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Pilkington believe to be relevant. It is not true to state as theydo that there is

" no information whatsoever about the diets of

the diabetic patients ". It was stated that these patients wereuntreated and that no dietary modifications were carried out,but that it was ascertained that the carbohydrate intake of thepatients was at least 180 g. daily. It is considered 3 that restric-tion of carbohydrate intake below 150 g. daily is required inorder to produce effects on glucose tolerance.We have endeavoured to show that there are a number of

conditions in which the presence of an elevated plasma con-centration of non-esterified fatty acids is correlated with poorglucose tolerance and insulin insensitivity, and we have docu-mented one of these (carbohydrate restriction) in some detail.We appreciate that readers with particular interest in specialaspects of diet and metabolism might wish for data in additionto those we published, but this does not influence assessment ofthe correlation which we are trying to show. Those interestedin exercise and G.T.T. might wish to know the precise activitiesof the subjects before, during, and after the diet; those in season-al effects, the time of year; those in emotion and G.T.T., whetherthere was any evidence of fear displayed by the participants;those in temperature, the temperature variations throughoutthe study.We agree most emphatically with Professor Yudkin and

Dr. Pilkington that full information should be given inscientific publications, and we submit that bearing in mindthe objectives stated in our paper this has been done.We suggest for their consideration that it is also importantto quote the published work of others accurately.

C. N. HALESP. J. RANDLE.Department of Biochemistry,

University of Cambridge.

HISTAMINE-FAST ACHLORHYDRIA

AND IRON ABSORPTION

J. L. MARKSON.Stobhill General Hospital,Glasgow.

SIR,-Dr. Goldberg and his colleagues (April 20) haveprovided evidence that, under the conditions of theirexperiments, their achlorhydric patients with iron-

deficiency anaemia absorbed less iron than those whosecreted acid. They have not, however, shown that thereis impairment of iron absorption in patients who exhibit lessadvanced lesions of the gastric mucosa. It is probable, infact, that they have produced evidence to the contrary.In the paper to which they refer,4 we demonstrated that, while

histamine-fast achlorhydria was present in 48% of the patientswith iron-deficiency anaemia, histological changes in the gastricmucosa ranging from superficial gastritis to gastric atrophy werefound in 74% of these patients. Such lesions, moreover, werefound in 50% of those patients in whom gastric analysisrevealed the presence of acid. It is clear from this that acid canbe present in the gastric juice even when the gastric mucosa isthe seat of severe gastritis. Unless, therefore, there is histologi-cal evidence to the contrary, it is highly probable that some ofthe patients in the authors’ group A (i.e., patients with iron-deficiency anaemia and acid in the gastric juice) had gastriticchanges in the gastric mucosa. If this is so, then on their ownevidence Dr. Goldberg and his colleagues may well havedemonstrated normal iron absorption in these patients, thusproviding support for the view that these changes are not afactor in the production of the anxmia.

It is not disputed that once severe mucosal atrophy hasdeveloped, with consequent achlorhydria, the absorption of ironday become impaired, with aggravation of an existing anxmia,although the evidence for this is still conflicting. It is still areasonable assumption, however, that the changes in the gastricmucosa which lead to histamine-fast achlorhydria are caused bythe iron-deficiency anaemia. Perhaps Dr. Goldberg and hisassociates will now help to solve this problem by studying ironabsorption in patients with iron-deficiency anaemia in whom3. Joslin, E. P., Root, H. F., White, P., Marble, A. Treatment of Diabetes

Mellitus; p. 164. Philadelphia, 1959.4. Davidson, W. M. B., Markson, J. L. Lancet, 1955, ii, 639.

gastric biopsy has revealed " gastritis ", but in whom the gastricjuice contains acid.

CASUALTY DEPARTMENT

A. J. SHILLITOE.

SIR,-Peter was fortunate in his experiences of a

casualty department, described in last week’s letter fromthe Widdicombe File. The majority of general practi-tioners, patients, and perhaps pathologists could tell farmore disquieting stories.

Every year the gap grows between what is actuallydone for patients and what is technically possible. Thereason is not hard to find; it is a fault in the N.H.S.structure that is now evident in many other hospitaldepartments-namely, the lack of medically qualifiedpersonnel in authoritative administrative positions. How-ever much we, as a profession of traditional individualists,may dislike the Army type of organisation where onedoctor is in a disciplinary position over another, we mustface the fact that it is not in the interests of humanity forthe present drift to continue, and that hospitals based onlay administration, bedevilled by a host of impotentcommittees, are wasting not only public money, but lifeas well.

