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the community have shown that, of those who couldbe traced, large numbers were unemployed and had nofriends or social ties. Many of these dischargedpatients ended up in common lodging-houses. A

rough estimate suggested that there could well be upto 3000 schizophrenics in England, Scotland, andWales living in lodging-houses who had been dis-charged from mental hospitals, very few of whomreceived any form of aftercare in the community. Thevoluntary organisations, which ran many of the hostels,were too short of staff to cope with the psychiatriccase-load, while the local authorities were reluctantto assume responsibility for the inmates of thesehouses. In such a situation, these people could fare noworse, and could well fare better, in the mental

hospital.Discussing alternatives to care in the mental hospital,

Dr. Tidmarsh said that the " current official favourite",the psychiatric unit in the district general hospital,rapidly became disrupted by an accumulation ofchronic disturbed schizophrenics; in such a settingrehabilitation of these patients was virtually impossible.Day hospitals were useful for some patients, particu-larly the phobic and neurotic cases, but many unitsexcluded patients whose behaviour was disturbing,and little success had been achieved with schizo-

phrenics. The psychiatric hostel had a similarly limitedpart to play in the treatment of the chronic psychotic.Surveys of these hostels had shown that they oftenbecame blocked by long-stay patients. Hostel inmates,many of whom were unemployed, had little contactwith the community. It was difficult to see that hostelcare of this kind for long-stay patients had manyadvantages over care in the mental hospital.The build-up of the community services was con-

tinuing at the expense of, and not in addition to, themental hospitals; if the mental hospitals were

abolished, the chronic patient would not receive

adequate care. Dr. Tidmarsh warned that the daymight not be far off when a two-tier psychiatric servicecame into being, with the teaching and district hospitalunits and day hospitals attracting staff away from themental hospitals. In such a situation, with the hospitalssubjected to yet more pressure to reduce bed numbers,the care of the chronic patient could only go from badto worse. The mental hospital was a very necessarypart of the social services: it was in danger of beingdestroyed without an adequate substitute being pro-vided.

WHERE TO MEASURE TEMPERATURE

ALL the body’s natural orifices, as well as excretedurine and exhaled breath, have been used to measuredeep body-temperature. The problem of whichmethod is best has long vexed clinicians and physiolo-gists investigating disturbances of body-temperature.The sublingual thermometer customary for routineclinical measurement in warm surroundings has

generally been avoided by environmental physiologists,because the temperature there is depressed by localcooling when the subject is exposed to cold. On

p. 424 this week Dr. Fox and his colleagues show thatthis depression can be large and they point out that at

least one survey of hypothermia in old people mayhave given a misleadingly high estimate of the incidenceof hypothermia, because it relied on sublingual tem-perature measured in cold houses. They advocatemeasuring the temperature of voided urine, which iscertainly a more satisfactory method in some ways,though it too has its drawbacks. It cannot be used forcomatose or uncooperative patients; and although ithas been successfully used to follow slow diurnal fluc-tuations in temperature, it cannot be measured atshort enough intervals to follow rapidly changingbody-temperature. Urine volumes greater than 100 ml.were necessary to provide reliable readings. Likerectal temperature 2,3 urine temperature is likely to lagbehind arterial blood-temperature when body-tem-perature is changing rapidly. The size of the apparatusmight restrict its use to surveys for the detection ofhypothermia, since it is unlikely to be carried aboutfor occasional use in the home. For situations otherthan surveys rectal temperature is likely to remain themost widely used measurement in suspected hypo-thermia, although it can lag 1°C or more behind a

rapidly changing cardiac temperature. Measurement ofoesophageal temperature gives a better indication ofcardiac temperature 3,4 but it carries some risk, sincereflex bradycardia induced by irritating the throat canprecipitate ventricular fibrillation. Measurement ofurine temperature may have a useful place as a simplemeans of excluding hypothermia when the sublingualreading is low in cold surroundings and when thepatient is conscious, cooperative, and has a full bladder.

