1279

sutures not more than 1 cm. apart. These must also be leftin for a full ten days. Normally I do not use any deep sutures.Mr. O’Malley does not say what approach he employed,

or whether a separate incision was required. With thevertical incision it can be simply extended up or down tocope with most stripper difficulties in the vicinity of thesaphenous termination.

F. T. CROSSLING.Stobhill General HospitalGlasgow.

1. Lancet, 1831-32, i, 490.2. Charakteristik der epidemischen cholera gegenuber verwandten trans-

sudationsanomalien. Leipzig, 1850.3. Lancet, 1831-32, ii, 274.

THIRST

M. B. STRAUSS.Veterans Administration Hospital,Boston, Massachusetts.

SIR,-Apropos of Dr. Eaton’s astonishment that salt

depletion can give rise to a sensation of thirst (May 10,p. 1021), it must be admitted that water is almost alwayslost as well. Nevertheless, since in severe depletion theloss of salt is greater than the loss of water, the concentra-tion of sodium in the serum is lowered and hypotonicityresults.

This has been commented upon by Dr. O’Shaughnessy,late of Newcastle upon Tyne, in a letter in your columns.l Henoted that in the worst cases of cholera the blood loses not onlya " large proportion of its water " but a " great proportion of

its neutral saline ingredients ". He further states that all thesalts deficient in the blood " are present in large quantities inthe peculiar white dejected matters ". Since Dr. Schmidt of

Dorpat 2 has more recently confirmed these observations (hefound the sodium reduced from the normal level of 3.18 g. perkg. of serum to 2-69 g. in cases of cholera-a decrease from 139to 117 mEq. per litie), I have no reason to doubt their accuracy.That thirst occurs in cholera despite this lowering of serum-

sodium is attested by Dr. Latta, late of Leith,3 who treated hispatients by infusing salt solution intravenously, notingthat "... the poor patient, who but a few minutes before wasoppressed with sickness, vomiting, and burning thirst, is

suddenly relieved from every distressing symptom " (italicsmine).

REGIONAL DISTRIBUTION OF CONSULTANTSAND S.H.M.O.s

SIR,-Thank you for publishing (May 31, p. 1169) thes.H.M.o. figures for the various regions in response to myletter in your issue of May 17. Using these figures withthe previously published population figures for eachregion I calculated the following:

With only two exceptions the backward areas in con-sultant cover are also the worst off for s.H.M.o.s-in orderof backwardness, Manchester, Sheffield, Leeds, and

Liverpool-which is what I suspected. In other words,the lack of consultants is not even compensated by anincrease in s.H.M.o.s (of the two exceptions, Newcastlehas the next best consultant cover, while Birminghamis about average). ,

The only conclusion is that the population in the backwardregions is having a poor deal in the way of Health Servicefacilities, whereas since they are all highly industrialised and

congested parts of the country they really require better thanaverage.As regards consultants and S.H.M.O.S in these areas, they

are obviously working under conditions where they cannot givethe full benefit of their knowledge and skill because the numbersthey have to cope with are too large. I say " obviously ",because having worked in one of the best organised regions Iam now working in one of the worst (according to the abovefigures) and therefore realise the disparity in facilities fromconsultants right down the line, including ancillary medicaland clerical staff, almoners, health visitors, &c.

General practitioners tell me they have to wait weeks foroutpatient appointments and sometimes weeks for diagnosisreports-indeed, I am surprised they get reports at all some-times, because I find it very difficult to get a reply when I referpatients to another specialist for an opinion I feel that thebasic trouble is not that of a studied discourtesy but that toofew people are trying with too few facilities to do too much workfor too many.

As I understand that regional-board finance is on a

per-capita basis, may I put in a plea for the backwardareas to have a higher proportional allocation of moneythan the advanced regions until the medical services

throughout the country are more evenly distributed ?S.H.M.O. (EX-SENIOR-REGISTRAR).

1. Fairbairn, A. S., Reid, D. D. Brit. J. soc. Med. 1958, 12, 94.2. Reid, D. D. Proc. R. Soc. Med. 1956, 49, 767.

THE NATURAL HISTORY OF

CHRONIC BRONCHITIS

SIR,-We are grateful for Dr. Medvei’s comments lastweek on our paper of May 31, although, since neither ofus has seen the unpublished report to which he refers, weare unable to follow his argument completely.We were aware (one of us, A.S.F., from several years in the

Treasury Medical Service) of some of the medical and adminis-trative problems involved in the disposal of postmen crippledby respiratory disease and of the special circumstances in somebigger offices. But we could find no evidence that any suchlocalised anomalies in disposal materially affected the broadpattern of results in the large groupings of areas, ranked simplyon the local frequency of fog, used in our study. The onlyobservations restricted wholly to the London area dealt withthe timing of onset of absence because of bronchitis in relationto climate.

All occupational groups are selected but this does not meanthat their experience is of no general relevance. The wastage-rate because of bronchitis among postmen in different areas is

quite closely related to local death-rates from that cause amongall middle-aged males. Nor does such selection make " con-trols " superfluous. Without control comparisons some of theresults would have been meaningless; and we believe that

presumably healthy postmen are the most appropriate choicein these circumstances.

-

It appears, however, that Dr. Medvei would have us defythe usual scientific conventions by going beyond the data

presented in our paper. It is clear from the distribution ofbronchitis frequency in adult sickness-absence records that allfuture invalids do not present with repeated attacks before theage of 45. Our sober assessment that these records had" some " value recognises that, taken alone, they are certainlynot infallible. Dr. Medvei’s term " exceptional " presumablyderives from his experience of their use with additional clinicaldata-e.g., on childhood disease, obtained by detailedinterview.Our hesitancy about drawing conclusions on the role of

smoking in chronic bronchitis resulted from the rather indirectnature of our evidence. We have already referred elsewhere 1 2to Oswald and Medvei’s paper which showed that the preval-ence of histories suggestive of chronic bronchitis is similar inthe two sexes but only when job, place of work, and smokinghabits are alike. We ourselves could offer no fresh information