Willerby, Hull. A. J. SHILLITOE.

DIABETIC COMA WITHOUT KETOACIDOSIS

SIR,-The report by Dr. Lucas and his colleagues(Jan. 12) of two cases of diabetic coma without associatedketoacidosis encouraged me to review the clinical recordand postmortem report of a patient who succumbed todiabetic coma in 1949, and who, in the four days of herterminal illness, did not exhibit evidence of ketoacidosis.Discussion of the case which I am reporting, in respectof the surprising absence of ketonuria, has heretoforebeen unenlightening and tempered with scepticism. Inview of the Dr. Lucas’s article I have reviewed my case,which has an area of similarity, and wish to add it to therecord.

Because the authors stress the effect of the large glucosecontent of the blood, and the associated hyperosmolarity anddehydration, as factors blocking the development of keto-acidosis, it is of interest that in my case the patient, a 49-year-old woman, not only disregarded all measures proposed tocontrol her diabetes but consumed exceedingly large quantitiesof cake, confections, and ice-cream, and became ill shortlybefore her admission to the hospital with gastroenteritis afterconsuming raspberry syrup. Admitted to the New British(Connecticut) General Hospital in coma with deep, sighingrespirations and soft eyeballs, she was found to have a blood-sugar level of 776 mg. per 100 ml., a CO2 content of 12volumes %, and a blood-urea-nitrogen of 60 mg. per 100 ml.Her urine was loaded with sugar but contained no acetoneor diacetic acid. Tests for plasma-ketones were not made.Treatment with insulin, hypotonic saline and then physio-logical saline infusions, blood, and potassium chloride, over-came shock, restored good urine flow, and 16 hours afteradmission brought about sugar-free urine and a blood-sugarof 100 mg. per 100 ml. The patient recovered consciousnessand was able to take liquids by mouth, but then showedevidence of right hemiplegia, lapsed into coma, and died3 days after admission.Postmortem examination revealed no unexpected findings.

There were many areas of focal softening and necrosis of thecortex of the left temporal and frontal areas of the brain,fibrosis of the pancreas, liver congestion, and hydrothorax.

While the report of this case does not contribute newinformation explaining the unusual situation of diabetic

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coma without ketonuria, it does support the idea that thevery large amount of sugar ingested by the patient mayhave created the " deleterious effect of hyperglyceemia,hyperosmolarity, and dehydration ", causing coma withoutassociated ketoacidosis.

JOHN C. WHITE.New British General Hospital,New Britain, Connecticut.

CONTRAST RADIOGRAPHY

ERIC SAMUEL.Radio-Diagnostic Department,

The Royal Infirmary,Edinburgh, 3.

SIR,-Mr. Matheson and Professor Dudley (April 27)emphasise the usefulness of contrast medium as an aid inpostoperative management, and this has been an establishedprocedure in the surgical service of the Edinburgh RoyalInfirmary. A feature that they fail to emphasise, however,and to which I have drawn attention previously,! is theneed for lateral films when assessing the radiologicalappearances in these cases.The illustrations shown by these authors indicate that

the films are taken in the supine position and the mainmass of contrast medium and gastric contents lies in thefundus of the stomach. Lateral views with some contrastmedium in the tube will often reveal that the nasal tubein this position lies above the level of the retained gastriccontents, and the cause of failure of suction immediatelybecomes obvious. Likewise the gastrectomy stoma is alsoseen to lie in a far more anterior position than is usuallyanticipated.We have used the information gained from the lateral

film to posture the patient and to assist emptying of thestomach by gravity, and also to aid in the correct position-ing of the intragastric tube.

THE DEMAND FOR PSYCHIATRIC BEDS

L. C. KREEGER.Shenley Hospital,Herts.

SIR,-I cannot understand why Dr. Russell Barton

(April 20) challenges me " to give the figures and nameany hospital in which several hundreds of long-stay patients were discharged in the early years of arehabilitation programme ". He must recall his own letter 2

criticising an article 3 in which Dr. A. A. Baker statedthat at Banstead Hospital there had been a reduction of450 beds over the previous three years. At that time Dr.Barton expressed concern for the fate of those patientssubject to rapid discharge, and indeed the arguments hepropounded then are very similar to those now levelledagainst him.At Shenley Hospital 200 beds have been taken down since

1957. It is difficult, however, to state exactly what proportionof this reduction was due to the discharge of long-stay patients.Obviously the more rapid turnover of short-stay patients hasplayed its part.

