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case for it has been made out, though war conditions andpolicy must of necessity exert an influence. It is reallyextraordinary how equipment has been provided by theMinistry of Health in so short a time. An ordinaryhospital gathers its equipment little by little over aperiod of years and it accumulates unnoticeably. Whenstarting from nothing the demands of a general hospitalare staggering in amount and cost. Yet this equippinghas been done, and the result is a hospital able to grapplewith almost any branch of work. Admittedly it is notperfect, but all the essential things, all those thingsabsolutely necessary for first-class work are there. Thereis an atmosphere of comradeship and mutual help through-out the senior staff, the residents and nursing staff whichmakes for smooth working and efficiency. I cannotbelieve that our problems have been very different fromthose of other hospitals, and I do not think such a com-plete organisation could have been got together in soshort a time and under such difficult conditions unlessit had had the drive and prestige of a Governmentdepartment behind it.

If Observer would visit this E.M.S. hospital I think hemight revise his views of hospitals run by the state.

CHARLES PANNETT.

MEDICAL BENEVOLENCE

SiR,—A loss in income of 21292 sufficiently explainsthe reason for this letter. This loss to the Royal MedicalBenevolent Fund is largely due to the fact that manyof our regular subscribers practising in towns heavilybombed have suffered serious financial loss, and have hadto reduce or cancel their subscriptions. Their numbermay well increase before the war is over. Everybodyknows the beneficent work of the fund in helping membersof our profession and their wives, widows and childrenwho are living in straitened circumstances ; and who,in many cases, are quite unable, through age and infirmi-ties, to do anything to help themselves. The committeehas done everything possible to cut down overheadcharges. Administration is carried out with a reducedstaff in less costly offices. Expensive annual reportshave been abolished and one way and another we havemanaged to effect a very considerable saving in ourannual expenditure. Unfortunately, however, this isnot nearly enough, and if the work is not to be seriouslycrippled we must get more help. We need donationsto meet the present emergency, and especially we needmany more annual subscriptions. Poverty is hard tobear under any circumstances, but when accustomed helpis curtailed and prices are soaring-as is the case today-the position may well become desperate. Here is apassage from a letter which reached me the other day :

" I am sending you a donation as a thank-offering for thefact that circumstances have placed my life in a spot where

there is*less danger from enemy action than is the case withmy brother practitioners."I appeal to all of your readers who feel that they are insimilar fortunate circumstances to come forward at thiscritical time to help in carrying out our duty to ourdistressed colleagues. Contributions should be sent tothe Royal Medical Benevolent Fund, 1, Balliol House,Manor Fields, Putney, London, S.W.15, and will begratefully acknowledged.

ARNOLD LAWSON,Chairman of the Committee of Management.

PUNCH WITH CARE

SiR,-The view expressed in your annotation ofJune 14 that punchdrunkenness is a condition mainlyfound in second-rate professional fighters of long standingis well supported by observation of a considerablenumber of boxers seen by Dr. E. Guttmann and myselfduring the past few years. We are, however, awarethat our outlook may have become too pessimistic as themajority of these boxers were severely affected and onlycame because they were either worried about theirhealth or had been urged to come by anxious relatives ormanagers. In order to obtain a well-balanced outlook

on the problem of punchdrunkenness a controlledinvestigation should be carried out. A group of say 50professional and 50 amateur boxers should be selectedfrom recruits to the Services and members of thesegroups should undergo special individual examination.

Such a comprehensive investigation of a representativecross-section of professional and amateur boxersselected in this way would have several advantages.

1. The policy which should be followed by the variousServices as regards boxing could be indicated.

2. Attention would be drawn to any recruits who have eventhe slightest damage to the central nervous system.

3. The very earliest symptoms of what is later termed

punchdrunkenness could be assessed.4. Definite instructions could be given to all doctors who

have the responsibility of examining at regular intervalsprofessional and amateur boxers both in the Forces and incivilian life.

London, ’Y.1. C. E. WINTERSTEIN LAMBERT.

THE SHORTAGE OF DOCTORS

Sir,,-The shortage of medical personnel has beensadly overemphasised both by political statement andthe press. That there is a shortage cannot be deniedbut it is only in two classes of the profession. It isunfortunate that these two classes are so important, fortheir importance has in part caused the overemphasis.The other cause has been the unwillingness of hospitalsand the authorities in charge of them to let men whomthey have trained to be competent surgeons and physi-cians go into the Services as regimental medical officersand corresponding ranks, to look after 500 fit men andthe requisite number of latrines. It is this feeling ofuncertainty about the proper utilisation of medical manpower which is worrying the hospitals and the professiongenerally, and hence the unwillingness, which has createda spurious atmosphere of shortage. It should be madequite clear that there is no shortage of medical or

