- Email: [email protected]
A NOTE ON THE FIBERSCOPE
88 Division of the Canadian Medical Association. Again I say let fulfil our traditional oath and do our duty outside the Act." But the great majority of the profession here were not of like mind, and the Emergency Medical Service based on the hospitals has gone into effect giving free but only emergency treatment. The indications for Government action in the medical
us
sphere were not as urgent in Saskatchewan as for instance in Britain in 1948. Indications there are, but I suspect that they are felt chiefly, if not solely, by the urban general practitioner, whose major surgical privileges are inevitably contracting and who therefore has to rely more and more on an income derived from numerous small fees. Those of us who have supported the plan-at least in principle-have had awkward decisions to make, mostly in isolation. We have been troubled by the haste in the Government’s moves. They have condensed into about six months changes which perhaps would have been better spread over two years. They delayed making concessions to the profession until after the recent Federal election of June 18, while preparations for the Emergency Medical Service were gaining a momentum of their own. On the other hand, our representatives’ advice to us to close our offices presented us with a difficult choice, between allegiance to our patients and allegiance to our profession. It is easier for a general practitioner, being independent of referral by other doctors, to come to a decision; but it has not been easy for anyone, whatever their decision.
to do so. The tip then be pushed through the pylorus (not an easy matter if the tube itself is flexible and the walls of the organ surrounding it offer no resistance and little guidance). Then the pylorus must be clearly identified as something more than an interruption in a series of rhythmic waves. Lastly, there is the difficulty of scrutinising the walls of a small cavity not much larger than the gastroscopic head. These have proved troublesome in my use of the fiberscope so that I have never been able to convince myself that the duodenum has been entered. Avery Jones and Kellockhave reported their own inability to do this except at laparotomy. Benedict3 says significantly "... it will be possible to inspect the duodenum ". Burnett 4 writes with reserve " duodenoscopy is often possible ...". Although published reports are scanty some workers have commented on the difficulty of passing through the pylorus with the fiberscope.
duodenum, it is
must
not easy to
compel them
first reach the antrum; it
must
Hirschowitz, however, did not find any such difficulties. He writes: " It has been possible to examine the bulb in all thirty patients in which the manoeuvre has been attempted. Passage through the pyloric sphincter is easy to recognise. The bulbar mucosa is a lighter shade of pink than the antrum and is more succulent than the antral mucosa."
He found no difficulty in inspecting the vaulted shape of the bulb, the walls of which could be compressed through the abdominal wall. Colour photographs of duodenal ulcers seen with the fiberscope were reproduced but admittedly these were as yet not of very high quality or clarity. ADVANTAGES AND DISADVANTAGES
Lord
Taylor
to
At the request of the Saskatchewan Government, Lord Taylor is going to Saskatoon to advise on the controversy. Member of Parliament from 1945 to 1950, he has had wide experience of medical administration and is the author of Good General Practice published for the Nuffield Provincial Hospitals Trust. The Times is wrong in describing him as an assistant editor of The Lancet-an appointment he relinquished on joining the Royal Naval Medical Service in 1939-but we join in hoping that he may be able to help in bringing the two sides
closer together.
A NOTE ON THE FIBERSCOPE ROBERT KEMP M.D. CONSULTANT
PHYSICIAN,
Lpool, M.R.C.P. HOSPITAL, LIVERPOOL, 9, HOSPITAL, LIVERPOOL, 6
WALTON
NEWSHAM GENERAL
AND
IN 1932 Schindler introduced his semi-flexible gastroscope which
immediately supplanted
the
dangerous rigid
With the Wolf-Schindler instrument or instrument. Hermon Taylor’s modification it is usually possible to see fully into the antrum itself. One can watch the concentric waves of peristalsis pass distally until they reach the pylorus, which pouts almost contemptuously, and emits a bubble or two. For years one has faced this frustration built into the available instruments-that of never being able to see into the duodenum, where nearly all of our problems of ulcer management lie. This is primarily due to optical limitations and to difficulty in flexing the instrument through an angle large enough to round the angulus and press forward. The claim by Hirschowitz1 that his new fiberscope had no such angular limitation and that through it the duodenal bulb could be inspected,
important breakthrough. problems of practice to solve. is fiberscope completely flexible and although
promised There
a most
are some
The flexible tubes, 1.
given time Hirschowitz,
most
and encouragement, will enter the B. I.
