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history of three weeks’ vomiting and abdominal pain beforeadmission. She was strikingly dehydrated and drowsy; urinecontained 2% glucose but no acetone; blood-sugar 600 mg.per 100 ml., serum sodium 154, potassium 3-3, chlorides 88,and alkali reserve 27-7, meq. per litre, and serum-urea 300 mg.per 100 ml. Her calculated serum osmolarity was 398 mosmolesper kg. water.The patient was treated with intravenous isotonic saline

solution and later oral fluids. In the first twenty-four hoursshe received 9 litres of fluid and twenty-two hours afteradmission her blood-sugar was 242 mg. per 100 ml. and herserum-urea 79 mg. per 100 ml. She was given no insulin. Herserum-urea later fell to 42 mg. per 100 ml. and her diabetes isnow satisfactorily controlled with diet, chlorpropamide, andphenformin.Whether or not hyperosmolar non-ketotic diabetic coma is

a disease entity, patients with it seem to have a wide spectrumof biochemical abnormalities. They all have hyperosmolarplasma (so do ketotic diabetics in coma), but their serum-sodium levels may be high, low, or normal, and they may beinsulin-resistant,! or insulin-sensitive,2 or they may even, as inour case, require no insulin at all.We wish to thank Dr. R. B. McConnell for permission to report

this fase.

T. M. HAYESC. J. WOODS.

Broadgreen Hospital,Liverpool 14.

THE KVEIM-SILTZBACH TEST

SIR,-Dr. James and his colleagues 3 are to be congratulatedon their painstaking validation of the Colindale Kveim-Siltz-bach (K.S.) antigen. There are two points, however, on whichwe should like to comment. Firstly, it is hardly surprising thatthere should be differences between the clinical features in

patients with negative and positive reactions. The authorsshow, for example, that erythema nodosum was much morecommon in positive reactors, but then erythema nodosum isalready known to be a strong indicator of systemic sarcoidosis.Furthermore, the fact that nearly twice as many K.s.-negativeas K.s.-positive reactors had respiratory symptoms may merelyreflect the greater age of the K.s.-negative patients in this series,who could be expected to have more respiratory disease.Secondly, in view of the recognised proportion of false-

negative results, we are unable to agree with the conclusion ofDr. James and his colleagues that a local sarcoid tissue reactionassociated with a negative K.S. test excludes diffuse or multi-system sarcoidosis.Kveim antigen has now been shown to be effective in freeze-

dried form 4: in patients with active sarcoidosis it gives dermalreactions macroscopically and microscopically identical to

those produced by fluid antigen, and it seems to retain itsnotencv for long oeriods at room temoerature.

W. P. U. KENNEDYI. W. B. GRANT.

Respiratory Diseases Unit,Northern General Hospital,

Edinburgh 5.

1. Jackson, W. P. U., Forman, R. Diabetes, 1966, 15, 714.2. Domowski, T. S., Nabarro, J. D. N. ibid. 1965, 14, 162.3. James, D. G., Sharma, O. P., Bradstreet, P. Lancet, 1967, ii, 1274.4. Douglas, A. C. Acta med. scand. 1964, suppl. 425, p. 189. Kennedy,

W. P. U. Br. J. Dis. Chest, 1967, 61, 40.

Public Health

Influenza

IN England and Wales deaths from influenza, which hadnumbered 44 in the week ended Dec. 15, rose to 101, 285,and 993 in the three succeeding weeks up to Jan. 5. In theweek ended Jan. 12 the total was 990. New sickness-benefitclaims fell to 403,947 in the week ended Jan. 16 from 484,841in the previous week.

Parliament

Cuts in the Social Services

ON Jan. 17, in the debate on the Prime Minister’s statementon public expenditure, Mr. Roy JENKINS, the Chancellor of theExchequer, emphasised the immense increase in demand forsocial-security benefits. The combined numbers of childrenunder 15, men over 65, and women over 60 had risen by2 million between 1955 and 1966, and this had inevitably ledto an increased demand on the education and health services.He intended to make sure that the 7s. addition to family allow-ances would go to those in need, which he considered was amost important step to selectivity. He wished that he couldhave gone further this year in widening the application of theprinciple of selectivity, and he hoped to introduce full selec-tivity for family allowances next year. This was the sensible

approach in using our limited resources to relieve real hardshipwithout the indignities of an individual means test.

Commenting on the prescription charges, he. said that theessence of the problem was that we could not have madeeffective economies without asking for some contribution fromhealth. In what other form could an equivalent sum have beenless damagingly recovered ? An increase in the stamp had beencanvassed, but he did not think that this should have beenincreased by more than 6d. He was sure that a reduction inthe hospital-building programme, which had been safeguarded,would have cut deeper into the sinews of the Health Service.

Mr. Jenkins also drew attention to the proposed sharpgeneral reduction in the rate of growth of local-authority cur-rent expenditure. These restrictions would limit the develop-ment of local-authority services and in some places there mighteven be a temporary lapse in standards.

Later in the debate, Mr. MICHAEL STEWART, First Secretaryof State, said that the Government could have avoided impos-ing prescription charges if they had put up the cost of thestamp by ls. instead of 6d. However, the stamp was alreadya considerable item and any substantial addition to it wouldbe an attempt to curb consumption by a regressive poll tax.The Government could have raised E50 million by imposingprescription charges without exemptions, but he did not

believe that this would have been a satisfactory alternative.Discussions had already begun with the doctors to create aviable exemptions scheme which he expected to cover abouthalf of the prescriptions issued.

In the second day of the debate on public expenditure, Mr.LAURENCE PAVITT criticised the imposition of prescriptioncharges. The whole basis of the Health Service was that thosewho were sick should be looked after by those who were well,but the charges stood this principle on its head. Any incomefrom charges would go into taxation, and therefore it wouldbe the sick who would have to help the country out of itsdifficulties and pay the healthy. When health charges werefirst imposed, and then increased, the Health Service bill rosebecause doctors over-prescribed. Because of the exemptionsscheme, the charges would probably yield about El to E15million rather than E25 million, and for this the Governmentwas scrapping a principle which they had held for a generation.He considered it would be preferable to take the money

from the superstructure of the service rather than from theroots. Since 1965 there had been a 10% growth in the HealthService. A 11/2% cut across the board would give the Chancel-lor the E25 million that he needed, and we should still havean increase on what was spent last year. In 1967 we had spentE190 million more than in 1966, and in 1966 £96 million morethan in the previous year. The hospital service took E873million, or 60%, of the total expenditure on health, and thegeneral practitioner, who was the first line of defence, tookonly 7½% . Mr. Pavitt wanted the hospital-building pro-gramme to be reduced for the first quinquennium, with morebuilding at the end and less at the beginning. More powers