PENTAZOCINE

THE relief of pain can earn more gratitude from apatient than almost any other benefit the doctor hasto offer. It is all the more surprising, therefore, thatpatients’ complaints of pain are so often ignored ortreated too lightly.5-7 One explanation may be theprevalent attitude that pain is to be endured withoutcomplaint-an attitude often so strong that inabilityor reluctance to tolerate pain is regarded as a sign ofmoral weakness. Again, the inadequacies of medicalteaching may have left the doctor ill equipped to dealwith pain, especially chronic and intractable pain;in particular, teaching may have induced a genuinefear in many doctors that the use of drugs in thealleviation of chronic pain must inevitably lead toaddiction.Some justification for this fear lies in the fact that

for many years every powerful analgesic drug in

regular use carried a strong liability to dependenceand that it was virtually impossible to prescribeanalgesic drugs for the relief of chronic pain withoutrunning the risk of inducing dependence. This

1. Cathcart, E. P., Paton, D. N., Pembrey, M. S. Practical Physiology;p. 169. London, 1929.

2. Mallett, H. C. Am. J. Physiol. 1950, 163, 734.3. Cooper, K. E., Kenyon, J. R. Br. J. Surg. 1956, 44, 616.4. Cranston, W. I., Gerbrandy, J., Smell, E. S. J. Physiol. 1954,

126, 347.5. Senex. Lancet, 1970, ii, 1040.6. Senex II. ibid. p. 1132.7. Bond, M. R. ibid. Jan. 2, 1971, p. 37.

440

apparent inability to separate analgesic properties fromdependence liability persisted until the discovery in1956 that nalorphine, a drug used to antagonise mor-phine, and itself having a mild analgesic action, wasvirtually devoid of any risk of abuse.9 9 The excitingpossibility then arose that similar morphine antagon-ists might possess stronger analgesic properties with-out the tendency to induce dependence. Accordingly,a series of compounds was prepared and investigatedand several derivatives of the benzmorphan nucleuswere judged worthy of clinical trial.10 Of these,pentazocine was shown to produce analgesia com-parable to that of morphine,11 and it was eventuallyapproved for general use in the United Kingdom inApril, 1967. Its clinical use has now been reviewed. 12The importance of pentazocine lies in the facts that

it is the first narcotic antagonist to have clinicallyuseful analgesic properties and that it is not sub-

ject to narcotics control. In this respect theW.H.O. expert committee on drug dependenceinvestigated the dependence liability of pentazocineand concluded 13 that there was no need for narcoticscontrol of the drug internationally or nationally, anopinion reaffirmed by the same committee. 14, 15The absence of a strong liability to dependence

has not prevented some abuse, and a few instances ofprolonged heavy dosage have been described. 16,17But when 6 patients, allegedly pentazocine-dependent,were investigated more thoroughly by the analysis ofblood and urine specimens no traces of pentazocinecould be detected, but evidence of morphine or

pethidine use was found in 5.1a It seems justified,therefore, to insist on laboratory evidence beforeattributing drug abuse to pentazocine.

Although the dependence liability of pentazocineis low, the drug has an analgesic potency comparableto that of morphine and pethidine.11 It is effective

by mouth and by injection, and plasma levels corre-spond to the onset, duration, and intensity of anal-gesia,19 if the initial levels after intravenous injectionare disregarded. When the drug is taken by mouth,detectable plasma levels may not appear for up to30 minutes, but they persist for up to 5 hours. Whenpentazocine is given intramuscularly the mean peakplasma level is reached about 45 minutes after injec-tion, and the plasma half-life is about 2 hours, whichcorresponds to the duration of action. After intra-venous injection the plasma levels decline rapidlyduring the first 20 minutes; thereafter the decayfollows the pattern after intramuscular injection;effective analgesia lasts about 1 hour.19

Pentazocine is well absorbed whatever the routeof administration: even when it is given by rectal

