24 October 1964 Correspondence BRITISH '1073
of the cardiac adrenergic receptors (beta report on the European Conference in the improve the " public image " of that industry,
adrenergic receptors in Ahlquist's termino- same issue (p. 502). at present the target of so much criticism.
logy). When noradrenaline is infused at a Incidentally, it is important to keep in Obviously there will be practical difficulties,
moderate rate into the intact circulation (of mind that " loss of control " does not mean but as doctors intimately concerned in the
the order of 20 pg./minute in man) one that the alcoholic will get drunk on each and prescription, supply, and identification of an
usually observes a slight decrease in heart every occasion when he starts drinking ; rather ever-increasing range of drugs, we feel such
rate and in cardiac output. These effects of does it mean that he could never be quite a scheme merits earnest consideration by the
noradrenaline are entirely indirect; they are certain that he would be able to stop once he profession and pharmaceutical industry.-
reflex effects originating from the sino-aortic had started to drink on a given occasion. For We are, etc.,
baroreceptors which are activated by the example, it is not very uncommon to meet Grantham, Lincs. F. C. CLOUTING.
peripheral pressor action of the agent. At people who, for a while, are able to drink J. WIGHTMAN.
a high rate of administration the reflex effects " in moderation " when switching from spirits
are overwhelmed, the direct effects of nor- to beer, or when drinking only with meals, or
adrenaline on the heart predominate, and the when drinking only in company, etc. How-
heart rate rises above normal. When the ever, sooner or later-and as a rule fairly Plastic Shoes for Ultra-clean Wards
action of the cardiac moderator reflex is pre- soon-this attempt becomes too much and
vented (atropinization, inactivation of the they resort to the uncontrolled drinking. SIR,-In discussing the provision of an
baroreceptors, administration of a blocker of One might, perhaps, speculate on the possi- ultra-clean ward, Dr. K. D. Bagshawe (3
the alpha adrenergic receptors) the direct bility of a certain threshold of blood-alcohol October, p. 871) states: " Other outstanding
cardiac effects of noradrenaline are apparent concentration, varying from person to person, problems that require further study are the
even at low rates of administration. and in the same person from time to time, design of suitable clothing and especially of
It would be most unfortunate if Ahlquist's below which the alcoholic could drink without sterilizable footwear." I wish to suggest that
suggested classification of adrenergic recep- losing control (depending possibly on psycho- the solution of the problem of sterilizable
tors were misunderstood to mean that logical, psycho-social, psychosomatic, or footwear is to be found in the field of plastic
sympathomimetic amines which are primarily chemical factors) but beyond which the " loss shoes.
alpha-receptor stimulators in the peripheral of control " becomes effective. However, Shoes of flexible plastic are currently made
blood-vessels cannot have highly effective quite clearly, there is a need for further re- in Australia and freely available in Sydney,
actions on the heart. A bit of reflection as search and for attempts at an even finer but do not appear to be on sale in London.
final evidence: since noradrenaline is the differentiation between the various types of I have seen two types-(1) Roman sandals,
sympathetic transmitter substance, how could alcoholics.-I am, etc., and (2) slipper shape without fastening.
the heart respond to sympathetic stimula- St. -Bernard's Hospital, M. M. GLATT. These shoes are cheap, very hard-wearing,
tion unless the beta adrenergic receptors in Southall, Middlesex. and comfortable, except that because the
the myocardium were stimulated by nor- plastic is impervious to fluid perspiration
adrenaline ?-I am, etc., REFERENCES
tends to collect under the sole of the foot.
Jellinek, E. M., The Disease Concept of Alcohol- This can be minimized by wearing cotton
Dept. of Pharmacology, JAN KoCH-WESER. ism, 1960. Yale Centre of Alcohol Studies, Yale socks. My own pair was originally obtained
Harvard Medical School, Station, New Haven, Conn.
