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be obtained from any efficiency

commence to absorb. (5) Under artificial pneumothorax treatment these shadows appear to form areas which do not readily collapse, indicating that at that point the pleura is adherent. It would be idle to deny the possibility of more than one cause for such a radiographic appearance, but to me a pleural origin seems most in accord with the observed facts.-I am, Sir, yours faithfully, ERNEST WARD. Paignton, Oct. 4th, 1932.

tests without whole-

cooperation of the subject concerned, especially in those requiring concentrated maximal For this reason I agree that the effort to perform. results obtained from out-patients cannot be satisfactorily compared with those obtained from Royal Air Force personnel. The essential purpose of the Royal Air Force efficiency tests is not directed so much towards gauging disordered function as towards the estimation of the relative degrees of efficiency among normal, healthy young adults. The average hearted

RESPIRATORY EFFICIENCY TEST To the Editor of THE LANCET

age of Dr. Moncrieff’s cases was about 40-the limits 17 to 70. Respiratory efficiency tests in general, such as those mentioned, are not applicable to elderly persons. The vital capacity may be quoted as a case in point. Calculated vital capacity from height, weight, and chest measurement as laid down in Air Publication 130, can only be applied up to the age of about 30, as increased weight and chest measurement occurring with increasing years would require a higher standard of vital capacity in an individual at 50 than at 20-which is absurd. The tests employed by Dr. Moncrieff have never been considered applicable to severe cases of disordered respiratory function and might be dangerous if applied in this connexion ; it is probable that in such cases a careful clinical examination in experienced hands is likely to prove of greater value than any of the existing tests of respiratory efficiency. I am, Sir, yours faithfully,

being

SIR,—The considerable interest aroused by the recent observations of Dr. R. A. Young on the need for the measurement of respiratory efficiency and by the report of Dr. Alan Moncrieff who, in your issue of Sept. 24th, describes the results of a series of such tests on " the hospital population," requires, in view of this interest, a more strictly accurate representation of the views of Flack than has been given and generally assumed in Dr. Moncrieff’s account. Flack, in the Milroy Lectures referred to, did not intend that the standards of efficiency as adopted by the Royal Air Force should be applied to the general civilian community. Instead, from a series of researches which included the study of a group of pilots who were stressed, unfit, and suffering from " breakdown in the bodily system " from various causes, he merely observed that " a similar condition of bodily inefficiency may be found among individuals who are deemed more or less normal members of the community." Surely this is not, as Dr. Moncrieff suggests, an " unjustifiable generalisation." The fact that evidence of similar inefficiency is discovered among the more or less normal patients attending Middlesex Hospital should come not as a surprise in terms of Air Force standards, but as a clear proof of Flack’s contention. Nevertheless, to those who have been long conversant with the work of Flack and more partic. ularly concerned with the application of his tests, the report of Dr. Moncrieff’s investigation has a refreshing appeal; but it must be remembered that these tests are too subjective in nature to give comparable results unless conducted under strictly standard conditions. Apart from a discussion of relative unfitness, one might offer this suggestion, that by retaining the principles, and by a modification of methods, Dr. Moncrieff might still find in these tests a solution to the clinical problems he had in I am, Sir, yours faithfully, view. H. W. CORNER, M.D.

H. A. TREADGOLD, Consultant in Medicine, R.A.F. Central Medical Establishment. Royal Air Force, Clement’s Inn, W.C., Oct. 3rd, 1932.

GASTRIC ACIDITY To the Editor of THE LANCET

SIR,—In a series of articles on gastric acidity this year you have repeatedly drawn attention to recent

an intimate relation between the acid-base balance in the blood and the secretion of acid in the gastric juice ; but you appear to be using these observations to support some new conception of gastric pathology. I admit I do not know what this new doctrine is ; I do not always understand what you mean by "gastric acidity," and at times I am left with a haunting doubt as to whether you are clearly distinguishing between gastric juice and gastric contents ; in one place in your first article (THE LANCET, 1932, i., 29) by a slip of the pen you definitely write gastric juice when you mean gastric contents. In the last article (August 13th, p. 352), however, you clearly invite us to believe that the Wimpole-street, W., Oct. 1st, 1932. acidity of the gastric contents is of little, if any, in the production of gastric symptoms. importance To the Editor of THE LANCET I cannot myself accept this invitation, but what SIR,—Dr. Moncrieff conveys the impression that puzzles me is where you find any connexion between the expiratory force and 40 mm. Hg tests are the these remarks in the opening paragraph and the very main, if not the only, methods employed by the Royalinteresting experiments of Browne and Vineberg, Air Force to estimate respiratory efficiency. This is which you discuss in the rest of your article. These far from being the case. The vital capacity, calculated experiments are entirely concerned with the control from height, weight, and chest measurements, and the of the gastric secretion by alterations in the acid-base breath-holding test, are at least of equal, if not greater, balance in the blood ; but variations in gastric secrevalue as a gauge of respiratory efficiency than the tion have nothing whatever to do with the quite test he quotes. Of the four tests connected with thedistinct problem of the effects produced in the stomach estimation of respiratory efficiency, the expiratory by variations in the acidity of the gastric contents. force is probably of the least value, while the 40 mm..Although this point is really very obvious, it is test is of more value in demonstrating the coordina-frequently missed by those who write on gastric tion between the cardiovascular and respiratory pathology. I do agree with your conclusion that wee systems under stress than it has as a purely respiratoryneed a wide outlook, but I do not get on very fast if, test. ] my eyes on the horizon, I stumble over the keeping It is unreasonable to expect that good results couldobstacles that lie at my feet. Will you help me by

