185 pneumococci resistant to co-trimoxazole. Examination of another hospital revealed that patient’s notes from one month previously she the a c...

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co-trimoxazole. Examination of another hospital revealed that

patient’s notes from one month previously she the

a course of coexacerbation of chronic bronchitis. At that time a normal mixed flora was grown from her sputum. So far as we could discover, this was the only previous occasion on which she had taken co-trimoxazole. The patient responded satisfactorily to

had been

trimoxazole when admitted with


an acute

penicillin. Belfast City Hospital, Belfast BT9 7AB, Northern Ireland.



SIR,-It is difficult to believe that the whole of your editorial on psychosurgery (July 8, p. 69) could have been written by one person. The first half is sober and reflective, the second slightly uncritical to say the least. Many psychiatrists would agree that there is a very small group of chronic, seriously depressed patients who may derive some benefit from a lower-quadrant frontal operation or from one of its variants, but to describe the results as " excellent, usually permanent, and occasionally miraculous " is surely going a bit far. Also, most of the other conditions listed can be alleviated by less drastic At a recent manoeuvres which are not even alluded to. symposium on psychosurgery at the Royal Society of Medicine the tone was closer to that of a revivalist meeting than to a scientific body, and there is now evidence of increasing interest in the use of psychosurgical operations. Most new drugs and many psychological procedures now go through fairly elaborate controlled evaluations before being widely used. Is it too much to ask that the same stringent criteria should be adopted in dealing with potentially more dangerous and certainly more expensive surgical procedures ? Maudsley Hospital, Denmark Hill, London SE5 8AZ.


technique may be in others’ hands, it burns with the pure white flame of objectivity in one’s own hands. Professor Lennox’s views on the parts played by nature and nurture in the development of examination technique, like those of Eysenck and Jensen in another area of education, are interesting but based on rather less factual evidence. The M.C.Q. is probably the most culture-fair method of examination in higher education, and after quite limited experience with the technique, candidates vary little in their ability to handle it. Innate differences in the ability to perform well in the more artificial and stressful setting of an oral examination are larger, as are differences in the ability to produce stylistically satisfactory essays. It is equally a false assumption to expect that the use of several examination techniques extends the area and quality of knowledge sampled. On the contrary, careful analysis of routine essay, oral, practical, and M.C.Q. examinations has shown a strong tendency for the questions asked to concentrate on a very limited range of low-taxonomy, simple factual-recall items in quite limited areas of the subject. It is only with careful definition of objectives, such as Professor Dudley proposes, that a suitable examination, using the most appropriate methods, can be designed. The American National Boards Specialty examinations, with defined objectives and " standards ", following properly an assessment

designed residency training




REVERSIBILITY OF AIRWAYS OBSTRUCTION SIR,-I am grateful for Dr. Brown’s support (July 1, p. 42) concerning the desirability of sputum examination in patients with bronchial disease, and have noted with interest his wet-smear methodfor such examination. I agree with him that examination of


SIR,-Professor Dudley’s views (June 24, p. 1386) on the primary F.R.C.S. were splendidly cogent and timely, and by no means as controversial as Professor Lennox considers them, for they are completely in accord with modern educational theory and practice. The detailed published syllabus advocated in the Australian scheme, kept under constant review, shares few of the disadvantages of the standard textbook. In the design of any educational it to define one’s objectives-if is necessary programme, you don’t decide where you’re going, you’ll never know how to get there, or when you have arrived (or whether you’ve arrived somewhere else instead). The very process of drawing up such a syllabus of objectives is of great benefit to the teachers and examiners themselves, for it is refreshing (even if unusual) for them to decide what precisely they are about. I have discussed this subject at greater length elsewhere, but some points require more specific comment. Professor Lennox’s arguments against the use of M.c.Q. alone in any important examinations are somewhat misleading. The use of a variety of methods is not necessarily more efficient than the use of a carefully designed and flexible system of M.c.Q. The oral examination, for example, can at times produce assessments scarcely more accurate than a random allocation of marks-it may owe its popularity to the widespread belief in the myth of the immaculate perception; that profound belief that however inaccurate 1. Simpson, M. A. Medical Education: A Critical Approach. London (in the press).

certainly provide

useful example than our haphazard, catch-ascatch-can system, in which the candidates train themselves as best they can to pass examination hurdles of varying and undefined height, width, and consistency. Guy’s Hospital, MICHAEL A. SIMPSON. London, S.E.1.



is unsatis-

factory, and any attempts at sputum eosinophil counts quite pointless. At this laboratory we examine paraffin sections from alcohol-fixed sputum,2 a technique which permits easy identification of the stigmata of allergic bronchitis, including eosinophils, shed epithelial fragments (Creola bodies), Curshmann’s spirals, and formed plugs with their characteristic laminar structure. By this technique it is possible to identify minute fragments with such stigmata, even in specimens which are predominantly mucopurulent. I feel it is regrettable that, although this technique was published in 1965, it has not been generally used outside Cardiff, and its diagnostic significance has been ignored by experts in bronchopulmonary disease.33 I note that while Dr. Brown is

broadly in agreement with " reclassification of bronchial asthma " and my proposed " chronic bronchitis ", he does not accept the concept of allergic bronchitis without airways obstruction. Nevertheless, his account1 makes it clear that many of his patients with allergic bronchitis had been confidently thought to be " chronic bronchitics ". He cites the case of a boy of 8, with simple recurrent bronchial catarrh and many rhonchi but no definite bronchospasm, and his brother of 9, with no signs in his chest at all, as producing sputum rich in eosinophils. Clearly, although neither of these children could be said to have asthma, both had an allergic inflammation of their bronchi and in my view suffered from allergic bronchitis sine asthma. 1. Brown, H. M. Lancet, 1958, ii, 1245. 2. Sanerkin, N. G., Evans, D. M. D.J. Path. Bact. 1965, 89, 535. 3. Porter, R., Birch, J. (editors). Ciba Fdn Study Grp no. 38: Identification of Asthma. Edinburgh, 1971.