ignores the important contribution high blood-pressure makes to the genesis of strokes, a condition which can be treated. It also ignores the fact that a high proportion of strokes are preceded by transient
It
to
ischsmic attacks. Action at this stage may well prevent a more serious vascular lesion. A second remark was that reconstruction of arteries is rarely
269 In fact about 15 % of acute strokes are associated with lesions in the internal carotid artery in the neck and many of these, especially if caught at the premonitory stage, are amenable
possible.
to surgery.
Finally, it was suggested that anticoagulants were out of favour. It is true that it has been shown they have no place in the management of the completed stroke, but the stroke-inevolution and transient ischaemic attacks undoubtedly benefit. There is a great deal of prevention and treatment which be applied and more will be possible if we remain alert and are not lulled into believing, as was suggested in this programme, that there is nothing to be done about strokes. can
of Clinical Neurology, The National Hospital, Queen Square, London, W.C.1.
University Department
JOHN MARSHALL.
NEW HOSPITALS: SINGLE OR MULTIPLE?
SIR,-There is growing frustration among doctors in this country; we feel we can no longer influence and change a defective service. One day those in authority will we workers in the field are often in the best advise on, and guide, the service. In Leicester position we consultants recommended to our regional hospital board that we should plan for the future a single hospital or hospital centre for our city and county, which have a population of perhaps 500,000. The advantages of such
realise that to
a
plan are:
Economy in cost and personnel-the latter being particularly important in a non-teaching centre. In the physiotherapy, radiology, dietetic, casualty, and pathological departments tremendous economies would be made by centralisation. Furthermore, a single nursing school would have more flexibility in times of shortage and would provide more comprehensive training facilities without the necessity for secondment to special hospitals. Economies in medical manpower would result from the reduction of travelling between hospitals and the availability of a larger resident and non-specialist staff to cover shortages. 2. Much more important, the quality of medicine practised would be improved greatly. Doctors of all levels would be in constant touch with each other; clinical conferences, discussions, and teaching sessions would all be in the same place; and research and teaching would be assisted. General practitioners must be encouraged to come to hospital conferences and informal discussions with consultants; they cannot be expected to go round multiple hospitals. Instead of several hospitals having indifferent and partly duplicated libraries, there would be only one-well-stocked and with a paid librarian able to look up references, get out papers, and generally provide the help needed for research and learning. 3. The ultimate object, of course, is to improve the quality of our service to the patients. I suggest that this would necessarily follow from the foregoing. We are not allowed this vision; we are to have 2, and possibly 3, district general hospitals at different points in the city several miles apart. The only reasons given for 1.
this
that: (a) it is difficult to administer a large unit is no real problem since separate blocks can have separate administrators, but we want them on the same site) and (b) hospitals must be near the people they serve. It is my experience that the public would willingly travel a few more miles if, at the end, there were a better service. In this connection, I am sure we should not are
(clearly this
submit to " popular " pressures where we feel these pressures would impair our service. We are thus having a hospital service planned for us against the advice of local consultants without adequate reasons. Perhaps someone in Whitehall has decided that a district general hospital shall be of a certain maximum
size and that multiple hospitals must be provided where the population requires it. I suggest that this sort of rigid thinking is wrong: our local problems should be considered first and then their best solution. There is surely room for experimentation and flexibility if we are to progress; here we all want a single medical centre; another city might prefer three hospitals. At all events, I hope those in high positions will look at our frustration before it
apathy.
turns to Leicester General Hospital, Leicester.
P. HICKINBOTHAM.
IMMUNOALLERGIC LUNG PURPURA TREATED WITH AZATHIOPRINE SIR,-The report by Dr. Steiner and Dr. Nabrady (Jan. 16) is of considerable interest. They point out that the possibility of spontaneous remission of idiopathic pulmonary haemosiderosis must be excluded. This is most important in a disease characterised by natural remissions, some of which may be complete and last for years. No doubt this fact is responsible for the enthusiastic claims for a wide variety of therapeutic measures.
Although the case-report of Dr. Steiner and Dr. Nabrady suggests a dramatic response to azathioprine, one wonders whether they are justified in precluding "
coincidence ".
mere
Bignold Hospital, Wick, Caithness, Scotland.
DAVID H. A. BOYD.
