- Email: [email protected]
HEALTH SERVICES IN 1961
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
90
expensive, preparations. This trend continued throughout 1961; but after the doubling of the prescription charge the average cost per prescription rose by a further 6-7d. beyond what would have been expected from continuance of this trend. Analysis of a sample of prescriptions suggested that a slight increase in the average quantity prescribed on a prescription accounted for rather less than half of this additional increase; the remainder was due mainly to the fact that fewer of the
cheapest prescriptions
were
being dispensed.
Points of View VISUAL
REQUIREMENTS
FOR DRIVERS
R. A. WEALE D.Sc., Ph.D. Lond. From the Department of Physiological Optics, Institute of Ophthalmology, University of London, Judd Street, London, W.C.1
BIRMINGHAM’S
recent experiment in which drivers encouraged to use dipped headlamps in lit-up streets prompts consideration of visual driving requirements as a whole. The success of the experiment, which resulted in a striking reduction in accidents, is beyond doubt; but whether it was due to better seeing may be questioned till were
evidence becomes available. So far from contributing better seeing, the headlamps, even though dipped, may have acted as glare sources. In the absence of any evidence to the contrary, it may be assumed that the average driving speed dropped, and that the increased safety was attributable to this factor. Birmingham might have achieved a similar result by cobbling its streets or by drilling pot-holes into them. Although night vision has, of course, been much studied,- its relation to driving efficiency still offers scope for detailed inquiry. The fact that the nocturnal accidentrate is nearly double the diurnal need not depend entirely on visual factors; but according to Peukert 2 the hazard may be greater than would at first appear. This study suggests that the night vision of 5-10% of drivers whose daylight vision is normal is so impaired as to constitute a traffic hazard. But our law ignores the distinction between day and night vision 3:visual acuity is tested under daylight conditions, the would-be driver having to decipher a number-plate at a distance of 25 yards. This corresto vision of Once the driver is ponds approximately 6/24. his to can of this value dark-adapted acuity drop 1/100 under stationary conditions,4and movement will reduce it to even further. (I have tried to apply the test at night and failed. However, the failure cannot be attributed exclusively to poor vision: the number-plates of most cars are lit so poorly as to be virtually undecipherable at the standard distance when they move at 30-40 m.p.h. Modern Ford cars are the only general exception to this more
to
observation.) The Law, however, is an ass not only as regards its ignorance of the duplicity theory of day and night vision. That the vision check administered during the driving test is farcical is well known: it is also potentially dangerous. Assuming that, armed with the appropriate correction, a candidate passes the vision check and the driving test, there is no means of ensuring that glasses will be worn whenever he drives. What is worse, there is nothing to show that he (or, more pointedly, she) ought to be wearing 1. 2. 3. 4.
Jayle, G. E., Ourgaud, A. G., Baisinger, L. F., Holmes, W. J. Night Vision. Springfield, Ill., 1959. Peukert, E. Verkehrsmed. 1958, 4, 202. Weale, R. A. The Eye and its Function. London, 1960. Mandelbaum, J., Sloan, L. L. Amer. J. Ophthal. 1947, 30, 581.
them.
Every application for a driving licence requires the applicant to make a statement regarding his or her disabilities. It is desirable that the licence should be clearly endorsed with the driver’s optical correction. One could argue in favour of any driving without the obligatory correction being worn being termed " dangerous." These considerations refer to existing provisions which seem to be inadequate. There are, however, one or two points in respect of which extension rather than reform seems to be indicated. No driver is tested for the extent of his visual fields. This means that a glaucoma patient with normal visual acuity and colour-vision, but suffering from tunnel vision, may be said to have vision adequate for modern traffic conditions. A crude field test would be better than nothing. Another desideratum relates to binocular vision. A driver with a non-functional right eye who is being overtaken on the right is potentially handicapped. Although one-eyed drivers are-rightly-allowed on the roads, their reduced field of view and stereoscopic vision render them more vulnerable and perhaps somewhat more of a risk than others. The difficulty here is that quite a few people are functionally one-eyed without knowing it. This minor disability can be detected by simple ad-hoc tests. While it would be invidious to penalise such drivers in any way, a case can be made for a warning to be shown on the back of any vehicle they drive. To sum up, the provisions for visual checking of wouldbe drivers, and also of drivers, need reviewing. When they were drawn up, horse-drawn trams were a matter of the not so distant past. Now we travel faster, in greater numbers, and during longer hours. While tests have to be practicable, they should conform to physiological fact: road safety is hardly promoted if the examiner is allowed to turn a blind eye to a blind eye.
Public Health Poliomyelitis
in Scotland
IN Scotland in the first six months of this year there were 75 notifications of cases of paralytic poliomyelitis and 65 of non-paralytic. The figures for the same period last year were 3 paralytic and 22 non-paralytic. Most of the notifications were in Glasgow (18 and 43 respectively) and Dundee (18 and 15 respectively).