Lancet,
1961, i, 1074.
nearly twenty fiberscopes have reached this Their country. high cost (over E600) is not surprising, since an immense amount of fine optical work must go into each. My own experience in the last six months seems to justify a preliminary note as to its value. It has been used in conjunction with either the usual Hermon Taylor instrument or the original Wolf-Schindler model. Patients have been prepared for the examination with atropine, cough suppressants, and amethocaine lozenges. They are placed at first in the left lateral position and later when necessary in the prone and right lateral positions. Usually one or other of the semirigid gastroscopes was passed first, and then the fiberscope. The obvious advantages are: (1) It passes easily and safely into the stomach. (2) The glass-fibre optical system is first class and will outmode the prism. (3) Photography is possible because of the much better light transmission. (4) Clear, indeed beautiful, pictures of the antrum can often (but not always) be obtained. In short the great merit of the new instrument must rest on its glass-fibre optical system. In its present form its is and drawbacks must be faced. The limited, scope following criticisms are made in the certainty that most of them can be overcome by further development: Up
Advise Government
to now
The excessive flexibility means that one cannot control the of the fiberscope head or push it directly forward. Rotation is, of course, possible, but the instrument naturally lies in the stomach along the greater curvature; hence pressure from above is as likely to increase the length of the bend as to advance the tip. This contrasts with the semirigid instrument which lies along the lesser curvature and posterior wall and does not coil up in the stomach. Nor is it easy to cajole the head into the antrum by positioning the patient or by abdominal palpation. In practice the tip can usually reach the antrum the long way round; but further progress is a matter of chance rather than certainty. Even so in my experience the antrum is seen far more readily
position
2. Jones, F. A., Kellock, T. D. ibid. 1961, p. 1285. 3. Benedict, E. B. Gastroenterology, 1962, 42, 171. 4. Burnett, W. Scot. med.J. 1962, 8, 114.
89 than the body of the stomach. In fact, gastric ulcers-easily seen with the conventional instruments-have never been visible with the fiberscope. Even focusing the gastric mucosa has been difficult. This is what one would expect with a freely mobile instrument without any control of the head, and with a short focusing range. One can neither move the patient round a fixed point of observation nor move a controlled objective inside the patient. MODIFICATIONS NEEDED
The failure of experienced gastroscopists to improve their results suggests that the fiberscope, excellent in principle, needs important modifications. (1) More stiffening is needed to strengthen the instrument so that it can be pushed forward in a straight line without buckling. (2) The proximal third needs more rigidity to keep the line of advance close to the lesser curve and posterior wall, and to enter the antrum by turning the angulus. (3) The distal third should be flexible in two directions as with the present Hermon Taylor pattern. (4) The Bowden cables required for this could replace the cables at present used to give distal focusing. A fixed-focus objective is probably all that is needed so long as the tip can be moved to-andfro. In addition, a smaller head would be an advantage for duodenoscopy. Undoubtedly the safety factor of a fully flexible gastroscope is high, but it remains to report an odd and almost
inexplicable mishap. The patient was a young man with a duodenal ulcer that had bled. Introduction was uneventful, and a fair view of the antrum was obtained. During the examination the patient belched and the stomach had to be reinflated-perhaps overinflated-because finally he gave an explosive belch. Because the examination was now complete, it was decided to withdraw the instrument. During withdrawal the patient complained of pain when the tip was at about the level of the cardia, and some slightly increased resistance was met after this. When the tip was at about the level of the pharynx it stuck, but after the patient had swallowed, withdrawal was completed. It was then found that the last three inches of the gastroscope had been forcibly bent, and had been drawn up through the cesophagus like a crochet hook. The force needed to bend the instrument into a j-shape had been such that the spiral metal sheath had been forcibly and permanently separated by the kinking. The patient was treated conservatively for oesophageal damage, but luckily no evidence of any trauma appeared. This alarming event cannot be easily explained, but there seem to be two possibilities. The first is that during the introduction the tip made a u-tum in the pharynx as a stomach tube may do, and went down as well as up in this fashion. One would, however, expect the kink to have straightened out in the stomach, or at least at the cardia, on withdrawal. The second possibility is that the explosive belch whipped the tip through the cardia before withdrawal, leaving the rest of the gastroscope hanging in a loop in the stomach. Whatever the explanation, and however rare or improbable the accident, this must be an unusual drawback of extreme flexibility. Luckily the optical system was not damaged. A similar type of injury can of course result from a patient damaging the spiral armour by a strong bite. Looking at a duodenal ulcer crater poses difficulties akin to direct inspection of the craters on the moon. In the fiberscope we have an instrument with both the range and the efficiency needed; to this must be added direction and control. My strong feeling is that the proper course to set for the duodenum is the old one-down the posterior wall and the lesser curve. Thereafter the angulus should be turned under full control, and the pyloric canal approached and entered under direct vision. Before the claims originally made in regard to duodenoscopy can be fully upheld, the manufacturers will have to produce an
improved
pattern.
