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skin and are present not only in human vitiligo but also in the animalmodels he has examined, the Smyth line chicken and the vit/vitmouse. In a large survey based on careful history-taking he foundsurprisingly little evidence that vitiligo is inherited or associatedwith other autoimmune diseases. In contrast, R. B. Goudie

(Glasgow) prefers to regard vitiligo as a primary disorder of Tlymphocytes. He has detected disease-specific clonal T cell receptorgene rearrangements in the lesions and is attempting to isolate therelevant clones in vitro to test the hypothesis that vitiligo is a benignvariant of symmetrical cutaneous lymphoma with receptors forautologous melanocytes-a new version ofBumet’s old theory thatautoimmunity is due to forbidden clones of neoplastic lymphocytes.From his observations on twins one or both of whom have vitiligoand previous studies of organ-specific autoantibody andautoimmune diseases in vitiligo families, Goudie suggests that mostBritish patients with vitiligo are genetically predisposed to organ-specific autoimmunity-a syndrome possibly due to a hereditaryform of benign neoplasia that affects multiple T cells and may leadto organ-specific autoimmune diseases.

Warning on &bgr;-agonistsBoehringer Ingelheim Ltd, manufacturers of fenoterol, have

issued a press statement on a paper being prepared for publicationbecause they believe the implications of the findings to be

sufficiently important to justify early discussion. The main findingis an association between increased chronic use of inhaled P-agonistby metered dose inhaler and risk of death from asthma. Thestatement points out that clarification is needed on whether thefindings represent a P-agonist effect or whether these drugs aremarkers of severe disease, and that, correctly used, the drugs can belife-saving.The findings come from a Canadian case-control study nested in

a cohort of 12 301 asthma patients. All the 44 who died from asthmahad taken p-agonists in the preceding 12 months. Another 85 had anear-death episode (hypercapnia and/or need for intubation). Riskof death or near-death was associated with increasing number ofcanisters of metered dose inhaler per month (RR =2-0 per canisterper month, 95% CI 1 6-24). The likelihood of death aloneincreased by 2-6 per canister per month (95% CI 19-3-9). Theassociation seems to hold for the 0-agonist class since weight forweight salbutamol and fenoterol produced similar effects.

’Prozac’ claims

In the United States claims that the antidepressant ’Prozac’(fluoxetine) has caused suicidal and homicidal behaviour have so farled to over 70 lawsuits against its manufacturer, Eli Lilly, but nonehas yet come to trial. Only a few of the doctors who prescribed thedrug have been joined as defendants, but the company has offered topay the legal costs of any who are sued. Lilly will hire lawyers todefend doctors who prescribed or dispensed prozac in accordancewith the officially approved product information. Until now nodoctor seems to have taken up Lilly’s offer.

Lilly is also helping the prosecution in cases where criminialdefendants are using the "prozac defence", disclaiming legalresponsibility for their crimes because the drug made them violent.Ten such cases have so far been tried, and in each this line of defencewas rejected and the defendant convicted. Perhaps it is now time torecognise that lawyers advising pharmaceutical companies can beevery bit as innovative as the companies’ research departments.

Antimotion promotion commotion

Pharmaceutical promotion is not aimed only at doctors; genericsand over-the-counter formulations are widely promoted to

pharmacists, and the Royal Pharmaceutical Society has its own codeof ethics for acceptable practices. Its law department recentlyalerted pharmacists to questionable promotion of ’Joy-rides’(Stafford-Miller, Welwyn Garden City, Herts), in which anadvertisement appears to offer an inducement to pharmacists torecommend the product because "mystery shoppers" might offer

"an instant cash award" if they do so.’ Such a sordid offer issubsequently described by a pharmacist from Bournemouth—nodoubt targeted as a likely destination of UK holidaymakers andtheir nauseous offspring. The Society suggests that it might not bean offence against its code of conduct to offer such inducements(although it does not explain why not), but that it would be unethicalfor any pharmacist to allow such enticements to influence

dispensing practice.

1. RPS Law Department. Joy-Rides promotion Pharm J 1991; 247: 63.2. Pins J Joy-Rides promotion. Pharm J 1991; 247: 109.

Brush strokes

Everything nowadays seems to be tailored towards maximumeffect for as little toil as possible, even to the seemingly effortlesstasks of dental hygiene. Plaque control has now been made lessarduous by the advent of the double-headed toothbrush. Even afterinstruction in oral hygiene, people have difficulty cleaning therelatively inaccessible lingual and palatal surfaces of their teeth, sothis brush has been designed to reach places that other toothbrushescannot reach. But are two heads really better than one? Agerholmlhas found that patients who used the double-headed brush hadsignificantly better plaque removal from these difficult toothsurfaces than those who used a conventional brush. The virtues ofsuch a brush have been previously extolled, but, says Agerholm,because those results have been published in inaccessible journals,they are unlikely to have come to the attention of general dentalpractitioners, who are consulted frequently about oral hygiene.However, the brush is not without its drawbacks: although it hasflexible arms, it proved too much of a mouthful for some patients,many simply did not like it, and others complained that theirmouths became sore when using it.

1. Agerholm DM A clinical trial to evaluate plaque removal with a double-headedtoothbrush. Br Dent J 1991; 170: 411-13.

In England Now

I took it for the compliment intended when I was invited to Paristo speak about drunkenness, since I knew, as did Sterne, that "theyorder these things better in France". Nevertheless I forearmedmyself with the French for "carry coals to Newcastle". However,my French friends instructed me that porter de l’eau ci la rivierereferred to doing something futile rather than somethingunnecessary. Besides, they said, was it not a sentiment unworthy of aguest? Besides, they made clear, they were all well-educated peopleperfectly capable of catching the meaning of porter du charbon àNewcastle.

Well educated the audience certainly was. Knowing it would beso, I had prepared a talk laced appropriately with philosophical andliterary allusions such as I could not have delivered in England. Itwas well received except for one incident. I had made a slide from a

postcard entitled "Drunk in London" printed with blurred focus tomimic the supposed double vision of the inebriate; two WestminsterAbbeys, two Big Bens, and two Nelson’s Columns were there.These last, I told them celebrated the victories that had saved usfrom the Code N apoléon and thereby secured our freedom fromgovernmental control. Hence we did not have notices in every barproclaiming the laws against public drunkenness. That was

certainly a propos, but drawing attention to French defeats caused acertain restiveness.We certainly preserve in Britain the right to go our own way, for

good or ill, particularly in relation to drunkenness, withoutauthoritarian direction to behave so as to protect our health. JohnStuart Mill’s "On Liberty" successfully balks the Health EducationAuthority at almost every turn; we are right to celebrate Nelson. Yetin other respects we have paid a high price. It was the Napoleoniccode and ensuing public policies that built for France the first-rateeducational system that the British lack. That is why they are awell-educated nation and we are not. Tant pis pour nous, if youfollow.