surgical specialists in the country or in the Services, andthat the training of many more is still going on.The first class in which there is a true shortage is in

the most important branch of the profession-generalpractitioners. This has resulted, first, from the over-riding demands of the Services, and secondly, from themethod by which the recruitment of G.P.s was done.The Central Medical War Committee, acting on behalf ofthe Government, delegated the duty of recommendingwho should be taken and who left to their local medicalwar committees. No other method of recruiting G.P.swas at hand, and to institute another would have costboth time and money. It is a pity that local’selectionsshould have contributed to this shortage, though natur-ally the final decision was not taken locally but by theCommittee of Reference of the C.M.W.C., to whom allpractitioners have a right of appeal. The system oflocal recommendation has resulted in the more activepractitioners in many spheres of medical interest beingrecommended and finally taken into the Services. Sothe elderly and the relatively inactive have been left.It must be remembered that many active practitionerswere territorials and many more volunteered, and therewas no court of appeal to whom their patients couldapply for their retention. All this seems inevitable butis scarcely fair to the public. The cure for this shortageis obvious but costly. The E.M.S. already has a

comprehensive regional hospital scheme in operation.If inpatient treatment for cases referred to these hospitalsby G.P.s was started it would greatly relieve the burdenof the over-worked G.P. If outpatient treatment wasalso allowed at these hospitals it would serve the doublepurpose of solving the G.P.’s problem and giving thehospitals more to do between blitzes.The second class in which there is a true shortage is the

house-officer, who as the youngest member of theprofession is naturally taken by the Services. Thisshortage too could be alleviated if all the newly qualifiedmen were compelled to work in hospital pending theirrecruitment. Too much blame should not be attachedto those of them who prefer to do locums in generalpractice, for in the six months before they are called upthey can earn .E200-E250 (all found) in this way, whereasas a house-officer they would only get 60 (all found).Much has been written and said lately about the

employment of alien doctors to replace our deficiencies,and more and more are being so employed, but, as

Professor Greenwood pointed out in his letter of May 31,there are difficulties in their employment. In the main

they are not suitable for general practice, even if they

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have British medical degrees (picture a fashionableGerman Jewish gynaecologist attempting to doctor aNorfolk agriculturist), and indeed many of these aliensare specialists of whom there is no shortage. Reasonsof national security also make them unsuitable foremployment as G.P.s. When considering their employ-ment as house-officers, it is well to bear in mind that thehouse-officer, admittedly under supervision, does a majorshare of the work of the hospital. Even under peace-time conditions he. is expected at most hospitals to givea large number of anaesthetics, and ansesthetics as weknow them, except in Scandinavia, do not form part ofthe medical curriculum on the Continent. It is quiteunderstandable that hospitals are not always willing toemploy middle-aged or elderly aliens as house-officers,and the aliens themselves are not always willing to acceptthis, the most ill-paid and menial task in the profession.

I am glad to see that a representative committee toinquire into the proper utilisation of all medical manpower, both in the Services and outside them, has beenset up. This should go a long way towards allaying thedisquiet in the hospitals and the profession generally.

A. B. C.THORACOPLASTY

SiR,—In his letter of June 14 Dr. Gregory Kaynewrites with a little dissatisfaction about my article andyour leader in the Lancet of May 31. It is with somehesitation that I ask you to give me space to make oneor two points in reply. I do know Overholt’s figuresand consider them very striking, but Dr. Kayne muststill allow us to hesitate over operating on the type ofolder patient that we get at Colindale Hospital. Exuda-tive and proliferative disease may be clinical ratherthan strict pathological terms (this is open to dispute)but it would be a mistake to fail in their separate con-sideration when the question of treatment arises.Alexander, in his classic on collapse therapy says (p. 427)" the predominance of productive or fibrotic lesions, incontradistinction to exudative lesions, indicates a

favourable resistance to tuberculosis " ; and later" serial roentgenograms should show that the exudativeelements are regressive or at least stationary," if a thora-coplasty is to be done. There is an excellent definitionof the exudative type of disease in " A Textbook ofX-ray Diagnosis, by British Authors " (p. 303). Asregards blood examinations, I certainly would not laytoo much stress on them ; but, as I said, they " playa part in our assessment of resistance and toxicity."Other clinical features help in this, of course, and per-haps bronchospirometry will come into fashion as ahelpful (though not essential) means of estimatingrespiratory function.

London, N.W.9. J. V. HURFORD.

SOCIALIST MEDICAL ASSOCIATION.—At the annual generalmeeting of this association, held on May 25, the followingresolution was put on record :

That in view of the recent appeal for a thousand doctors fromthe United States and the decision to employ 4th and 5th yearmedical students as house officers, this meeting protests againstthe Government’s failure to make use of the medical services of theanti-Fascist refugee doctors in this country. Since only about onehundred of the 1400 now in England are being allowed to use theirmedical skill and training, we demand that there should be animmediate speed-up of the machinery to effect the registration andemployment of eligible alien doctors, and that those now employedon demolition and construction work in the Pioneer Corps be releasedfor work in which their medical experience can be used.