Infectious Diseases in
England
and Wales
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
90
expensive, preparations. This trend continued throughout 1961; but after the doubling of the prescription charge the average cost per prescription rose by a further 6-7d. beyond what would have been expected from continuance of this trend. Analysis of a sample of prescriptions suggested that a slight increase in the average quantity prescribed on a prescription accounted for rather less than half of this additional increase; the remainder was due mainly to the fact that fewer of the
cheapest prescriptions
were
being dispensed.
Points of View VISUAL
REQUIREMENTS
FOR DRIVERS
R. A. WEALE D.Sc., Ph.D. Lond. From the Department of Physiological Optics, Institute of Ophthalmology, University of London, Judd Street, London, W.C.1
BIRMINGHAM’S
recent experiment in which drivers encouraged to use dipped headlamps in lit-up streets prompts consideration of visual driving requirements as a whole. The success of the experiment, which resulted in a striking reduction in accidents, is beyond doubt; but whether it was due to better seeing may be questioned till were
evidence becomes available. So far from contributing better seeing, the headlamps, even though dipped, may have acted as glare sources. In the absence of any evidence to the contrary, it may be assumed that the average driving speed dropped, and that the increased safety was attributable to this factor. Birmingham might have achieved a similar result by cobbling its streets or by drilling pot-holes into them. Although night vision has, of course, been much studied,- its relation to driving efficiency still offers scope for detailed inquiry. The fact that the nocturnal accidentrate is nearly double the diurnal need not depend entirely on visual factors; but according to Peukert 2 the hazard may be greater than would at first appear. This study suggests that the night vision of 5-10% of drivers whose daylight vision is normal is so impaired as to constitute a traffic hazard. But our law ignores the distinction between day and night vision 3:visual acuity is tested under daylight conditions, the would-be driver having to decipher a number-plate at a distance of 25 yards. This corresto vision of Once the driver is ponds approximately 6/24. his to can of this value dark-adapted acuity drop 1/100 under stationary conditions,4and movement will reduce it to even further. (I have tried to apply the test at night and failed. However, the failure cannot be attributed exclusively to poor vision: the number-plates of most cars are lit so poorly as to be virtually undecipherable at the standard distance when they move at 30-40 m.p.h. Modern Ford cars are the only general exception to this more
to
observation.) The Law, however, is an ass not only as regards its ignorance of the duplicity theory of day and night vision. That the vision check administered during the driving test is farcical is well known: it is also potentially dangerous. Assuming that, armed with the appropriate correction, a candidate passes the vision check and the driving test, there is no means of ensuring that glasses will be worn whenever he drives. What is worse, there is nothing to show that he (or, more pointedly, she) ought to be wearing 1. 2. 3. 4.
Jayle, G. E., Ourgaud, A. G., Baisinger, L. F., Holmes, W. J. Night Vision. Springfield, Ill., 1959. Peukert, E. Verkehrsmed. 1958, 4, 202. Weale, R. A. The Eye and its Function. London, 1960. Mandelbaum, J., Sloan, L. L. Amer. J. Ophthal. 1947, 30, 581.
them.
Every application for a driving licence requires the applicant to make a statement regarding his or her disabilities. It is desirable that the licence should be clearly endorsed with the driver’s optical correction. One could argue in favour of any driving without the obligatory correction being worn being termed " dangerous." These considerations refer to existing provisions which seem to be inadequate. There are, however, one or two points in respect of which extension rather than reform seems to be indicated. No driver is tested for the extent of his visual fields. This means that a glaucoma patient with normal visual acuity and colour-vision, but suffering from tunnel vision, may be said to have vision adequate for modern traffic conditions. A crude field test would be better than nothing. Another desideratum relates to binocular vision. A driver with a non-functional right eye who is being overtaken on the right is potentially handicapped. Although one-eyed drivers are-rightly-allowed on the roads, their reduced field of view and stereoscopic vision render them more vulnerable and perhaps somewhat more of a risk than others. The difficulty here is that quite a few people are functionally one-eyed without knowing it. This minor disability can be detected by simple ad-hoc tests. While it would be invidious to penalise such drivers in any way, a case can be made for a warning to be shown on the back of any vehicle they drive. To sum up, the provisions for visual checking of wouldbe drivers, and also of drivers, need reviewing. When they were drawn up, horse-drawn trams were a matter of the not so distant past. Now we travel faster, in greater numbers, and during longer hours. While tests have to be practicable, they should conform to physiological fact: road safety is hardly promoted if the examiner is allowed to turn a blind eye to a blind eye.
Public Health Poliomyelitis
in Scotland
IN Scotland in the first six months of this year there were 75 notifications of cases of paralytic poliomyelitis and 65 of non-paralytic. The figures for the same period last year were 3 paralytic and 22 non-paralytic. Most of the notifications were in Glasgow (18 and 43 respectively) and Dundee (18 and 15 respectively).
Infectious Diseases in
England
and Wales