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problems obscured any effect of mercury on behaviour.Patient 1 particularly illustrated this difficulty, with wideswings in urinary mercury over short periods. Recalculatingthe urinary mercury loss as a mercury/creatinine ratio in anattempt to correct for incomplete collection did not lessen thevariation found. Blood mercury levels, however, were

consistent.

Pink disease (acrodynia) is generally found in infants andhas been attributed to long-redundant mercury-containingteething powders.1 Spillage of metallic mercury has producedpink disease on one previous occasion.4 The onset is

insidious, with fretfulness and irritability, anorexia,weakness, and occasional slight fever-"The hands and feetare red, swollen and cold". In this family the typical featuresof pink disease were almost wholly present in the presentingcase, but patient 1 was 14 years of age, not an infant. Manyfeatures of the disease were present in a milder form in thefather. Onset beyond early childhood is very rare, and wewere fortunate that the disease was recognised. Unlike theinfants in earlier reports, both patients made a full recovery,including considerable behavioural improvement in patient1, corresponding to the clearing of mercury from the body.

The nephrotic syndrome is well recognised as a con-

sequence of metallic mercury poisoning. Proteinuria is aneven more common findings and is thought to be due toimmune-complex deposition.-’ The patient with nephroticsyndrome (patient 4) was the only one to show transienttubular damage, aminoaciduria being present before theonset of the nephrotic syndrome but not after. The nephroticsyndrome started after the illnesses of the other familymembers and persisted for longer. She recovered as expected.

The value of penicillamine or its derivatives in mercurypoisoning remains uncertain. In these cases the use of

penicillamine did not produce any significant improvementin mercury elimination. Kazantzis et a15 also found that thepreparation was of no value in the nephrotic syndrome.Preventing continuing exposure to mercury vapour seemedthe most important therapeutic manoeuvre for the family as awhole, though appropriate therapy for the nephroticsyndrome was also required.For the family one of the most distressing aspects was being

rehoused at 24 h notice and the loss of carpets and furniture.The measures needed to eradicate mercury show how well

mercury droplets enter any crevice, from which mercuryconstantly evaporates into the air.

In the episode described here recognition of the cause andremoval of the family from further exposure to mercuryvapour were the most important aspects of management.

We thank Dr G. Katz for suggesting the diagnosis, Dr J. Scanlon and Dr P.Christian for their help in the care of this family, the National PoisonsInformation Service, New Cross Hospital, for the blood and urine mercuryestimations, and the London Borough of Islington Environmental andConsumer Services Department for providing details of the mercurycontamination.

REFERENCES

1. Bidstrup PL. Toxicity of mercury and its compounds. Amsterdam, London: Elsevier,1964.

2. Magos L. Mercury and mercurials. Br Med Bull 1975; 31: 241-45.3. Hunter D. The diseases of occupations. London. Hodder and Stoughton, 1978.4. Spiers AL. Further evidence of the association between mercury and pink disease. Br

Med J 1959; ii. 142-43.5. Kazantzis G, Schiller KFR, Asscher AW, Drew RG. Albuminuria and the nephrotic

syndrome following exposure to mercury and its compounds Quart J Med 1962; 31:403-18.

Medication for the ElderlyA report1 from a working party of the Royal College of

Physicians of London examines the provision of drug treatmentfor older patients and points to five aspects where the situation inBritain could be improved: inadequate clinical assessment;excessive prescribing; inadequate supervision of long-termmedication; appreciation of changes in pharmacokinetics andpharmacodynamics with age; and the patients’ compliance.

Recommendations of RCP Working PartySince treatment involves not only the patient but members of

many professions, a single set of recommendations would not beappropriate. The working party classified them as far as possibleinto different sections related to the different professional groups.

TO DOCTORS GENERALLY

1. Make a careful clinical assessment of the situation and thenconsider whether the patient is taking any unnecessary drugs andwhether any additional medication is really required. At this stage,take account of any factors which might modify the patient’sresponsiveness to the proposed drug and his/her susceptibility tomedications in general.