9. Isbell, H. Fedn Proc. 1956, 15, 442.10. Archer, S., Albertson, N. F., Harris, L. S., Peirson, A. K., Bird,

J. G., Keats, A. S., Telford, J., Papadopoulos, C. N. Science, 1962,137, 541.

11. Keats, A. S., Telford, J. J. Pharmac. exp. Ther. 1964, 143, 157.12. Potter, D. R., Payne, J. P. Br. J. Anœsth. 1970, 42, 186.13. Wld Hlth Org. techn. Rep. Ser. 1966, no. 343.14. ibid. 1969, no. 407.15. ibid. 1970, no. 437.16. Hart, R. H. Lancet, 1969, ii, 689.17. Schoolar, J. C., Indänpään-Heikkila, P., Keats, A. S. ibid. 1969,

i, 1263.18. Roth, C. H., Trout, M. E. Hosp. Formul. Manag. 1970, 5, 13.19. Berkowitz, B. A., Asling, J. H., Shnider, S. M., Way, E. L. Clin.

Pharmac. Ther. 1969, 10, 320.

suppository less than 2% appears in the faeces.2oA substantial part, up to 30%, is excreted, mostlywithin twelve hours of administration,19 as a glu-curonide in the urine, accompanied by at least oneother, as yet unidentified, metabolite. The amount ofpentazocine excreted unchanged in the urine variesbetween 4-5% and 24%,22 and the suggestion is thathigh levels of unchanged drug appear in the urinewhen the metabolic capacity of the body is exceeded;such high levels are apparently also associated withmore side-effects. 20 Individuals vary greatly in themetabolic handling of pentazocine, but in the sameperson it is remarkably constant, even for differentroutes of administration. 20

Pentazocine is not the perfect analgesic, but as thefirst clinically useful drug in which a powerful anal-gesic action exists without an associated strongdependence liability, it augurs well for further develop-ments in this important area.

FLUORIDE IN DROPS

FLUORIDATION of the water-supply remains the mosteffective public-health measure available to urbancommunities for reducing the prevalence of dentaldecay. Yet resistance to such a measure is widespreadthroughout the world and other means of providingfluoride for children have been sought. One methodadvocated for the past few years in the United Stateshas been a vitamin solution containing fluoride 23, 24A double-blind study (reported on p. 441) has beencompleted in Sweden and it confirms the efficacy ofsuch preparations. Up to 6 years of age the meannumber of decayed teeth was about 50% lower inthe fluoride group. The children were given, frombirth, a solution of vitamins A and D containingsodium fluoride corresponding to 0-5 mg. of fluoridefor every 10 drops of solution. Dr. Hamberg recom-mends the use of fluoride drops in areas wherethe public water-supply contains less than 0-6 p.p.m.of fluoride. The results achieved are comparable tothose obtained in children of similar age in this

country where fluoride has been supplied in drinkingwater. 25 Owing to the very slow adoption of fluorida-tion by British local authorities and the problem ofrural communities without a piped water-supply,the possibility of giving a vitamin-fluoride preparationto young children at child-welfare centres in low-fluoride areas should obviously be considered. Theannouncement 2s by the Secretary of State for SocialServices that welfare orange juice is to be replaced bya new preparation containing vitamins A, D, and Cin the form of drops suggests that such a further

change may be envisaged.

20. Burt, R. A. P., Beckett, A. H. Br. J. Anœsth. 1971 (in the press)21. Berkowitz, B., Way, E. L. Clin. Pharmac. Ther. 1969, 10, 681.22. Beckett, A. H., Taylor, J. F., Kourounakis, P. J. Pharm. Pharmac.

1970, 22, 123.23. Hennon, D. K., Stookey, G. K., Muhler, J. C. J. Dent. Child. 1967,

34, 439.24. Margolis, F. J., Macauley, J., Freshman, E. Am. J. Dis. Child. 1967,

113, 670.25. Fluoridation Studies in the United Kingdom and the Results

Achieved After Eleven Years. Rep. publ. Hlth med. Subj., Lond.1969, no. 112.

26. Lancet, 1970, ii, 1368.