Annotations 281

syndrome, and loss of sensation over the right side of the face and the left side of the body. It was thought that she had had an ischemic episode in the territory of the posterior inferior cerebellar artery. She improved gradually. The second patient was 46 years old and had been taking “the pill” for 6 months. She had a sudden onset of vertigo and un- steadiness with lurching and a tendency to fall to the right. She also had visual discomfort and exces- sive drowsiness. Both plantar responses were es- tensor. She improved gradually.

Baines2 reported the case of a 29-year-old woman who died from thrombosis of the left middle cerebral and right anterior cerebral artery. No source for an embolus was found at necropsy. She had been taking norethynodrel for 2 weeks only.

As pointed out previously,‘* it is, of course, true that even young people can, rarely, have thrombotic cerebrovascular lesions from no apparent cause and with a normal blood pressure. However, we do not know the true incidence of such episodes. Aring and Merritt’ had not encountered a single patient under the age of 30 and had one under 40 years of age in their series of 106 cases of cerebral throm- bosis, verified at autopsy. The Registrar General’s Statistical Review of England and Wales, 1961, records that of 22,368 females who were certified to have died of cerebral embolus or thrombosis, one was between 15 and 30 years of age, two were be- tween 30 and 3.5, nine were between 3.5 and 40, and eighteen were between 40 and 4.5. We do not know the morbidity incidence.

On the other hand, Oliver,’ commenting on the incidence of coronary thrombosis in women taking oral contraceptives, reported that over a period of 12 years he had seen 144 women under 45 years of age with ischemic heart disease. Sixty-two of these women presented with acute myocardial infarction, and two were taking oral contraceptives and con- tinued to do so.

It is perhaps pertinent that Egeberg and Owren,” in a study of blood coagulability in women taking Enovid, reported an increase in Factor VIII and possibly an increase in Factor VII. Habe? reported a case of Factor X (Stuart-Power factor) deficiency in a patient, with remissions during pregnancy, who responded well to treatment with norethynodrel.

The drinking driver*

Interesting clinical and sociological findings emerged from a survey of 392 drivers arrested on suspicion of being under the influence of alcohol. All were examined during my 6-year tenure of office as Divisional Police Surgeon (part time) in the City of Manchester (1958-1964). In the clinical picture

*Based on an article by the same title published in the British Medical Journal. December 26, 1964, by permission.

It remains to be seen whether there is a true increase in the incidence of thrombotic lesions in women taking oral contraceptives, and whether these drugs do increase the coagulability of the blood; but, obviously, these cases should be reported and the possible serious side effects, however remote, of these drugs should be borne in mind.

K. J. Zilkha, M.D., M.R.C.P. Physician to the National Hospital,

Queen Square, London, and Neuralogist to King’s College Hospital,

London, England

REFERENCES

1. Aring, C. D., and Merritt, H. H.: Differential diagnosis between cerebral haemorrhage and cerebral thrombosis, Arch. Int. Med. 56:435, 1935.

2. Baines, G. P.: Cerebrovascular accidents and oral contraception, Brit. M. J. 1:189, 1965.

3. Boyce, J., Fawcett, J. W., and Noah, E. W. P.: Coronary thrombosis and Conovid, Lancet

4.

5.

10.

11.

12.

l:Ill, 1963. Egeberg, O., and Owren, P. A.: Ural contracep- tion and blood coagulability, Brit. M. J. 1:220, 1963. Haber, S.: Norethynodrel in the treatment of Factor X deficiency, Arch. Int. Med. 114:89, 1964. Jordan, W. M.: Pulmonary embolism, Lancet 2:1146, 1961. Oliver, M. F.: Oral contraceptives and coronary thrombosis, Brit. M. J. 1:31.5, 1965. Registrar General’s Statistical Review of England and Wales, 1961, p. 138. Schatz, I. J., Smith, R. F., Brenerman, G. M., and Bower, G. C.: Thrombo-embolic disease associated with norethynodrel, J.A.M.A. 188:- 493, 1964. Stewart-Wallace, A. M. : Cerebrovascular ac- cidents and oral contraception, Brit. M. J. 2:1528, 1964. Thrombo-embolic phenomena in women, Pro- ceedings of a conference, Searle, Chicago, Illinois, 1962. Zilkha, K. J.: Cerebrovascular accidents and oral contraception, Brit. M. J. 2:1132, 1964.

which emerged, several features manifested them- selves with such consistency and clarity that their importance has to be stressed.