2. Simplify the dose and drug regime as far as possible. This willhelp in explaining the regime to the patient (where appropriate inspeech and by writing)-a process which cannot be hurried. Thentry to discover if the patient has really understood your explanation.Supply each patient with a drug record card.

3. In your prescription to the pharmacist, specify the dose andtiming of the drugs as precisely as possible so that he has thenecessary information to label the container clearly and correctly.

4. Before a patient leaves you, advise him or her of any seriousadverse drug effects. Arrange for adequate follow-up, which mayinitially have to be at frequent intervals, to check that the desiredtherapeutic effect is being obtained and that there are no seriousreactions. Patients should be asked to bring their medicines withthem when attending for follow-up to enable compliance to beassessed.

5. Ensure good communication with any medical and othercolleagues who are sharing the care and treatment of the patientwith you.

6. Avoid inappropriate or over-energetic treatment when thepatient’s physical and mental problems and disabilities indicate aless active therapeutic role.

7. Doctors should report any suspected adverse drug reactions tothe Committee on the Safety of Medicines.These are considerations which should be brought to the notice of

all doctors throughout their training, not by set courses, but inappropriate clinical situations as they occur. Good prescribingpractice often only requires existing resources to be used in a moreefficient, sensible manner and does not necessarily require extrafinances.

In Hospital Practice

1. A senior member of the clinical team should regularly reviewall medication given to older patients.

2. A ward prescribing policy should be established.3. Prescriptions for patients should be confirmed every 10 days.

In General Practice

1. Patients who fail to keep appointments at surgery should beidentified, followed up and, if necessary, placed on an ’at risk’register.

2. The number of repeat prescriptions that a patient may obtainwithout seeing the doctor must be specified and the practice staff soinformed.

1. J R Coll Physns Lond 1984, 18: 7-17.

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3. Appropriate members of the primary health care team who visitthe elderly at home should review the drug therapy and check thatdrugs prescribed for a particular patient are not used for any otherpurpose.

4. Bulk prescribing in old people’s homes should be avoided.

THE NURSING PROFESSION

Nurses should be well aware of the need for accurate prescribingand compliance so that they may take advantage of their close andunderstanding relationship with the patient to assist them to co-operate in their treatment.

They should in addition be alert to the problems of overdosageand adverse effects on the one hand and those of inadequatetherapeutic effect or lack of compliance on the other.

THE PHARMACISTS

Because of their special training, pharmacists are well placed tomake prescribed medicines simple of access and to help patientswith appropriate explanations.

More specifically, when dispensing medicines, they should usecontainers which elderly people can open and should label themedicine in such a way that it can be clearly understood. Theyshould be able to advise on memory aids such as the Dosett box.

They should enquire about their current drug therapy before sellingover-the-counter medicines.The ward pharmacist can play a role in the education of doctors on

the ward.The District Pharmaceutical Officer has a responsibility to

improve supervision of medication in old people’s homes.

THE PHARMACEUTICAL INDUSTRY

Since the elderly are given medication out of proportion to theirnumbers, and are also vulnerable to many drugs, the industry has aparticular responsibility to consider the special needs of elderlypatients. It follows that adequate numbers of aged and very agedpatients should be included in the trials of drugs which are likely tobe prescribed to the elderly. Drug data sheets should containspecific prescribing advice for the elderly.

In England Now

GILES and I were late when we joined our wives in the village hall.The place was packed to capacity and it was with difficulty that theyhad managed to keep us two seats. For it was the event of the

year-the Christmas Nativity play. Mothers were there to see theirchildren, maiden aunts to see their nephews, and fathers becausethey had been ordered to attend; The vicar was backstage and, onceagain, was experiencing a series of familiar emotions: panic anddespair, rage and resignation. He knew, as did we all, that thisoccasion more than any other had a penchant for going wrong andproviding stories for the year to come. Once he had brought a realdonkey to the production thinking it would add both realism anddrama to the performance. And, indeed, it did. The result was thatthe curtains had to be drawn for a time to make the stage, once again,habitable. Last year our eldest sons played the parts of Joseph andthe innkeeper, respectively. When Joseph knocked on the door ofthe hostel and asked for accommodation, Giles’s son replied, "Comeaway in. I’ve kept a big room and a bath for you". Once again thecurtains had to be drawn.

