76

which was therefore defined as the period of initialmortality. A serious difficulty in any study of cerebro-vascular disease is that it must deal not with a singleentity but with a variety of syndromes, in severalanatomical sites, whose different pathological changesresult from distinct setiological mechanisms. A

meaningful prognosis cannot be given without first

distinguishing these groups. Cerebral hEemorrhage,for instance, has a mortality of 60-90%,2,3 whereasthe mortality from infarction ranges from 15 to 50 %.2,4,5Yet in clinical practice it is often impossible to makeeven so crude a distinction with accuracy.2,6,7Marquardsen recognised the problem, but he wasunable to solve it, for none of the patients in hisseries had been investigated neuroradiologically andonly a few had a lumbar puncture, which clearlylimits the value of the series.

The most important factor influencing immediatemortality was the state of consciousness. Less than

1% of those who were comatose on admission sur-vived three weeks, compared with 76% of those whowere alert; this finding accords with other serie.3,7,8

Pupillary and respiratory abnormalities, conjugatedeviation of the eyes, and bilateral extensor plantarresponses were bad prognostic signs.

Long-term survival cannot be satisfactorily assessedwithout constructing life tables and comparing themwith tables for the general population of the same ageand sex. By this method Marquardsen found that54% of the patients survived three years, as againstthe expected rate of 88%. Causes of death wererecurrent stroke (23%), myocardial infarction (10%),and heart-failure and bronchopneumonia (30%),emphasising that cerebrovascular disease is only partof a widespread vascular disease. When the survivalcurve was plotted logarithmically it showed that theaverage annual probability of dying for the survivorsof the period of initial mortality was 16% for menand 18% for women. These probabilities did not

change significantly over ten years, indicating that,once the period of initial mortality was over, the riskof dying was related not to the effects of the strokebut to the progression of the underlying vasculardisease. This observation underlines the difficulty ofassessing the value of a prophylactic measure such asendarterectomy; the cause of symptoms, such as acarotid stenosis, may be removed, but the prognosisfor life may remain unchanged. Amongst the factorsinfluencing long-term survival, hypertension andheart-disease again emerge as crucial, as they did inother series5,9—11 apart from those of Droller 12 andMerrett and Adams,13 whose patients were older than

2. Dalsgaard-Nielsen, T. Acta psychiat. scand. 1956, suppl. 108, p.101.

3. McKissock, W., Richardson, A., Taylor, J. Lancet, 1961, ii, 221.4. Glynn, A. A. Br. med. J. 1956, i, 1216.5. Carter, A. B. Cerebral Infarction; p. 169. Oxford, 1964.6. Heasman, M. A., Lipworth, L. Accuracy of Certification of Causes

of Death. Rep. publ. Hlth med. Subj., Lond. 1966, no. 207. Rankin, J. Scott. med. J. 1957, 2, 200.8. Melville, I. D., Renfrew, S. J. Neurol. Neurosurg. Psychiat. 1961,

24, 346.9. Marshall, J., Shaw, D. A. Br. med. J. 1959, i, 1614.

10. Marshall, J., Kaeser, A. C. ibid. 1961, ii, 73.11. Howard, F. A., Cohen, P., Hickler, R. B., Locke, S., Newcomb, T.,

Tyler, H. R. J. Am. med. Ass. 1963, 183, 921.12. Droller, H. Geriatrics, 1965, 20, 630.13. Merrett. J. D., Adams, G. F. Br. med. J. 1966, ii, 802.

those in most other series. Less gloomy prognosticpoints included diffuse cerebral damage, persistentincontinence, failure to gain independence, and anabnormal electrocardiogram.The role that hypertension plays in determining

long-term mortality offers some hope for the future,since hypertension is treatable, though whether theunderlying vascular disease can be sufficientlyretarded to affect mortality has not yet been estab-lished beyond doubt. But there is evidence that thismay be So.14,15

The social problems created by strokes emergeclearly in Marquardsen’s report. Only 52% of thesurvivors of the period of initial mortality achievedindependence. A further 15% were able to walk, butwere not entirely independent, and 14% requiredlong-stay hospital accommodation. Only 33% ofthose who were working before the stroke were ableto return to work. Patients with right-sided lesionswere again found to fare less well in terms of functionalrecovery, presumably because of defects in visual,motor, and spatial concepts.12,13

MISDIRECTED MONEY-RAISING

DOCTORS are on the whole more fortunate thanmost others in what they earn; but they, and con-sequently their widows and their children, are notimmune to financial distress and disaster. For an

unhappy minority the Royal Medical BenevolentFund provides an indispensable lifeline; and the Fundshould be supported by doctors who are able to supportthemselves.16

One aspect of the Fund’s work causes unease. ItsLadies Guild (with branches throughout the country)raises money with which it helps beneficiaries of theFund. The methods adopted by the Guild are some-times embarrassing. At one end of the scale is theannual dance for which lay people have been asked tobuy tickets. At the other end is the public jumble sale(perhaps in a church hall) associated with the Fund’sname. In between are the bring-and-buy sales, withlay-women helping and lay people invited; and thesherry parties (with a charge for admission) where thehapless doctor is apt to be buttonholed by a solicitor,a chartered accountant, or a priest who wants to knowwhy medical people cannot look after their own.Why indeed ? The Ladies Guild seems to enjoy

a large measure of autonomy: its accounts are notincluded in those of the Fund itself. If the Fund is

resigned to the Guild’s catch-as-catch-can method offund-raising (this practice is not universal, but nor is itnew), then it should say so; and some doctors may feela corresponding lightening of their own responsibility.If, on the other hand, the Fund does not approve ofthis approach, then it should monitor the Guild’sactivities and close the branches which continue tooffend. The Ladies Guild should confine itself tomedical households.

14. Leishman, A. W. D. Lancet, 1963, i, 1284.15. Marshall, J. ibid. 1964, i, 10.16. Subscription may be sent to the Secretary, Royal Medical Benevo-

lent Fund, 24 King’s Road, Wimbledon, London S.W.19.