In compliance with legal requirements all drivers were given the right of refusal to examination. Here a pattern emerged in which the more sober the driver, the more anxious he was to agree to exami- nation; at the’other extreme there was even more eagerness to clutch at the straw of refusal.-Such

282 Annotations Am. Heart .I. August, 1965

p.m. a.m. TiHE

Fig. 1. Percentage of drivers examined in relation to time of examination. Shaded areas show drivers examined after pre-Christmas office and works parties. (From Freeman, S., The Drinking Driver, British Medical JOW?XZ~, December 26, 1964, page 1634, by permission.)

drivers were carefully observed over a period of 15 to 20 minutes, and assessment thus proved to be relatively simple. At the same time it would be preferable to copy the New York State technique by making agreement to examination a condition of holding a driving license.

Examination, after consent given in writing, proceeded generally along lines laid down in the British Medical Association’s publication “Recog- nition of Intoxication.” A careful assessment had to be made of the over-all picture, giving due credit to tests satisfactorily performed and making full al- lowance for fatigue and for anxiety due to arrest, always bearing in mind the axiom, “With the excep- tion of the smell of the breath, each and every sign can be explained by a cause other than alcohol.” On this premise, excluding other causes, the follow- ing appeared with significant regularity: (1) Slurred speech. (2) Impaired memory. (3) Poor coordina- tion. (4) Full, bounding pulse. The pulse was al- ways abnormally rapid (range of 100 to 130), but the rate was deliberately discounted since such was consistent with the natural worry and excitement of arrest. A simiIar interpretation was placed on the regular finding of blood pressure elevated 20 to 40 mm. Hg above the age norm. Both the rapid pulse and the raised blood pressure were regarded as of no value in the final assessment. (5) Widely dilated pupils with little or no reaction to strong light. Such was evidenced in 98.2 per cent of the cases certified on examination and was considered to be of the greatest diagnostic significance. Its importance has received insufficient emphasis in the appropriate medical literature. (6) Fine lateral nystagmus. This was noted in 96 per cent of the cases and corroborates opinion emphasized by many authorities. Its diagnostic value was con- sidered to be second only to the state of the pupils. However, attention must be drawn to its temporary disappearance when the level of alcohol in the blood becomes exceptionally high, when the driver is patently drunk.

Two cases were seen in which the arrested driver, believed to be incapacitated by alcohol, was found to be in an advanced state of hypoglycemia. Both individuals made speedy and dramatic recovery

with appropriate emergency treatment. Since the signs so closely resembled those produced by al- cohol (grossy slurred speech, staggering gait, dis- orientation, etc.), the importance of eternal vigilance in examination is stressed.

ANALYSIS OF RESULTS.

Age incidence showed the large majority of drivers (71 per cent) to be between 20 and 40 years old. Teenagers were rare (1 per cent); and in an age when denigration of youth is fashionable-and sometimes justifiable-the figures are most heart- ening.

Occupation was most varied, but in spite of the dangers of loss of license almost two thirds (63.5 per cent) were dependent upon driving for a liveli- hood. Employers are largely to blame for lack of firm discipline. All classes were included, one third being of executive or professional standing; 8 (2 per cent) were doctors. No women or members of the Jewish race were seen; it has long been estab- lished that the latter have little interest in alcohol.

Time of euaminntion was usually after midnight when licensed premises and drinking clubs close. The notable exception was the pre-Christmas week, when many arrests occurred during the afternoon after office and works parties. This is clearly shown in Fig. 1. The major responsibility for such a state of affairs rests with well-meaning but stupid em- ployers.

Urinalysis was of minimal value since present legislation lays down no maximum level. Juries paid scant regard to such forensic findings. A sample survey in this series showed over 75 per cent with blood/alcohol over 200 mg./lOO ml.

Certification and disposal findings showed that 323 drivers (82.4 per cent) were certified, of whom 292 (90.4 per cent) were convicted.

Escape r&e was shown to be in frequent use. Many drivers under the influence of alcohol and involved in a crash retained sufficient cunning to pretend or exaggerate injury and insisted on re- moval to a hospital casualty department, out of police hands. By the time the hospital investiga- tions were completed, so was the sobering-up pro- cess. Legislation should be enacted to ensure that all drivers removed to hospital after road accidents undergo some form of chemical analysis to de- termine the level of alcohol, if any, in the blood stream.

Conclusion. Much rethinking is urgently required to deal with the menace of the drinking driver-and the medical profession should lend all assistance. Our laws are outdated and totally inadequate to combat the ever-growing problem. The tragedy is that the magnitude of the dangers is still not appreciated by the public at large. Propaganda must be intensified-via press, radio, and televi- sion, and, above all, by the good example of leaders in all branches of the community.

Simon Freeman, O.B.E., T.D., M.C.G.P., L.R.C.P.&S.E., L.R.F.P.bS.G.,

General Practitioner* Manchester, England

*Formerly, Divisional Police Surgeon, City of Manchester, Lanes.. England.