52

episodes of cardiac dysrhythmia 10 must be soughtand treated before attention is turned to the pos-sibility of carotid disease as the cause of the attacks.By screening patients for such conditions, an impor-tant minority who are not candidates for endarter-ectomy can be spared angiography.11 A further pointwhich has emerged from twenty years’ experience isthat endarterectomy must be seen as a prophylacticmeasure rather than as a curative measure. Endarter-

ectomy has been disappointing in patients with occlu-sion (complete obstruction) of the internal carotidartery which has already given rise to a completestroke.12 2 In more than half such cases the flowcannot be re-established; and, even when flow is

re-established, there is rarely appreciable clinical

improvement. Endarterectomy is for the patientwith a stenosis who has as yet experienced onlyT.I.A.S. A word is needed on the term " completedstroke ". This is most commonly used of a strokethat has rapidly reached its peak, at which it hasstabilised. But the term may also be used of astroke that has involved the entirety of an arterialterritory, and in this second usage it contrasts withan

"

incomplete " stroke such as a persisting dyspha-sia without hemiplegia. When a patient with theincomplete type of stroke leads a worth-while lifewhich would be seriously impaired if a further strokewere to complete the lesion, the problem should bemanaged as a T.I.A.When carotid stenosis was first recognised as a

cause of T.I.A.S the assumption was made that

narrowing of the artery interfered with flow. Stenosesof less than 25% of the lumen were frequentlydismissed as unimportant. Experiments 13 haveindeed shown that the lumen of the internal carotid

may be reduced by as much as 90% without inter-ference with flow. Stenosis of lesser degree cannot,however, be dismissed as unimportant: circum-stantial, but compelling, evidence 14 has shown thatthe thrombus which forms on a stenosis often givesrise to embolisation of the cerebral vessels and is thecause of most T.I.A.s. Thrombus may also form,when there is no stenosis, on an atheromatous ulcerin the wall of the artery. These ulcers may readilybe missed at angiography unless the bifurcation ofthe common carotid artery is viewed in two planes.Treatment is indicated not only when the artery isstenosed but also when there is atheromatous ulcera-tion.

Against what is endarterectomy prophylactic ?Formerly, ignorance of the natural history of cerebro-vascular disease made it difficult to assess the valueof the operation, but in the past two decades things

10. McAllen, P. M., Marshall, J. ibid. 1973, i, 1212.11. Marshall, J. ibid. 1971, i, 719.12. Thompson, J. E., Austin, D. J., Patman, R. D. Ann. Surg. 1970,

172, 663.13. Brice, J. G., Dowsett, D. J., Lowe, R. D. Br. med. J. 1964, ii, 1363.14. Gunning, A. J., Pickering, G. W., Robb-Smith, A. H. T., Ross

Russell, R. Q. Jl Med. 1964, 33, 155.

have become clearer. MILLIKAN 15 has latelyreviewed the evidence provided by seven series whichshow that 10-35% (mean 28%) of patients withcarotid T.I.A.S go on to develop a completed stroke.This is the hazard endarterectomy seeks to avert.

When stenosis of the artery is so severe that inter-ference with flow is probable, endarterectomy is

clearly the treatment of choice. But when thestenosis is of lesser degree or there is no stenosis butsimply ulceration, the choice between endarterectomyto remove the source of emboli or anticoagulants tosuppress their formation is more difficult. MILLI-KAN 15 assembled 296 anticoagulant-treated patientsand 276 controls from a number of T.I.A. series.4% of the treated patients had cerebral infarction asagainst 29% of the controls. 5% of the treated

patients and 3% of the controls had cerebral

haemorrhage. Anticoagulants therefore seem bene-ficial in this situation. But is endarterectomy stillbetter ? ? The evidence is not compelling. In the

