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Division of the Canadian Medical Association. Again I say letus fulfil our traditional oath and do our duty outside the Act."But the great majority of the profession here were notof like mind, and the Emergency Medical Service basedon the hospitals has gone into effect giving free but onlyemergency treatment.The indications for Government action in the medical

sphere were not as urgent in Saskatchewan as for instancein Britain in 1948. Indications there are, but I suspectthat they are felt chiefly, if not solely, by the urbangeneral practitioner, whose major surgical privileges areinevitably contracting and who therefore has to rely moreand 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, mostlyin isolation. We have been troubled by the haste in theGovernment’s moves. They have condensed into aboutsix months changes which perhaps would have been betterspread over two years. They delayed making concessionsto the profession until after the recent Federal election ofJune 18, while preparations for the Emergency MedicalService were gaining a momentum of their own. On theother hand, our representatives’ advice to us to close ouroffices presented us with a difficult choice, between

allegiance to our patients and allegiance to our profession.It is easier for a general practitioner, being independentof referral by other doctors, to come to a decision; but ithas not been easy for anyone, whatever their decision.

Lord Taylor to Advise GovernmentAt 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 wideexperience of medical administration and is the author of GoodGeneral Practice published for the Nuffield Provincial HospitalsTrust. The Times is wrong in describing him as an assistanteditor of The Lancet-an appointment he relinquished onjoining the Royal Naval Medical Service in 1939-but we joinin hoping that he may be able to help in bringing the two sidescloser together.

A NOTE ON THE FIBERSCOPE

ROBERT KEMPM.D. Lpool, M.R.C.P.

CONSULTANT PHYSICIAN, WALTON HOSPITAL, LIVERPOOL, 9, ANDNEWSHAM GENERAL HOSPITAL, LIVERPOOL, 6

IN 1932 Schindler introduced his semi-flexible gastro-scope which immediately supplanted the dangerous rigidinstrument. With the Wolf-Schindler instrument or

Hermon Taylor’s modification it is usually possible to seefully into the antrum itself. One can watch the concentricwaves of peristalsis pass distally until they reach thepylorus, which pouts almost contemptuously, and emits abubble or two. For years one has faced this frustrationbuilt into the available instruments-that of never beingable to see into the duodenum, where nearly all of ourproblems of ulcer management lie. This is primarily dueto optical limitations and to difficulty in flexing theinstrument through an angle large enough to round theangulus and press forward. The claim by Hirschowitz 1that his new fiberscope had no such angular limitationand that through it the duodenal bulb could be inspected,promised a most important breakthrough.There are some problems of practice to solve.The fiberscope is completely flexible and although most

flexible tubes, given time and encouragement, will enter the1. Hirschowitz, B. I. Lancet, 1961, i, 1074.

duodenum, it is not easy to compel them to do so. The tipmust first reach the antrum; it must then be pushed throughthe pylorus (not an easy matter if the tube itself is flexible andthe walls of the organ surrounding it offer no resistance andlittle guidance). Then the pylorus must be clearly identified assomething more than an interruption in a series of rhythmicwaves. Lastly, there is the difficulty of scrutinising the walls ofa small cavity not much larger than the gastroscopic head.These have proved troublesome in my use of the fiberscope sothat I have never been able to convince myself that the duo-denum has been entered. Avery Jones and Kellock havereported their own inability to do this except at laparotomy.Benedict 3 says significantly "... it will be possible to inspectthe duodenum ". Burnett 4 writes with reserve " duodeno-scopy is often possible ...". Although published reports arescanty some workers have commented on the difficulty of

passing through the pylorus with the fiberscope.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. Passagethrough the pyloric sphincter is easy to recognise. The bulbarmucosa is a lighter shade of pink than the antrum and is moresucculent than the antral mucosa."

He found no difficulty in inspecting the vaulted shape ofthe bulb, the walls of which could be compressed throughthe abdominal wall. Colour photographs of duodenal ulcersseen with the fiberscope were reproduced but admittedlythese were as yet not of very high quality or clarity.

ADVANTAGES AND DISADVANTAGES

Up to now nearly twenty fiberscopes have reached thiscountry. Their high cost (over E600) is not surprising,since an immense amount of fine optical work must gointo each. My own experience in the last six months seemsto justify a preliminary note as to its value.

It has been used in conjunction with either the usualHermon Taylor instrument or the original Wolf-Schindlermodel. Patients have been prepared for the examinationwith atropine, cough suppressants, and amethocaine

lozenges. They are placed at first in the left lateral posi-tion and later when necessary in the prone and rightlateral positions. Usually one or other of the semirigidgastroscopes 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 systemis first class and will outmode the prism. (3) Photographyis possible because of the much better light transmission.(4) Clear, indeed beautiful, pictures of the antrum canoften (but not always) be obtained.

In short the great merit of the new instrument must reston its glass-fibre optical system. In its present form itsscope is limited, and drawbacks must be faced. The

following criticisms are made in the certainty that mostof them can be overcome by further development:The excessive flexibility means that one cannot control the

position of the fiberscope head or push it directly forward.Rotation is, of course, possible, but the instrument naturallylies in the stomach along the greater curvature; hence pressurefrom above is as likely to increase the length of the bend as toadvance the tip. This contrasts with the semirigid instrumentwhich lies along the lesser curvature and posterior wall and doesnot coil up in the stomach. Nor is it easy to cajole the head intothe antrum by positioning the patient or by abdominal palpa-tion. In practice the tip can usually reach the antrum the longway round; but further progress is a matter of chance ratherthan certainty.Even so in my experience the antrum is seen far more readily

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.