BRITISH POSTGRADUATE MEDICAL SCHOOL.——A course onWar Surgery of the Chest will be held from July 7-11, atwhich the following will lecture : Mr. Tudor Edwards,Mr. T. Holmes Sellors, Mr. 0. S. Tubbs, Mr. Price Thomas,Dr. H. Woodfield Davies, Prof. J. A. Nixon, Mr. A. K.Henry, Prof. G. Grey Turner, Dr. J. Duncan White,Surg. Rear-Admiral G. Gordon-Taylor, Mr. R. C. Brock, Mr.N. Barrett, Mr. J. E. H. Roberts and Dr. A. J. Morland.Officers of the armed forces wishing to attend without pay-ment should apply through their Director-Generals. Forothers the fee is a guinea, and tickets may be obtained fromthe Dean, British Postgraduate Medical School, Ducane Road,W.12.

Further courses will begin on the following dates : WarSurgery of the Nervous System, July 21 ; Operative Surgery inWar-time, Aug. 22 ; War Surgery of the Extremities, Sept. 1.

Parliament

’

Economy of Medical PersonnelMr. E. BROWN, Minister of Health, in the House of

Commons on June 24, announced his decision, in agree-ment with the Service ministers and the secretary ofstate for Scotland, to set up a committee to investigatewhat further steps can usefully be taken to secure theutmost economy in the employment of medical personnelin the Forces, the emergency hospital scheme and thecivil defence services, and all other medical servicesincluding general practice. The names of its membersare as follows :

Mr. Geoffrey Shakespeare, parliamentary under secretary ’

for the dominions (chairman).Prof. R. M. F. Picken, M.B., D.P.H., Welsh National

School of Medicine. ;

Sir Alfred Webb-Johnson, vice-president R.C.S. ’

Dr. J. Crighton Bramwell, F.R.C.P.Prof. Sydney Smith, M.D., Edinburgh University.Dr. J. A. Brown.Dr. William Malcolm Knox.with medical representatives of the Admiralty, War

Office and the Air Ministry.In addition the following have agreed to be closely

associated with the work of the committee :—

Sir Charles Wilson, P.R.C.P. JSir Hugh Lett, P.R.C.S.Mr. H. S. Souttar, F.R.C.S., chairman of the Central

Medical War Committee.

QUESTION TIME

Clothing CouponsQuestions addressed to the President of the Board of Trade

elicited the following information.Temporary inmates of hospitals and institutions are already

in a position to purchase the normal ration, since they possessa food ration book. The normal supply of clothing couponswill be issued to permanent inmates as soon as this can bearranged. In the meantime, hospitals of all kinds may, as aprovisional arrangement, obtain their essential requirementsby giving a formal receipt to the supplier. This latter pro-vision enables hospitals to obtain supplies both for patientsand for nurses. Similar facilities are available to institutionsunder local authorities.

Special temporary arrangements have been made fornurses of the British Red Cross Society, the St. John’s Ambu-lance Brigade and members of the Joint War Organisationto obtain their uniforms without surrendering coupons. Forother hospital nurses, arrangements are under discussion withthe British Hospitals Association and, in the meantime, the.hospitals may obtain supplies of rationed goods .withoutcoupons by giving traders a receipt specifying the goods andstating that these have been supplied for their use.

The Wholemeal Loaf ’

Commander LocKER-LAMsoON asked the ParliamentarySecretary to the Ministry of Food if he had made an estimateof the amount of shipping which could be saved if a wholemealloaf of 95 % content were adopted ; what saving in meat andother food products would ensue ; and how many tons ofoffals would be available for pigs and poultry if all wheat weremilled here.-Major LLOYD GEORGE replied : The Ministerhas estimated the amount of shipping space which could besaved on the transport of grain for bread for various rates ofextraction and has considered this in relation to other factorsof importance which must be taken into account. In replyto the second part of the question, as raising the rate ofextraction would not be likely to increase the consumptionof bread, it is unlikely that any saving in meat and other foodswould ensue as a result of altering the rate of extraction offlour. In reply to the third part of the question, as the flourmills of this country are already milling wheat practically totheir full capacity, it is obvious that to raise the rate ofextraction to the figure mentioned would result in a sub-stantial reduction of the wheat by-products available for pigsand poultry.

In reply to a further question Major LLOYD GEORGE added :It is estimated that since July, 1940, the consumption ofwholemeal and wheatmeal flour has increased and now repre-sents some 3 % of the flour consumption of the country, exclu-