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One hundred and twenty consecutive deeply jaundiced patients undergoing surgery for bile duct obstruction were analysed. Diagnosis by either ultrasound or percutaneous transhepatic cholangiography was correct in 84 per cent and 86 per cent of patients respectively. Combination of the two procedures resulted in a diagnostic accuracy of 96.5 per cent. Despite pre-operative antibiotics and intravenous fluids, including Mannitol, infective complications and renal failure were common. Gastrointestinal haemorrhage was a major cause of postoperative morbidity and mortality. The operative mortality in this series was 14.2 per cent and was related to the depth of jaundice in patients with benign disease. The same relationship did not appear to occur in those with malignant disease. The median survival after palliative bypass surgery in patients with malignant obstruction was 6.5 months.

The biliary tract has been prospectively studied in a consecutive series of 769 patients undergoing surgery for gallstones to determine whether differences exist between subjects with and without a history of acute pancreatitis. The incidence of acute gallstone pancreatitis (AGP) was 7.7 per cent and men with gallstones were significantly more likely to develop pancreatic inflammation. Operations on patients with AGP were accompanied by a higher mortality rate which was almost entirely due to the severity of the disease at the time of surgery. The earlier operations were performed after the onset of pancreatitis the more often stones were found in the common bile duct and at the ampulla. Patients with AGP had smaller and more numerous gallbladder stones in association with a wider cystic duct that controls. The common bile duct diameter in patients with AGP was independent of the presence of choledochal calculi implying either previous temporary obstruction to the biliary tree or a dilated duct ab initio. Pancreatic duct reflux was far more commonly observed on the cholangiograms of patients with AGP and in these patients reflux occurred into a wider pancreatic duct, at a greater angle and was associated with a longer functioning common channel. No patient developed recurrent pancreatitis following biliary surgery. These features strongly support the concept of gallstone migration and suggest that patients with gallstones who develop acute pancreatitis have essential differences in their biliary tree which mechanically facilitate migration of calculi.

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SUMMARY The influence of the type and size of solid particles on their emptying from the stomach was studied using isotopically labelled chicken liver and inert particles in normal subjects and in patients who had undergone gastric surgery. In normal subjects, initial emptying of the liver was slower than that of inert particles both for large liver cubes (1 cm) and small cubes (0.3 cm). Liver emptying subsequently accelerated to be faster than emptying of the inert particles. Overall emptying of the liver given as small cubes was faster than large cubes; 50% emptied in 50 minutes and 70 minutes respectively. In the postoperative subjects, emptying of the liver and of the inert particles was identical. The findings are consistent with the hypothesis that solid foods such as liver are ground down and 'liquefied' by the action of gastric peristalsis before being discharged to the duodenum. Ingested particle size appears to influence the rapidity of this process, which should be distinguished from the propulsive function of the stomach where small solid particles are concerned.After the ingestion of a mixed liquid and solid meal, the liquid component empties from the stomach more rapidly than the solid. Although there is still debate about the relative importance of the proximal stomach' and of gastric peristalsis2 in controlling the emptying of liquids, it is generally agreed that the emptying of solids is controlled by the distal stomach,3 where peristaltic activity also serves to grind and mix the gastric contents before their delivery to the duodenum. Recent interest in the gastric emptying of solids has led to the development of several radioisotopically labelled solid foods suitable for study by scintigraphic methods. Liver labelled with technetium 99m has been particularly favoured46 but emptying studies using bread7 and egg white,8 cellulose fibre,9 and bran'0 have also been described.We have previously reported studies of gastric emptying in man using small inert particles labelled with technetium 99m, which are added to a normal meal.11 These particles are emptied from the stomach in an approximately linear manner with time, corresponding to the pattern observed for solids which are normal dietary constituents. How-* Present address:

dispense with inpatient beds altogether. Even when intensive care is given by enthusiastic and committed staff with residential care facilities outside hospital psychiatric admissions will always be needed.' '" Probably a greater proportion of those who need admission will be more disturbed as others can be dealt with outside hospital. This has been our experience and has economic implications. 15 Although generalising from services in one part of the country to another is difficult, Nottingham is representative of areas with middling demand. Its use of psychiatric beds for the 15-65 age group in 1980 was close to the mean of 0 45 bed per 1000 population estimated by Hirsch to reflect the requirements of England and Wales as a whole.'6 If the fall to the 1985 rate in Nottingham was reflected nationally the requirements for beds would be reduced by over a third. Our findings of reduced use of beds should not be interpreted as showing the newer service to be superior; that is the subject of a separate investigation. Nevertheless, we conclude with some confidence that when community and hospital psychiatric services are combined in an integrated model the benefits are quickly shown and economically feasible. We thank Professor John Cooper and other members of the Nottingham case register, particularly Dr Sarah White, Pat Mounser, Norah Davis, and Richard Gancarzyk, for their help in preparing and checking data from the case register for this survey in statistical bulletins. We also thank Karen Robinson of the Department of Health and Social Security for help in obtaining national figures and for estimating the average number of beds used daily in NHS mental illness hospitals.

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