HEALTH SERVICES
IN 1961
FIGURES in the Ministry of Health’s latest annual report1 seem substantially to viridicate the hope that, under the Mental Health Act of 1959, compulsion would be applied to the admission of patients to psychiatric beds only where this was really necessary in the interest of the patient or of the community, and that, in general, mental disorder would be dealt with in the same way as other kinds of illness. The main provisions of the Act, including those dealing with compulsory powers, came into effect on Nov. 1, 1960. Statistics are now available for the ensuing six months. At April 30, 1961, over 90% of the patients occupying psychiatric beds were in hospital on an informal basis (the percentages for different categories were: mental illness 92-5, psychopathic disorder 51-6, subnormality 82-6, severe subnormality 88-7; all 90-7). Until 1958, virtually all mental defectives (who would now be classified as suffering from severe subnormality, subnormality, or, in a few cases, psychopathic disorder) were subject to compulsory detention under the Mental Deficiency Acts. In the first six months after the new Act came into force, nearly 80% of all admissions to psychiatric beds were informal; and, where compulsory powers were needed, it was the provisions for compulsory admission for a period of observation that were mainly used. The percentages for informal admissions were: mental illness 79-0, psychopathic disorder 79.0, subnormality 75 1, severe subnormality 94-3; all 79-3. The contrast with the past is again greatest in the case of the subnormal and severely subnormal, virtually all of whom would until 1958 have been admitted under compulsory powers. * * *
Other features of the report include the following:
Hospital waiting-lists.-The number of patients whose names hospital waiting-lists at the end of 1961 was about
were on
than at the end of 1960. The increase did not take in place every region; but where it occurred it was mainly in the surgical specialties. Waiting-lists in their present form are not an accurate index of the unsatisfied demand for hospital 9000
more
inpatient care. Average stay in hospital.-The reduction in length of stay of patients in hospital continued same rate as
the average about the
at
in 1960.
Consultants.-During the year the Ministry approved increases in hospital consultant staff equivalent to 160 wholetime consultants (170 in 1960). The increases were greatest in psychiatry (34), general medicine (18), and pathology (16). Applications for additional posts in psychiatry exceeded the number of potential candidates by a substantial margin. General practice.-The number of principals providing general medical services at Oct. 1, 1961, was 20,188, compared with 19,928 at July 1, 1960. Of these principals 72% were in partnership, compared with 70 3% in 1960. The number of permanent assistants decreased from 1345 at July 1, 1960, to 1169 at Oct. 1, 1961. The average number of patients on the National Health Service lists of principals rose between July 1, 1960, and Oct. 1, 1961, from 2287 to 2292; but these figures conceal some inflation by the continued inclusion in doctors’ lists of names which should no longer be there. Pharmaceutical services.-In 1961 the average cost per prescription to the N.H.S. was 8s. 1-3d.’ Between 1957 and 1960 the average cost rose by 4-6d. each year. These increases were almost entirely due to changes in prescribing practice following the introduction of new and more effective, but more 1. Report of the Ministry of Health for the Year ended Dec. 31, 1961. Part l: Health and Welfare Services. Office. Pp. 250. 15s.