Boston, Mass., U.S.A. 2 Davies, D. L., Quart. 7. Stud. Alcohol, 1962, 23,
for use as wading shoes, to protect my feet
94. while studying seashore animals. They have
successfully withstood repeated prolonged
immersion in sea-water. Because the shoes
Drug Dependence are washable I have used them as operating-
Code for Drugs theatre shoes. My practice was to rinse the
SIR,-As pointed out in your leader on insides and scrub the outsides of the shoes
drug dependence (22 August, p. 461), con- SIR,-As dispensing doctors we have with soap and water. I have not yet tried
fusion surrounding the subject still has recently noticed the increasing tendency. of to sterilize them completely, but suggest that
remained despite the World Health Organiza- drug firms to mark individual tablets and after washing they could be soaked in an
tion's attempt clearly to differentiate between capsules with the brand name or symbol of antiseptic solution. Autoclaving might be
drug addiction and drug habituation. Such each company. This has undoubtedly been possible if care is taken not to damage the
confusion, for instance, was evident in the stimulated by the introduction into this shoes while hot and therefore soft.
frequent verbal quarrels as to whether the country of tablets and capsules of similar Plastic shoes of slipper form can be
amphetamines were habit-forming or addic- appearance manufactured on the Continent. changed quickly and easily when walking
tive drugs. However, the attempt to make a We had not until now realized that it was from a clean area into a dirty area or vice
clear pharmacological differentiation between possible to mark a sugar-coated tablet or a versa, the change being accomplished if
psychological dependence (" habituation ") capsule, but now that the problem apparently desired without touching the shoes with one's
and physical dependence (" addiction ") cer- no longer exists we feel it is appropriate to hands.-I am, etc.,
tainly had (and still has) its merits, as for investigate the possibilities of introducing a London W.12. F. W. D. ROST.
instance in regard to the question of whether comprehensive individual tablet-identification
sudden withdrawal is possible, as in the case code using a series of letters and numbers.
of stimulating drugs, or whether tapering-off Such a code would enable a doctor,
is necessary, as with barbiturates. chemist, nurse, or other qualified person to Circumcision and Cervical Cancer
Certainly, in the example of alcoholism identify immediately without doubt an other-
which you quote, the difference between wise anonymous tablet by reference to a SIR,-Your leading article on " Circum-
psychological and physical dependence proved standard key. This information we believe cision and Cervical Cancer" (15 August, p.
of great importance in Jellinek's recent classi- would prove of inestimable value in the day- 397) is very important for the Turkish popu-
fication of the various types of alcoholism, to-day use of drugs, apart from the more lation, 99% of whom are Moslems and 96%
in which he describes only two of them as dramatic and potentially life-saving effects fully circumcised. The Moslem women in
" addictions "-namely, those producing in cases of suicide and accidental poisoning. Yugoslavia mentioned in your article live
pharmacological dependence. One of them is The individual companies could, of course, usually in areas where many of the men are
the " loss of control " variety (gamma retain their- own tablet markings in addition not circumcised, and these facts make assess-
alcoholism).' Dr. Davies's finding of a to the code. A recognized body like the ment of the problem difficult. Turkey
number of alcohol addicts who were able to Dunlop Committee, in association with the furnishes a suitable area of investigation in
return to normal drinking is certainly of high Formulary Committee and the pharma- this field, since noncircumcised men are few
theoretical interest, but as Dr. Davies, in spite ceutical industry, could no doubt devise, and they are settled in definite regions of the
of his findings, states, "all patients should assign, and publish code numbers for each country. Intercourse between Moslem women
be advised to aim at total abstinence."' This, drug. and the noncircumcised men is therefore un-
certainly, is the almost unanimous view of The adoption of such measures would seem likely and in some parts impossible. The
many European and American experts, with to us a rational step in the control and use incidence of cervical cancer among Turkish
wide experience, with whom I discussed this of drugs. The advice and co-operation of women is therefore of some interest. Our
question on recent International Conferences, the pharmaceutical industry, so important in survey' 2 of the material from different hos-
in spite of the exception quoted in your such a system, would, we feel, go far to pitals in Turkey has led us to the conclusion