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than the body of the stomach. In fact, gastric ulcers-easilyseen with the conventional instruments-have never beenvisible with the fiberscope. Even focusing the gastric mucosahas been difficult. This is what one would expect with a freelymobile instrument without any control of the head, and with ashort focusing range. One can neither move the patient rounda fixed point of observation nor move a controlled objectiveinside the patient.

MODIFICATIONS NEEDED

The failure of experienced gastroscopists to improvetheir results suggests that the fiberscope, excellent in

principle, needs important modifications. (1) Morestiffening is needed to strengthen the instrument so that itcan be pushed forward in a straight line without buckling.(2) The proximal third needs more rigidity to keep the lineof advance close to the lesser curve and posterior wall,and to enter the antrum by turning the angulus. (3) Thedistal third should be flexible in two directions as with the

present Hermon Taylor pattern. (4) The Bowden cablesrequired for this could replace the cables at present usedto give distal focusing. A fixed-focus objective is probablyall that is needed so long as the tip can be moved to-and-fro. In addition, a smaller head would be an advantagefor duodenoscopy.Undoubtedly the safety factor of a fully flexible gastro-

scope is high, but it remains to report an odd and almostinexplicable mishap.The patient was a young man with a duodenal ulcer that had

bled. Introduction was uneventful, and a fair view of theantrum was obtained. During the examination the patientbelched and the stomach had to be reinflated-perhaps over-inflated-because finally he gave an explosive belch. Becausethe examination was now complete, it was decided to with-draw the instrument. During withdrawal the patient com-plained of pain when the tip was at about the level of the cardia,and some slightly increased resistance was met after this. Whenthe tip was at about the level of the pharynx it stuck, but afterthe patient had swallowed, withdrawal was completed. It wasthen found that the last three inches of the gastroscope had beenforcibly bent, and had been drawn up through the cesophaguslike a crochet hook. The force needed to bend the instrumentinto a j-shape had been such that the spiral metal sheath hadbeen forcibly and permanently separated by the kinking. Thepatient was treated conservatively for oesophageal damage, butluckily 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 intro-duction the tip made a u-tum in the pharynx as a stomach tubemay do, and went down as well as up in this fashion. Onewould, however, expect the kink to have straightened out in thestomach, or at least at the cardia, on withdrawal. The secondpossibility is that the explosive belch whipped the tip throughthe cardia before withdrawal, leaving the rest of the gastro-scope hanging in a loop in the stomach. Whatever the explana-tion, and however rare or improbable the accident, this must bean unusual drawback of extreme flexibility. Luckily the opticalsystem was not damaged. A similar type of injury can of courseresult 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. Inthe fiberscope we have an instrument with both the rangeand the efficiency needed; to this must be added directionand control. My strong feeling is that the proper course toset for the duodenum is the old one-down the posteriorwall and the lesser curve. Thereafter the angulus shouldbe turned under full control, and the pyloric canal

approached and entered under direct vision. Before theclaims originally made in regard to duodenoscopy can befully upheld, the manufacturers will have to produce animproved pattern.

HEALTH SERVICES IN 1961FIGURES in the Ministry of Health’s latest annual

report 1 seem substantially to viridicate the hope that,under the Mental Health Act of 1959, compulsion wouldbe applied to the admission of patients to psychiatric bedsonly where this was really necessary in the interest of thepatient or of the community, and that, in general, mentaldisorder would be dealt with in the same way as otherkinds 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 occupyingpsychiatric beds were in hospital on an informal basis(the percentages for different categories were: mentalillness 92-5, psychopathic disorder 51-6, subnormality82-6, severe subnormality 88-7; all 90-7). Until 1958,virtually all mental defectives (who would now beclassified as suffering from severe subnormality, sub-

normality, or, in a few cases, psychopathic disorder) weresubject 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 wereinformal; and, where compulsory powers were needed, itwas the provisions for compulsory admission for a periodof observation that were mainly used. The percentagesfor informal admissions were: mental illness 79-0, psycho-pathic disorder 79.0, subnormality 75 1, severe sub-

normality 94-3; all 79-3. The contrast with the past is

again greatest in the case of the subnormal and severelysubnormal, virtually all of whom would until 1958 havebeen admitted under compulsory powers.

* * *

Other features of the report include the following:Hospital waiting-lists.-The number of patients whose names

were on hospital waiting-lists at the end of 1961 was about9000 more than at the end of 1960. The increase did not take

place in every region; but where it occurred it was mainly in thesurgical specialties. Waiting-lists in their present form are notan accurate index of the unsatisfied demand for hospitalinpatient care.

Average stay in hospital.-The reduction in the averagelength of stay of patients in hospital continued at about thesame rate as in 1960.

Consultants.-During the year the Ministry approvedincreases in hospital consultant staff equivalent to 160 whole-time consultants (170 in 1960). The increases were greatest inpsychiatry (34), general medicine (18), and pathology (16).Applications for additional posts in psychiatry exceeded thenumber of potential candidates by a substantial margin.

General practice.-The number of principals providinggeneral medical services at Oct. 1, 1961, was 20,188, comparedwith 19,928 at July 1, 1960. Of these principals 72 % werein partnership, compared with 70 3% in 1960. The number ofpermanent assistants decreased from 1345 at July 1, 1960, to1169 at Oct. 1, 1961. The average number of patients on theNational Health Service lists of principals rose between

July 1, 1960, and Oct. 1, 1961, from 2287 to 2292; but thesefigures conceal some inflation by the continued inclusion indoctors’ 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 and1960 the average cost rose by 4-6d. each year. These increaseswere almost entirely due to changes in prescribing practicefollowing the introduction of new and more effective, but more1. Report of the Ministry of Health for the Year ended Dec. 31, 1961.

Part l: Health and Welfare Services. Cmnd 1754. H.M. StationeryOffice. Pp. 250. 15s.