joint study carried out in the United States, among45 patients who had had endarterectomy for unilateralcarotid stenosis there were 1 postoperative death and2 later non-fatal strokes, whereas among 49 patientsnot operated on there were 3 non-fatal and 3 fatalstrokes.16 Uncontrolled surgical series 6,12,17-20 haveproduced varied results; at best the operativemortality is less than 1%, with persisting post-operative neurological defect in 2%. During follow-up some 5% die of a cerebrovascular cause over fiveyears and 10% over ten years. 1% have a non-fatalcompleted stroke. Comparison of the results withthose achieved by anticoagulants is not easy since,apart from the incidence of further strokes, post-operative’mortality and morbidity have to be weighedagainst the complications of anticoagulant therapy.Both treatments are better than doing nothing, and,on balance, operation seems preferable to anti-

coagulants-particularly since the patient does nothave to be under medical care for a long period.

Hospital ComplaintsFOR over twenty-five years the National Health

Service has been coping with complaints about

hospital services without the help of a standard

complaints procedure. Now comes the report of theCommittee on Hospital Complaints Procedure 21 witha new code of practice for investigating complaints.The Committee has not had a free hand: it has had to

negotiate a winding path around three fixed points15. Millikan, C. H. Stroke, 1971, 2, 201.16. Fields, W. S., Maslenikov, V., Meyer, J. S., Hass, W. K., Remington,

R. D., Macdonald, M. J. Am. med. Ass. 1970, 211, 1993.17. De Bakey, M. E., Crawford, E. S., Cooley, D. A., Morris, G. C.,

Garnett, H. E., Fields, W. S. Ann. Surg. 1965, 161, 921.18. Gurdjian, E. S., Darmody, W. R., Lindner, D. W., Thomas, L. M.

Surgery Gynec. Obstet. 1965, 121, 326.19. Kenyon, J. R., Thompson, A. E. Br. med. J. 1965, i, 1460.20. Murphy, F., Maccubin, D. A. J. Neurosurg. 1965, 23, 156.21. Report of the Committee on Hospital Complaints Procedure,

H.M. Stationery Office, 1973.

53

- the untested Health Service Commissioner, theuntried community health councils, and the alreadyoperational Hospital Advisory Service. Nevertheless,Sir MICHAEL DAVIES and his Committee see greatadvantage in introducing the new code now, to

coincide with the reconstruction of the N.H.S.The code itself may best be viewed as a first map of

previously uncharted territory-open to change inthe light of further exploration. It embodies a

straightforward set of principles, but some of thedetails may need radical change, particularly if theHealth Service Commissioner fails to exploit his

role, or if the new community health councils do notseize a full and lively independence. But the philo-sophy underlying the report could do away for everwith the old partisanship which has so often souredthe dialogue between apprehensive hospital anddissatisfied patient. Health authorities are urged toproceed with openness and fairness, moved by a

spirit of genuine inquiry, and this new dimension ofrelationships will no doubt bring its own problems.The Committee stands firmly by the principle

that investigation of complaints is primarily the func-tion of management; that the health authority’sexercise of this function should itself be subject toexternal review; that all formal inquiries be governedby the six cardinal principles set out by the RoyalCommission on Tribunals of Inquiry 22; and, of greatimportance, that the badly enunciated oral complaintof the diffident, unlettered, or mentally disabled

person shall carry as much weight as the most

expertly drafted letter of complaint. There are morecomplaints about medical treatment and care thanabout anything else, and these are the ones whichcause the most trouble-health authorities are

ever-burdened by the fear of the " fishing " com-plaint, the innocent-seeming inquiry with a cash

tag; thus they have tended to act defensively, and toprotect the authority and its staff, rather than toproceed with the complete openness and fairnessadvocated by the report. The Committee seemsconvinced that complainants are rarely motivatedby a desire for punitive damages, and much moreoften by a desire to prevent the same accident