Cmnd 1754.
H.M.
Stationery
us
sphere were not as urgent in Saskatchewan as for instance in Britain in 1948. Indications there are, but I suspect that they are felt chiefly, if not solely, by the urban general practitioner, whose major surgical privileges are inevitably contracting and who therefore has to rely more and more on an income derived from numerous small fees. Those of us who have supported the plan-at least in principle-have had awkward decisions to make, mostly in isolation. We have been troubled by the haste in the Government’s moves. They have condensed into about six months changes which perhaps would have been better spread over two years. They delayed making concessions to the profession until after the recent Federal election of June 18, while preparations for the Emergency Medical Service were gaining a momentum of their own. On the other hand, our representatives’ advice to us to close our offices presented us with a difficult choice, between allegiance to our patients and allegiance to our profession. It is easier for a general practitioner, being independent of referral by other doctors, to come to a decision; but it has not been easy for anyone, whatever their decision.
to do so. The tip then be pushed through the pylorus (not an easy matter if the tube itself is flexible and the walls of the organ surrounding it offer no resistance and little guidance). Then the pylorus must be clearly identified as something more than an interruption in a series of rhythmic waves. Lastly, there is the difficulty of scrutinising the walls of a small cavity not much larger than the gastroscopic head. These have proved troublesome in my use of the fiberscope so that I have never been able to convince myself that the duodenum has been entered. Avery Jones and Kellockhave reported their own inability to do this except at laparotomy. Benedict3 says significantly "... it will be possible to inspect the duodenum ". Burnett 4 writes with reserve " duodenoscopy is often possible ...". Although published reports are scanty some workers have commented on the difficulty of passing through the pylorus with the fiberscope.
duodenum, it is
must
not easy to
compel them
first reach the antrum; it
must
Hirschowitz, however, did not find any such difficulties. He writes: " It has been possible to examine the bulb in all thirty patients in which the manoeuvre has been attempted. Passage through the pyloric sphincter is easy to recognise. The bulbar mucosa is a lighter shade of pink than the antrum and is more succulent than the antral mucosa."
He found no difficulty in inspecting the vaulted shape of the bulb, the walls of which could be compressed through the abdominal wall. Colour photographs of duodenal ulcers seen with the fiberscope were reproduced but admittedly these were as yet not of very high quality or clarity. ADVANTAGES AND DISADVANTAGES
Lord
Taylor
to
At the request of the Saskatchewan Government, Lord Taylor is going to Saskatoon to advise on the controversy. Member of Parliament from 1945 to 1950, he has had wide experience of medical administration and is the author of Good General Practice published for the Nuffield Provincial Hospitals Trust. The Times is wrong in describing him as an assistant editor of The Lancet-an appointment he relinquished on joining the Royal Naval Medical Service in 1939-but we join in hoping that he may be able to help in bringing the two sides
closer together.
A NOTE ON THE FIBERSCOPE ROBERT KEMP M.D. CONSULTANT
PHYSICIAN,
Lpool, M.R.C.P. HOSPITAL, LIVERPOOL, 9, HOSPITAL, LIVERPOOL, 6
WALTON
NEWSHAM GENERAL
AND
IN 1932 Schindler introduced his semi-flexible gastroscope which
immediately supplanted
the
dangerous rigid
With the Wolf-Schindler instrument or instrument. Hermon Taylor’s modification it is usually possible to see fully into the antrum itself. One can watch the concentric waves of peristalsis pass distally until they reach the pylorus, which pouts almost contemptuously, and emits a bubble or two. For years one has faced this frustration built into the available instruments-that of never being able to see into the duodenum, where nearly all of our problems of ulcer management lie. This is primarily due to optical limitations and to difficulty in flexing the instrument through an angle large enough to round the angulus and press forward. The claim by Hirschowitz1 that his new fiberscope had no such angular limitation and that through it the duodenal bulb could be inspected,
important breakthrough. problems of practice to solve. is fiberscope completely flexible and although
promised There
a most
are some
The flexible tubes, 1.
given time Hirschowitz,
most
and encouragement, will enter the B. I.