ANTIVIRAL AGENTS
SIR,-Your annotation (Jan. 16) discusses the imporof toxicity in the use of these compounds and their limitations if used at a time when characteristic pathological changes have appeared, but when virus titres have already commenced to fall. Support for this can certainly be found in the treatment of recurrent herpes simplex skin infections, in which 5-iodo2’-deoxyuridine has been shown to be ineffective in the majority of cases treated by topical applications, and which is too toxic for parenteral administration. An investigation in virus isolation from the lesions of herpes genitalis was recently carried out in conjunction with the Virus Reference Laboratory, Colindale. Herpes simplex virus was isolated from superficial scrapings of most lesions which had persisted for an average duration of 3-85 days, but rarely from lesions which had persisted for an average of more than 8-26 days. In those lesions which had persisted for 1 day the virus was present in 81-8% of cases, whereas no virus was isolated from lesions which had persisted for more than 14 days: it was, however, present in 50% of cases in lesions which had persisted for 5, 6, or 8 days. In
tance
the virus was isolated from fluid obtained from bullae, which were seen in 25 % of patients attending. During this investigation it was noted that most patients attended with lesions that had been present for an average time of 5-7 days, or at a time in which the virus was found to be present in 50% of cases. Topical therapy with an antiviral agent given at this time would be fully effective in only 50% of cases. Parenteral therapy, however, might still be effective in all cases should the virus be in cells deeper in the lesions or in nerve-endings or in other places hitherto unknown. Parenteral therapy would also probably be more effective in vesicular lesions, since the virus is concentrated in the basal layers and fluid of vesicles, or in a situation relatively inaccessible to topical application, unless ruptured mechanically. Parenteral therapy would appear to be the effective form of treatment for recurrent cases, in which the virus is thought to remain latent in the tissues between attacks and for which topical applications of an antiviral agent have been found to be useless.l Finally, it might be the only effective method of treatment in cases of
every
case
vesicles
or
1.
Hutfield,
D. C. Brit.
J.
vener.
Dis. 1964,
40,
210.
facilities. The latter result from economic and educational resources that are strictly limited, and likely to be so for many years to come. Planning for the future must take cognisance of this. There are three possible solutions: to maintain an inadequate flow of high-quality doctors; to substantially lower the standard of doctors and increase output; or to screen the high-quality doctors with auxiliaries. No doubt each method will in the end achieve the same endpoint-namely, the application of the best medicine to the greatest number of people for most of the time. What is at issue is how best to supply the needs of the majority during this somewhat lengthy interim period. Until a decision is made on this point much of the discussion on reform of medical education will be sterile. The last alternative, which is not a compromise, offers the opportunity of affording those in most dire need the best that medicine can offer, whilst offering to the many with lower needs a more modest but adequate service. It offers the doctors and the auxiliaries an opportunity to practise their skills in circumstances more befitting their respective degrees of learning: and thus produces job-satisfaction and a solution to maldistribution. If this is accepted, then the need for quality in the doctor becomes more evident, and his education requires revision accordingly, with a stronger bias towards social responsibilities. As the economic and educational resources improve, so the emphasis on quantitative production will shift from the auxiliary to the professional: but at all times the gap between the two should be clear and distinct. You rightly emphasise two important aspects in your leaderinternational schools, whose possibilities have yet to be fully explored and exploited, and education in the local milieu. The latter, I think, needs clarification. The multiplication of medical schools is limited by economic and educational resources, and there is little prospect of achieving one school for every two and a half million people. More emphatically, there is little hope of achieving a sufficiency of teaching at the basic-medical-science level. At the basic-science level there is the prospect of concentrating resources in a pre-university school. At the clinical level there are many excellent hospitals in the main urban centres of the underdeveloped territories, which could with a little assistance become clinical teaching centres. The main bottle-neck at the basic-medical-science level could be widened by developing courses in social and biological sciences at international centres. The siting of such international centres would require the prior and careful consideration of selection criteria, such as political stability, social and economic status, and source of funds. Moreover, such a proposition would not deprive individual countries of their natural desire to train their own doctors, whilst concentrating resources where the deficiency is greatest. The encouragement of clinical teaching centres in a country is a sure way of maintaining local standards. The expansion of existing medical schools overseas on a regional international basis is a second but less satisfactory solution. Undergraduate training in the schools of industrialised countries IS the least happy solution. How does a medical student. educated under such optimal circumstances, and possibly having had postgraduate education as well, react and adiust to the minimal conditions of his own country ? Does aggravate maldistribution ? At postgraduate level, there should be a reasonable chance of readjustment. but the difficulties even at this level are illustrated by your quotation from Dr. Lenrie Peters. How many come to be educated and how many to acquire a certificate ? this
not
At this level there might well be a two-stage programme combining the bulk of the teaching locally with the final " polishing " prior to examination overseas. A necessary prerequisite to acceptance at overseas postgraduate centres could be the acquisition of a local degreee.g., M.M. (master of medicine)-which could be recognised for all but the most exacting of consultative posts. These two proposals, on the delivery of services and on
education,are complementary. They are put forward, also, on the understanding that comparability of standards does not necessarily imply comparability of content. N. R. E. FENDALL. WHY DO WE STILL NOT TELL?
