In every case where the condition had cleared, the disease had been present six months or more at the time of clearance. From these results it appears that dipasic has little or no influence on the natural progress of lichen
planus. London, W.1.
P. D. SAMMAN.
PROFESSIONAL SECRECY AND THE LAW years about the powers of of law to subpoena doctors to give evidence on professional confidences between the doctor and his
SIR,-I have felt strongly for
patients. I was recently subpoenaed by a wife to give evidence at a divorce court to substantiate her allegations of cruelty against her husband. Both are patients of mine. Before giving evidence I told the commissioner that it caused me great distress to have to state in open court facts and opinions based on confidential consultations with the parties concerned. The commissioner replied at some length that, though he sympathised with my point of view, the law as it stood compelled me to give evidence; he himself thought that doctors should enjoy the same privileges as lawyers in this respect, and not be forced to give evidence on professional matters between them and their clients. He also said that if a sufficient number of doctors felt strongly enough about this, the law could be changed. I should be very interested to know the views of others.
M. J. KEATING.
BRONCHODILATORS AND CORTICOSTEROIDS IN ASTHMA
SIR,-I found Dr. Gandevia’s letter (May 13) of great interest. He indicates that a few patients with a clinical diagnosis of emphysema and a persistently poor response to bronchodilators will occasionally respond dramatically to steroids. As he points out, these usually have sputum eosinophilia. If they are assumed to have simple emphysema they will not get steroids. I have previously emphasised the importance of sputum examination in apparent chronic bronchitis and emphysema, and described a speedy and simple method of examining the sputum. This method is so easy and useful that I am surprised that it has not been more widely adopted. I am convinced that it is impossible to distinguish between chronic allergic asthma and chronic bronchitis in any other way. Since then my only modification has been to use a microscope lamp with a flask of water as a lens, the water being tinted with cresyl-blue with a dash of acetic acid to keep it stable. In this light the eosinophils are quite unmistakable. Dr. Gandevia has also drawn my attention to the work of Dr. Hume and Dr. Rhys Jones.2 It would have been of interest to know what proportion of patients fall into each of the five groups they described, as, without some idea of the frequency of such patterns of response to 1% isoprenaline aerosol, it is most difficult to judge the importance of their work. Their forthcoming paper may resolve this question. I strongly deplore the naive tendency to believe that the reading on a machine always takes precedence over the patients’ statements, particularly when the estimation of the F.E.V)! is assumed to provide an infallible yardstick. Measurement of ventilatory function is only one aspect of respiratory physiology; many other factors must be involved. I have observed that established chronic asthmatics with sputum eosinophilia, when treated with steroids for the first time, sometimes report considerable subjective improvement in their exercise tolerance; but spirometry records either very little improvement or no improvement at all. To my mind two factors are not sufficiently taken into account. Firstly, there 1. 2.
Brown, H. M. Lancet, 1958, ii, 1245. Hume, K. M., Jones, E. R. ibid. 1960, ii, 1319.
doubt whatever but that the F.E,V’l is primarily a of the power of the muscles of expiration and the degree of rigidity of the thoracic cage itself. It seems probable that a well-established case with a fixed barrel chest may not be able to push out more air in one second whatever the state of the airways. It should, therefore, be possible for the patient’s airway to improve greatly but for the F.E,V.1 to be only slightly increased, because of the rigid thorax. Secondly, in a patient whose F.E,V.1 is less than 1 litre, very slight improvement may produce subjective improvement which appears out of proportion to the actual increase measured. can
I should like to see more interest shown in the gross and microscopic appearances of the sputum. Even simply getting the patient to cough up sputum into a disposable plastic petri dish can provide much useful information. Just as the urologist looks at urine, and the gastroenterologist at stools, so the chest physician should look at sputum. The Chest Clinic,
H. MORROW BROWN. THE HANDICAPPED
SIR,-Your leading article of June 10 draws attention the need for centres for the initial assessment of handicapped children, for periodical reviews of their progress, and to act as an advisory service to the family doctor. You also suggest that there may be a need for a doctor who will make a special study of one type of handicap. Although a few specialised centres would be of great value, I do not think that the need is so much for specialists in each type of handicap as for doctors able to coordinate medical and non-medical services and to mobilise a team composed of members of the services appropriate for each patient. Many of the problems that beset handicapped people are common to them all, irrespective of age or disability, and stem from ignorance of the available services, from psychological maladjustment, and from adverse social circumstances. By advising patients with any type of handicap, a clinic can gain considerable experience and establish personal contact with many medical, paramedical, and non-medical people. But the doctor in charge should not consider himself a specialist in every medical and surgical condition that the patients may have. He is there to advise and be advised by his colleagues (especially the patient’s family doctor), coordinate the efforts of all who are able to help, and give continuity of care. This continuity is particularly important at times of difficulty-such as the failure of the original plan, or the occurrence of a new and unexpected problem-and on leaving school, when a handicapped young person passes out of the supervision of the school medical officer and often of the pxdiatrician too. M. D. M. D. WARREN Royal Free Hospital, to
W.C.1. London, W.C.I.
Chairman, Resettlement Clinic.
SIR,-I visited the diagnostic and evaluation centre at Johns Hopkins Hospital in the summer of 1959 and was struck by the following points in its planning and organisation: It was set up at the request of the Maryland State Planning Commission and was not started in opposition to the school medical services. Its object is not merely to make a diagnosis, or diagnoses, but to assess disabilities in terms of the child’s present and future educational needs. Many complex learning disorders must be studied in detail, both at the neurological and the psychological level, before a conclusion can be reached which will be of use to the teacher: a diagnosis alone is not enough.