Lancet,
1961, i, 1074.
nearly twenty fiberscopes have reached this Their country. high cost (over E600) is not surprising, since an immense amount of fine optical work must go into each. My own experience in the last six months seems to justify a preliminary note as to its value. It has been used in conjunction with either the usual Hermon Taylor instrument or the original Wolf-Schindler model. Patients have been prepared for the examination with atropine, cough suppressants, and amethocaine lozenges. They are placed at first in the left lateral position and later when necessary in the prone and right lateral positions. Usually one or other of the semirigid gastroscopes was passed first, and then the fiberscope. The obvious advantages are: (1) It passes easily and safely into the stomach. (2) The glass-fibre optical system is first class and will outmode the prism. (3) Photography is possible because of the much better light transmission. (4) Clear, indeed beautiful, pictures of the antrum can often (but not always) be obtained. In short the great merit of the new instrument must rest on its glass-fibre optical system. In its present form its is and drawbacks must be faced. The limited, scope following criticisms are made in the certainty that most of them can be overcome by further development: Up
Advise Government
to now
The excessive flexibility means that one cannot control the of the fiberscope head or push it directly forward. Rotation is, of course, possible, but the instrument naturally lies in the stomach along the greater curvature; hence pressure from above is as likely to increase the length of the bend as to advance the tip. This contrasts with the semirigid instrument which lies along the lesser curvature and posterior wall and does not coil up in the stomach. Nor is it easy to cajole the head into the antrum by positioning the patient or by abdominal palpation. In practice the tip can usually reach the antrum the long way round; but further progress is a matter of chance rather than certainty. Even so in my experience the antrum is seen far more readily
position
2. Jones, F. A., Kellock, T. D. ibid. 1961, p. 1285. 3. Benedict, E. B. Gastroenterology, 1962, 42, 171. 4. Burnett, W. Scot. med.J. 1962, 8, 114.
89 than the body of the stomach. In fact, gastric ulcers-easily seen with the conventional instruments-have never been visible with the fiberscope. Even focusing the gastric mucosa has been difficult. This is what one would expect with a freely mobile instrument without any control of the head, and with a short focusing range. One can neither move the patient round a fixed point of observation nor move a controlled objective inside the patient. MODIFICATIONS NEEDED
The failure of experienced gastroscopists to improve their results suggests that the fiberscope, excellent in principle, needs important modifications. (1) More stiffening is needed to strengthen the instrument so that it can be pushed forward in a straight line without buckling. (2) The proximal third needs more rigidity to keep the line of advance close to the lesser curve and posterior wall, and to enter the antrum by turning the angulus. (3) The distal third should be flexible in two directions as with the present Hermon Taylor pattern. (4) The Bowden cables required for this could replace the cables at present used to give distal focusing. A fixed-focus objective is probably all that is needed so long as the tip can be moved to-andfro. In addition, a smaller head would be an advantage for duodenoscopy. Undoubtedly the safety factor of a fully flexible gastroscope is high, but it remains to report an odd and almost
inexplicable mishap. The patient was a young man with a duodenal ulcer that had bled. Introduction was uneventful, and a fair view of the antrum was obtained. During the examination the patient belched and the stomach had to be reinflated-perhaps overinflated-because finally he gave an explosive belch. Because the examination was now complete, it was decided to withdraw the instrument. During withdrawal the patient complained of pain when the tip was at about the level of the cardia, and some slightly increased resistance was met after this. When the tip was at about the level of the pharynx it stuck, but after the patient had swallowed, withdrawal was completed. It was then found that the last three inches of the gastroscope had been forcibly bent, and had been drawn up through the cesophagus like a crochet hook. The force needed to bend the instrument into a j-shape had been such that the spiral metal sheath had been forcibly and permanently separated by the kinking. The patient was treated conservatively for oesophageal damage, but luckily no evidence of any trauma appeared. This alarming event cannot be easily explained, but there seem to be two possibilities. The first is that during the introduction the tip made a u-tum in the pharynx as a stomach tube may do, and went down as well as up in this fashion. One would, however, expect the kink to have straightened out in the stomach, or at least at the cardia, on withdrawal. The second possibility is that the explosive belch whipped the tip through the cardia before withdrawal, leaving the rest of the gastroscope hanging in a loop in the stomach. Whatever the explanation, and however rare or improbable the accident, this must be an unusual drawback of extreme flexibility. Luckily the optical system was not damaged. A similar type of injury can of course result from a patient damaging the spiral armour by a strong bite. Looking at a duodenal ulcer crater poses difficulties akin to direct inspection of the craters on the moon. In the fiberscope we have an instrument with both the range and the efficiency needed; to this must be added direction and control. My strong feeling is that the proper course to set for the duodenum is the old one-down the posterior wall and the lesser curve. Thereafter the angulus should be turned under full control, and the pyloric canal approached and entered under direct vision. Before the claims originally made in regard to duodenoscopy can be fully upheld, the manufacturers will have to produce an
improved
pattern.