I cannot accept Dr. Barton’s accusation of my having mar-shalled " the usual objections and prejudices to excuse profes-sional sloth, institutional inertia, and therapeutic floundering ".The main point of my letter of March 16 was that, in spite of anactive rehabilitation programme for long-stay patients, manywere left disabled to an extent that made discharge from hospitalunthinkable. I would agree with Dr. Barton that one cannotalways predict who will respond to rehabilitation methods, andI have not suggested that our principles of treatment should beabandoned because some patients do not respond to them. Forexample, two years ago at Shenley Hospital one female wardwas set aside for the treatment of the most deteriorated chronic

psychotic patients who had previously been dispersed through-out several different wards. These patients, about 30 in num-

1. Samuel, E. J. R. Coll. Surg. Edinb. 1961, 6, 179.2. Lancet, 1958, ii, 583.3. ibid. p. 253.

ber, were mostly incontinent, dirty in their habits, and incapableof performing elementary tasks. As a result of two years’

intensive effort most of these patients are no longer incontinent,and they can be occupied at a simple level. Only one of them,however, has shown a striking improvement, and even she is notconsidered to be well enough for discharge. Although no dis-charges have resulted from this endeavour, the work continues,for the satisfaction of seeing patients previously degradedreaching a level of behaviour that bears some semblance ofhuman dignity is felt to justify the time spent with them.

Dr. Barton may be right. Perhaps with improving com-munity services it will be possible to provide adequate psychi-atric inpatient care with 1.8 beds per 1000 population by 1975.But it is also possible that he exhibits that same prognosticarrogance of which he accuses me.

In the correspondence that followed Dr. Baker’s article, thelate Prof. W. Mayer-Gross and Dr. J. A. Harrington ended theirletter 4: " Psychiatrists battling with a human problem of thegreatest practical difficulty are certainly not immune from self-deception ; but neither are experts in social medicine, nor ourGreat Planners and Medical Politicians. A lack of criticalevaluation of what we are trying to do often leads to an over-activity in the wrong direction and to a repetition of past errors."

EFFECTS OF DIAGNOSTIC IRRADIATION

SIR,-Dr. Burch (Feb. 23) has discussed four importantpoints relating to the Oxford adult leukaemia survey.sHe rejects Hypothesis a (that the excess of myeloidleukxmias is due to diagnostic X-rays to the trunk) infavour of Hypothesis b (that most of this excess is due tolower preleuksemic fitness of the groups receiving trunkX-rays in excess).

In all these points the time intervals between irradia-tion and onset have to be considered. He is one of thefew who have appreciated how important these are;

despite this, most of his conclusions seem unjustified.(1) Our modal interval (the one occurring most frequently

- Dr. Burch in error discussed medians, which are difficultto estimate because there are not enough data on the longertime intervals) in the Oxford survey is between 36 and 40months. From this Dr. Burch concluded that in most cases

myeloid leukaemia was initiated before the irradiation, on thegrounds that the true mode was much greater than 50 months,which was my estimate for leukaemia induced in spondyliticsby therapeutic X rays .6 In fact this estimate was arrivedat after a lengthy calculation allowing for the two sources ofbias that he mentions-the multiple treatments on most

patients and the many irradiations within 3 to 5 years of theend of the survey period.7 8 Also, introducing 8 follow-upcases seems to reduce this mode to a value nearer to that ofthe Oxford survey, which we have not yet managed to esti-mate accurately.

(2) The time intervals for the 20 or so myeloids assumed tobe mostly induced by therapeutic X rays show two modes at4 and at 7 years, which for such small numbers is not bad

agreement with other findings.(3) According to the Oxford survey, peripheral therapeutic

X rays induce little or no myeloid leukaemia although thedoses to, for example, the spinal marrow may be much largerthan diagnostic X-ray doses to the trunk that do induce it.One of the conclusions from the time-interval analysis in thespondylitics survey 11 was that if a smooth dose-response curvereally exists the mean dose to the spinal marrow could not initself be a good measure of the leukxmic hazard. It now looksas if localised irradiation is relatively less dangerous. Is it

4. ibid. p. 697.5. Stewart, A., Pennybacker, W., Barber, R. Brit. med. J. 1962, ii, 882.6. Court Brown, W. M., Doll, R. Spec. Rep. Ser. med. Res. Coun., Lond.

1957, no. 295.7. Wise, M. E. Hlth Phys. 1961, 4, 250.8. Wise, M. E. in Physicomathematical Aspects of Biology, New York,

1962.