SIR,-The need
improve communication between which doctor and patient, your leading article (Jan. 9) draws attention, is important not only for the reasons which you outlined, but also because it is essential to the flourishing of medical research in Britain. to
to
The ominously increasing influence of an uninformed climate of opinion is restricting the use of patients for research purposes. It is surely no accident that the move to thwart research activity has sprung from the laudable efforts of the general public to form " patient protection societies "-which themselves originated in part from a desperate effort to force the doctors to communicate more fully with their patients. If the attitude of British doctors continues to make medicine " a mystery ", the public will remain ignorant of the imperative need to use the patient as a tool in research. One can quite well imagine Joe Bloggs saying: " Well, the doctor won’t tell me what is going wrong, and why, and what he’s going to do about it, and what my chances are, even when he’s doing his best job in the ordinary way. So why should I let him muck about with me just so that he can do his bit of interesting research?" But let Joe Bloggs and his wife know what problems are to be faced, and an army of enthusiastic helpers in research activities will rapidly be gathered, for the public will then understand that they are indeed coworkers in the struggle to advance the health of the nation.
An informed public, accustomed in its role as patient to confident communication with the doctor, will agree with surprising, often moving, eagerness to cooperate in research projects designed to raise the level of medical care and understanding. These are the facts of life as I have seen them in the United States. I am sure that if the doctors in Britain continue to hold aloof from sympathetic communication with their patients, research will wither, for the days when penurious patients could be dragooned into providing " warm bodies " have gone for ever. Section of Anesthesiology,
Department of Surgery, University of Chicago, Chicago, 37, Illinois.
J. SELWYN CRAWFORD.
TREATMENT OF STROKES
SIR,-While welcoming the new venture in postgraduate medical education by television, one must deplore several things which were said about strokes in the opening programme. The programme was concerned with rehabilitation but it opened with remarks which gave the impression there is nothing to be done about strokes before the stage of rehabilitation. was said, for instance, that since strokes are largely due degenerative vascular disease prevention will not be possible until we discover the cause. This ignores the important contribution high blood-pressure makes to the genesis of strokes, a condition which can be treated. It also ignores the fact that a high proportion of strokes are preceded by transient
It
to
ischsmic attacks. Action at this stage may well prevent a more serious vascular lesion. A second remark was that reconstruction of arteries is rarely
269 In fact about 15 % of acute strokes are associated with lesions in the internal carotid artery in the neck and many of these, especially if caught at the premonitory stage, are amenable
possible.
to surgery.
Finally, it was suggested that anticoagulants were out of favour. It is true that it has been shown they have no place in the management of the completed stroke, but the stroke-inevolution and transient ischaemic attacks undoubtedly benefit. There is a great deal of prevention and treatment which be applied and more will be possible if we remain alert and are not lulled into believing, as was suggested in this programme, that there is nothing to be done about strokes. can
of Clinical Neurology, The National Hospital, Queen Square, London, W.C.1.
University Department
JOHN MARSHALL.
NEW HOSPITALS: SINGLE OR MULTIPLE?
SIR,-There is growing frustration among doctors in this country; we feel we can no longer influence and change a defective service. One day those in authority will we workers in the field are often in the best advise on, and guide, the service. In Leicester position we consultants recommended to our regional hospital board that we should plan for the future a single hospital or hospital centre for our city and county, which have a population of perhaps 500,000. The advantages of such
realise that to
a
plan are:
Economy in cost and personnel-the latter being particularly important in a non-teaching centre. In the physiotherapy, radiology, dietetic, casualty, and pathological departments tremendous economies would be made by centralisation. Furthermore, a single nursing school would have more flexibility in times of shortage and would provide more comprehensive training facilities without the necessity for secondment to special hospitals. Economies in medical manpower would result from the reduction of travelling between hospitals and the availability of a larger resident and non-specialist staff to cover shortages. 2. Much more important, the quality of medicine practised would be improved greatly. Doctors of all levels would be in constant touch with each other; clinical conferences, discussions, and teaching sessions would all be in the same place; and research and teaching would be assisted. General practitioners must be encouraged to come to hospital conferences and informal discussions with consultants; they cannot be expected to go round multiple hospitals. Instead of several hospitals having indifferent and partly duplicated libraries, there would be only one-well-stocked and with a paid librarian able to look up references, get out papers, and generally provide the help needed for research and learning. 3. The ultimate object, of course, is to improve the quality of our service to the patients. I suggest that this would necessarily follow from the foregoing. We are not allowed this vision; we are to have 2, and possibly 3, district general hospitals at different points in the city several miles apart. The only reasons given for 1.