All seemed to be going well this year. There had been no untowardincidents and the vicar was beginning to relax. The stable waspeaceful and the crib was bathed in a soft light. The three wise men,in their false beards, were holding out their gifts. The audience wasstill. Then from the stalls a clear young voice piped forth. It camefrom the daughter of our local champion for women’s rights."Mummy," trilled the child, "was it a home confinement, then?"Tradition had been maintained.

* * *

WE each bask in our Jungian near-individuality. But can there beothers unable to answer the question: "Have you been to Waikiki?"My wife and I were Pacific-hopping our way back from Australia.Jet-lagged, we walked slowly from the Honolulu hotel to the beach."Yes," replied another strolling visitor, "I guess Waikiki Beachbegins hereabouts-or maybe just over there." "We’ll have plentytime to see it tomorrow," we said as we returned to the hotel.But that night I shot a temperature which felt like 105°F. Rigor,

profuse sweating, shocking headache, but no localising signswhatever. There had not been enough exposure to postulateheatstroke. My wife woke me two-hourly through the night and day,to sponge me down and maintain the fluid intake. It was fortunatelyone of those palatial suites with a fridge, and an iron-railed balconyon which the wrung-out sheets and pyjamas could be dried. Twentyhours after its onset, the disease went as mysteriously as it came. Iwas only a little wobbly, but eager to take the evening air. Wethought it unwise to go as far as the beach. The plane to Los Angelesleft early next morning.

It’s the double uncertainty that makes the whole event so unreal. Iwish some bright bacteriologist would eliminate one of the

unknowns. Something like Organism honolulensis ought to look wellin the textbooks.

* * *

ONCE in our callow youth we undertook to teach surface anatomyto art students, and were struck by the fact that the names of thefemale members of the class differed widely from those of the femalemedical students with whom we had used to associate. Our friendshad been Jean or Margaret, Dorothy or Mary, but here were Dee-Dee, Merome and Lorrel, Demetria and Davilia. After some

thought we arrived at the conclusion that although destiny mayshape our ends, we rough-hew them to some purpose at the

baptismal font. To give a girl a name like Nari or Kirrily is to directher firmly towards the arts rather than the sciences. We weretherefore encouraged to pursue our inquiries in the realm of

secondary education, and nowadays if anyone asks our advice weconsult an analysis prepared twenty years ago by our youngest childafter study of the Schoolgirls Library file in the boot cupboard. Atour request she categorised a series of names (n=88) as goodies,baddies, fatties, and brains, and experience has shown that theresults afford a reliable basis for predicting character and behaviourwhile in statu pupillari.The survey revealed more goodies (70’ 5%) than baddies (19 - 3%).

The 8 fatties and the single brain constituted a neutral group,neither malevolent nor particularly public-spirited. Nor was anyindividual name significantly associated with adiposity. Exoticnames such as Jocelyn or Gelda were more likely to lead theirowners to become prefects, and (deplorably) among these holders ofhigh office there were more baddies than goodies (p<0’05): thethree monitors, on the other hand, were on the whole a goodinfluence.

18 (29 - 0%) of the goodies had names beginning with J or P, and ifparents want their daughter to rescue the headmistress’s dog fromdrowning or prevent the old study block from being burned down(by a prefect, naturally) they cannot do better than christen her Pam,with Patsy, Janet, and Jenny as runners-up. If, on the other hand,they set store on unorthodoxy, and would applaud their daughterfor joining the raffish group of prefects who meet behind thegymnasium for a quick drag and a bottle ofcreme de menthe, theyshould consider names such as Olga or Berril. Helen is a specialcase; three Helens in the series were solid upright citizens, but afourth became a prefect and promptly (and perhaps inevitably) wentto the bad. Parents have to be warned that the danger of thishappening to a Helen is by no means negligible.Those who wish their daughter to become brainy are regrettably

restricted in their choice, Viviane being the only certainty. Andthose who hanker after trendiness must select Charlotte or Victoria,the current favourites among top people notified in The Times. Howthese two will get on at school is anybody’s guess, for they do notfeature in the Schoolgirls Library data.