investigations showing

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going back to that matter of the production of gastricnot suggest that symptoms are produced by changes in symptoms with which you started, and explain how the plasma bicarbonate. It was not suggested that oral administration of alkalis in the treatment of peptic changes in the acid-base balance in the blood can any part therein, if by hypothesis we deny any ulcer should be replaced by intravenous injections, and Balint’s interesting observations were cited merely importance to changes in gastric acidity? If, indeed, in the treatment of peptic ulcer, oral to show that the exact significance of gastric acidity administration of alkalis should have to be replaced in this disease is as yet far from fully understood by intravenous or subcutaneous injections, a prospect and that experimental work bearing on it should not that you seem to regard rather light-heartedly, it pass unnoticed. It is known for instance that, in will surely and rightly be hailed by the surgeons as i cases of ulcer, gastric acidity may be higher after the last nail in the coffin of the medical treatment of alkali treatment and cessation of symptoms than that condition.-I am, Sir, yours faithfully, it was when symptoms were present, also that a G. W. GOODHART. high or low acidity may be found during the active Group Laboratory, Archway Hospital, N., Sept. 24th, 1932. , stage without relation to the severity of the symptoms. **Our object in drawing attention to experi- - ED. L.

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mental work on the acid-base balance in the blood and the secretion of hydrochloric acid into the stomach ERRATUM.—Dr. V. Rendall writes : " In a paper was to point out that the secretion of HC1 did not! on Diathermy and Constipation, published in THE LANCET on August 6th last, an unlucky misprint depend solely upon local changes in the stomach occurs. In the comment on Case 5 the first six lines itself. It was not suggested that variations in acidity were a quotation from the findings at the New Lodge brought about by changes in the blood led to gastric Clinic, while the last five lines were my observations. symptoms " ; the intention was rather to indicate The quotation marks should have been placed, of that the degree of acidity alone does not fully explain course, at the end of the first six lines, and not at the symptoms of indigestion. Extremes are compatible the end of the paragraph, and I regret the oversight with perfect health, and the investigations quoted do, which Dr. Hurst properly resents." "

PUBLIC HEALTH SERVICES Sanatorium, Swilly, and the City Hospital. At the Suggested Economies at Plymouth City Hospital the saving effected by the change was THE Plymouth City Council recently appointed a E650, and at Swilly £156 per annum. The average special committee of inquiry into public healthweekly maintenance cost at Didworthy, 52s. 2.8d., administration, and this committee has now issued ais 9s. 5d. per week per patient above the average report recommending measures which will save more for such institutions. Here, again, reduction in staff than 16000 a year. Plymouth employs 547 persons is recommended-to a total staff of 25-and also in its public health service, and the committee reduction in the emoluments of some of the staff, considers that several institutions are overstaffed. a total economy of E1500 being held to be possible. It suggests that one of the total staff to 1-6 patients The committee also strongly recommended that the is adequate in the Swilly Hospital for infectious new Mount Gold orthopaedic hospital should only i disease, where the matron has a waiting-list of nurses be staffed and equipped for one-half of its capacity, who could be called upon in an epidemic. At Lee Mill since not more than 50 patients belonging to the city small-pox hospital, at present quite unoccupied, were suitable for admission. there seems no reason to supply the caretaker and A saving of E1627 is suggested on the maternity his wife with an assistant who is paid E120 a year. and child welfare service, as the committee came to A consignment of beds and bedding for this institution ( the conclusion that there was considerable overlapping is lying there unpacked, and the committee advises with the voluntary organisations. It recommends that it be taken into use elsewhere. At the City the dismissal of one medical officer, four health visitors, Hospital the staff ratio is 1 to 2-1 patients. For one assistant investigation officer, and one clerk, 456 patients in 17 wards the committee found and the abandonment of a proposed sixth centre. 4 medical officers, 8 consultants, 134 nurses, a i Since 1925 the staff has been increased by two medical dispenser, a radiographer, a masseuse, and 103 others, officers, three health visitors, and a clerk, and the

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and considers this

excessive ; the medical superin- annual cost has risen from E5225 to £13,349. There tendent, however, declared that the place was under- are 18 sanitary inspectors, and the committee recomrather than overstaffed. The average cost per patient mends that the number be reduced to 15, a saving

I

per week was E2 5s. 5d.;in the absence of figures of £1050 per annum, by letting vacancies remain from other institutions for comparison, the committee unfilled when they occur. The town hall staff of made no recommendation, but pointed out that at ten should also, it thinks, be reviewed. this hospital about 100 beds were usually vacant, The committee emphasises the fact that its investiwhile at the South Devon and East Cornwall !gations have been by no means exhaustive and could (voluntary) Hospital there is a waiting-list of over 200;profitably be continued. Its report is signed by four this led them to the view that more coördinationof the five members, and the fifth presents a minority between the voluntary and municipal undertakings, report suggesting that the economies proposed are and avoidance of unnecessary duplication of plantapparent rather than real, and will only shift the and appliances were required. £600 a year could, expense from one department to another. He it was held, be saved by appointing junior medical disagrees with practically all the specific proposals officers annually instead of permanent medical officers made. at 9350 a year. The committee also advised the When the report was submitted to the Plymouth reinstitution of the pay-bed system, patients in these (City Council the Labour members protested, and beds being attended by their private practitioners. expressed unwillingness to accept any reductions in Considerable economy has already been effected expenditure . on public health. After prolonged by using ordinary raw milk for cooking purposes. (discussion, both reports were referred to the Public Health and Maternity and Child Welfare Committees. Hitherto Grade A (T.T.) has been used at

Didworthy