happening to someone else. One hopes that this willcontinue to be so; but not to expect a rise in claimsfor damages is to pit hope against experience. Anypatient dissatisfied with the quality of professionaltreatment has the right to expect that his complaintshall be professionally investigated, but at present nodoctor is ex officio in a position to evaluate thework of a consultant. The Committee suggests an

approach through the chairman of the medical

executive, or of the appropriate Cogwheel division,or through the consultant member of the district

management team. As ever, in these distasteful and

embarrassing circumstances, it is left for doctors

22. Royal Commission on Tribunals of Inquiry. H.M. StationeryOffice, 1966.

themselves to decide how to proceed, and thus theproblem remains largely unsolved, though the Com-mittee suggests that the health authority be free toseek professional assistance from outside. Never-

theless, the report recognises that these methods ofinvolving doctors in dealing with complaints againstdoctors may founder because, in the background,fears of litigation and public discredit loom. Thus,the Committee pins its faith on a new system ofinformal investigating panels, made up of pro-fessionally qualified and lay members, under a

legally qualified chairman. An investigating panelwould assist in the investigation of any complaintthat could be the subject of litigation, whether or notdoctors were involved. Its task would be to establishthe facts without expressing a judgment on possiblenegligence or other matters that should be determinedin court or in disciplinary proceedings. It would

report to the health authority complained against,and to the next higher authority. A complainantdissatisfied by the results of an investigation bymanagement could request the panel to reinvestigate,provided he were able to show that he did not intendto take legal proceedings. A health authority wouldbe equally entitled to ask a panel to investigate acomplaint of this kind. In all, says the Committee,standing investigating panels could develop as a

flexible instrument to assist health authorities to deal

fairly and effectively with complaints about pro-fessional matters. The Committee is so convincedof the central importance of these panels as to claimthat, if they are not established, most of the presentdifficulties and shortcomings in this substantialarea of complaints will continue, and will constitutea black spot on the complaints procedure. Anyoneopposing the idea of the investigating panel is

challenged to produce a better proposal.There is a world of difference between a complaint

by a competent adult whose stay in hospital is

temporary, and the complaint, or worse still the

unspoken misery, of the man or woman whose stayin hospital is indeterminate. The melancholy evi-dence of a series of inquiries is that the

existing complaints procedure has broken down mostdramatically in the hospitals for the mentally sickand handicapped and in long-stay wards for old

people. The Davies Committee, while claimingthat these less articulate and more vulnerable peoplewill enjoy greater safeguards under the new code,rightly states that more is necessary. It advocatesthe active support of external checks and safeguards;it presses for a quality of vigilance in management,particularly at regional level; and it looks for closework by community health councils. The Committeeis surprised and saddened by the decision to reducethe activities of the Hospital Advisory Service: tostop quality control whilst reorganising the headoffice certainly does not seem a good idea. Indeed,the Committee looks for the expansion of this valuable

54

service, and a better deal for the staff who volunteerto work within it. If the Health Service Commis-

sioner, the community health councils, and the Hospi-tal Advisory Service do not flourish, or if they do noteffectively carry out their functions as providers ofexternal checks, the Committee sees a real possibilityof a future Ely, Farleigh, or Whittingham. Com-

munity health councils will have to help patientsmake effective use of the machinery and guide themthrough sometimes bewildering paths. To keep awatch on general standards of service, they willneed a resourceful and penetrating research arm.This may be one of the most important recommen-dations ; without this resource, evaluation will be

unsure, and criticism uncertain. Great benefit to

providers and consumers could flow from a researchunit capable of objective evaluation of the service,particularly if it is independent enough to earn theconfidence of health professionals and patients alike.We hope that the new code will be adopted and usedin the liberal spirit which the Committee has so

successfully conveyed.

OPEN UNIVERSITY MEDICINE?