this
that: (a) it is difficult to administer a large unit is no real problem since separate blocks can have separate administrators, but we want them on the same site) and (b) hospitals must be near the people they serve. It is my experience that the public would willingly travel a few more miles if, at the end, there were a better service. In this connection, I am sure we should not are
(clearly this
submit to " popular " pressures where we feel these pressures would impair our service. We are thus having a hospital service planned for us against the advice of local consultants without adequate reasons. Perhaps someone in Whitehall has decided that a district general hospital shall be of a certain maximum
size and that multiple hospitals must be provided where the population requires it. I suggest that this sort of rigid thinking is wrong: our local problems should be considered first and then their best solution. There is surely room for experimentation and flexibility if we are to progress; here we all want a single medical centre; another city might prefer three hospitals. At all events, I hope those in high positions will look at our frustration before it
apathy.
turns to Leicester General Hospital, Leicester.
P. HICKINBOTHAM.
IMMUNOALLERGIC LUNG PURPURA TREATED WITH AZATHIOPRINE SIR,-The report by Dr. Steiner and Dr. Nabrady (Jan. 16) is of considerable interest. They point out that the possibility of spontaneous remission of idiopathic pulmonary haemosiderosis must be excluded. This is most important in a disease characterised by natural remissions, some of which may be complete and last for years. No doubt this fact is responsible for the enthusiastic claims for a wide variety of therapeutic measures.
Although the case-report of Dr. Steiner and Dr. Nabrady suggests a dramatic response to azathioprine, one wonders whether they are justified in precluding "
coincidence ".
mere
Bignold Hospital, Wick, Caithness, Scotland.
DAVID H. A. BOYD.
ANTIVIRAL AGENTS
SIR,-Your annotation (Jan. 16) discusses the imporof toxicity in the use of these compounds and their limitations if used at a time when characteristic pathological changes have appeared, but when virus titres have already commenced to fall. Support for this can certainly be found in the treatment of recurrent herpes simplex skin infections, in which 5-iodo2’-deoxyuridine has been shown to be ineffective in the majority of cases treated by topical applications, and which is too toxic for parenteral administration. An investigation in virus isolation from the lesions of herpes genitalis was recently carried out in conjunction with the Virus Reference Laboratory, Colindale. Herpes simplex virus was isolated from superficial scrapings of most lesions which had persisted for an average duration of 3-85 days, but rarely from lesions which had persisted for an average of more than 8-26 days. In those lesions which had persisted for 1 day the virus was present in 81-8% of cases, whereas no virus was isolated from lesions which had persisted for more than 14 days: it was, however, present in 50% of cases in lesions which had persisted for 5, 6, or 8 days. In
tance
the virus was isolated from fluid obtained from bullae, which were seen in 25 % of patients attending. During this investigation it was noted that most patients attended with lesions that had been present for an average time of 5-7 days, or at a time in which the virus was found to be present in 50% of cases. Topical therapy with an antiviral agent given at this time would be fully effective in only 50% of cases. Parenteral therapy, however, might still be effective in all cases should the virus be in cells deeper in the lesions or in nerve-endings or in other places hitherto unknown. Parenteral therapy would also probably be more effective in vesicular lesions, since the virus is concentrated in the basal layers and fluid of vesicles, or in a situation relatively inaccessible to topical application, unless ruptured mechanically. Parenteral therapy would appear to be the effective form of treatment for recurrent cases, in which the virus is thought to remain latent in the tissues between attacks and for which topical applications of an antiviral agent have been found to be useless.l Finally, it might be the only effective method of treatment in cases of
every
case
vesicles
or
1.
Hutfield,
D. C. Brit.
J.
vener.
Dis. 1964,
40,
210.