HEALTH SERVICES
IN 1961
FIGURES in the Ministry of Health’s latest annual report1 seem substantially to viridicate the hope that, under the Mental Health Act of 1959, compulsion would be applied to the admission of patients to psychiatric beds only where this was really necessary in the interest of the patient or of the community, and that, in general, mental disorder would be dealt with in the same way as other kinds of illness. The main provisions of the Act, including those dealing with compulsory powers, came into effect on Nov. 1, 1960. Statistics are now available for the ensuing six months. At April 30, 1961, over 90% of the patients occupying psychiatric beds were in hospital on an informal basis (the percentages for different categories were: mental illness 92-5, psychopathic disorder 51-6, subnormality 82-6, severe subnormality 88-7; all 90-7). Until 1958, virtually all mental defectives (who would now be classified as suffering from severe subnormality, subnormality, or, in a few cases, psychopathic disorder) were subject to compulsory detention under the Mental Deficiency Acts. In the first six months after the new Act came into force, nearly 80% of all admissions to psychiatric beds were informal; and, where compulsory powers were needed, it was the provisions for compulsory admission for a period of observation that were mainly used. The percentages for informal admissions were: mental illness 79-0, psychopathic disorder 79.0, subnormality 75 1, severe subnormality 94-3; all 79-3. The contrast with the past is again greatest in the case of the subnormal and severely subnormal, virtually all of whom would until 1958 have been admitted under compulsory powers. * * *
Other features of the report include the following:
Hospital waiting-lists.-The number of patients whose names hospital waiting-lists at the end of 1961 was about
were on
than at the end of 1960. The increase did not take in place every region; but where it occurred it was mainly in the surgical specialties. Waiting-lists in their present form are not an accurate index of the unsatisfied demand for hospital 9000
more
inpatient care. Average stay in hospital.-The reduction in length of stay of patients in hospital continued same rate as
the average about the
at
in 1960.
Consultants.-During the year the Ministry approved increases in hospital consultant staff equivalent to 160 wholetime consultants (170 in 1960). The increases were greatest in psychiatry (34), general medicine (18), and pathology (16). Applications for additional posts in psychiatry exceeded the number of potential candidates by a substantial margin. General practice.-The number of principals providing general medical services at Oct. 1, 1961, was 20,188, compared with 19,928 at July 1, 1960. Of these principals 72% were in partnership, compared with 70 3% in 1960. The number of permanent assistants decreased from 1345 at July 1, 1960, to 1169 at Oct. 1, 1961. The average number of patients on the National Health Service lists of principals rose between July 1, 1960, and Oct. 1, 1961, from 2287 to 2292; but these figures conceal some inflation by the continued inclusion in doctors’ lists of names which should no longer be there. Pharmaceutical services.-In 1961 the average cost per prescription to the N.H.S. was 8s. 1-3d.’ Between 1957 and 1960 the average cost rose by 4-6d. each year. These increases were almost entirely due to changes in prescribing practice following the introduction of new and more effective, but more 1. Report of the Ministry of Health for the Year ended Dec. 31, 1961. Part l: Health and Welfare Services. Office. Pp. 250. 15s.
Cmnd 1754.
H.M.
Stationery