THE Open University has now been teaching forthree years and its graduates are already making theirmark. Having broken away from many of the tra-ditions of higher education it has received both praiseand criticism, but many of those involved as teachersor students would wish it to develop. For some ninemonths the Open University Society for MedicalSciences, already with a membership of over eighthundred, has been campaigning for a degree coursein medical science at the Open University.’ The

Report on Adult Education, by Sir Lionel Russell’sCommittee, last year recommended that bodiesoffering professional recognition should create op-portunities for adult students to obtain their awardby part-time study and practical work, and this hasnaturally fired the enthusiasm of those interested insomehow increasing the intake of mature studentsinto medicine. The case is, briefly, that the UnitedKingdom needs more doctors and that numbersshould be increased not by reliance on overseas

graduates (a source which may suddenly diminish),nor by radically lifting the intake to conventionalmedical schools, but by allowing students to participatein what is basically a correspondence course in medi-cine. This, it is felt, would fill the need, and at thesame time provide a stimulus to teaching and to thewhole sphere of traditional medicine. Although thecourse would be in the strictest sense " open " (as areall the Open University courses), competition may wellfavour science graduates, hospital technicians, andnurses who for one reason or another had no previousopportunity to study medicine.A conference of the society at Leeds University,

held simultaneously with a meeting of the Open Uni-versity Students Association, was addressed by DrWalter Perry, vice-chancellor of the Open University,1. Shipley, W. I. Lancet, 1973, ii, 1271.

who previously held the chair of pharmacology at

Edinburgh University, when he had a hand in therecasting of the medical curriculum. He gave nocause for optimism, arguing against the proposalsmainly on economic grounds and because of theproblems of clinical teaching. He felt the OpenUniversity might be better used to improve post-graduate medical teaching. Subsequent speakers,including two surgeons, a medical journalist, a

pharmaceutical consultant, and the indefatigablechairman of the Open University Society for MedicalSciences, himself a pharmacist, accepted Dr Perry’sremarks as a challenge. The meeting then discussedthe problems and the ways they could be overcome. IMost of preclinical medicine could be taught by postand tutorials. Many of the traditional methods suchas anatomical dissection were already an anachronism.Ethical and legal problems were minor and could be ;overcome. It was well argued that the Open Univer-sity was substantially cheaper by comparison withfull-time medical teaching, although the true costs

could not be accurately predicted. Clinical teachingwould be much more difficult, but by careful manage-ment the district general hospitals and interestedconsultants could probably cover the ground. Time- Iconsuming for participants it might be, but not

altogether impossible.Postgraduate medical studies by post were strongly

supported, both as a way to get Open Universitymedicine off the ground and to replace some of theless good correspondence courses now used by doctors.The medical members certainly favoured tacklingthis as a priority, with a good chance that under-graduate medicine might follow. Medicine could

only benefit from an influx of older graduates alreadyexperienced in other professions, in industry, or

elsewhere. And medicine would benefit too, byadmitting some of those excellent younger aspirantswho are now disbarred by their unorthodox academicrecords. 2

ROOMING-IN

IN the best-known birth history in Christendom, itseems certain that Mary, like her son, was accom-modated in the stable-mother and child together inthe same room. But in the intervening 2000 years, inthe Western world at least, the practice of rooming-in 3has been eroded. In hospitals, separation of parents andchildren is common in both obstetric and pxdiatricdepartments, though this strange ritual has differentorigins in the two specialties. In paediatrics parentswere, and in a few cases still are, regarded as anirritating nuisance, and " bad for the children " intothe bargain. - It has taken more than 20 years to

repair the damage, and the task is not yet complete.Obstetrically, the separation has been for the benefitof the mothers, to give them maximum peace and restduring the puerperium. Obviously the larger ’the

individual unit the greater the probability that someinfant will disturb the peace beyond a reasonabledegree, so that if there is to be a return to rooming-in,2. Acheson, E. D. ibid. Jan. 5, 1974, p. 26.3. Gesell, A., Ilg, F. Infant and Child Culture of To-day. New York,

1943.