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The Pharmaceutical Journal
Vol 270 No 7235 p204
8 February 2003

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Onlooker

Little Cinders [more]
Words and actions [more]
Falling elderly [more]


Little Cinders

Pantomime is the inevitable sequel to the excitement of the Christmas festivities, It remains a firm favourite with children and those who ought to have grown up. Although I have not for several years taken an active part in producing a pantomime, there was a time when this hectic activity played an important part in my annual fixtures.

For as long as I can remember, my expertise in the realms of special stage makeup and pyrotechnics has been called upon by pantomime producers. Many of the products of the past would today be soundly denounced by the nanny-statesmen, but they were great fun and much appreciated. I cannot remember ever having caused any damage to health or property. And I have always looked forward to being part of the audience in January.

This year my local pantomime was Cinderella, "Little Cinders", known long ago in France as Cendrillon. The fairy tale on which it is based is thought to be ancient and of Eastern origin. It reached the German literature in the 16th century and became popular throughout Europe when Charles Perrault published his Contes de ma mère l'oye in 1697.

The pantomime differs from most others in not having an animal such as a cat, a cow or a wolf as a principal character. (It is true that Cinderella's fairy godmother transformed mice into coach-horses, a rat into coachman, and lizards into footmen, but these creatures do not usually appear on stage.) Instead, a rather pitiful but generous character called Buttons is the real hero of the show, and offers the born comic a grand opportunity to shine. When Buttons first entered the scene is unknown, because he does not feature in Perrault's script. Perhaps he was invented by John Weaver, the Shrewsbury dancing-master who promoted the pantomime or harlequinade in 1702.

The serious theme beneath the Cinderella story concerns the relationship of daughters of successive wives who have to live in some kind of equilibrium with one another and with their common father. This has always been a tricky situation. The poor baron, a widower, has remarried and thereby acquired two grown-up daughters who share the pride and overbearing character of their mother, while his young daughter by his mild-mannered first wife has inherited her loving and modest character. The haughty sisters, characterised in the pantomime as the Ugly Sisters, tyrannise their young sister, and are eventually defeated only through the intervention of a fairy godmother, assisted to a great extent by the comic and acrobatic Buttons. It offers food for thought to conjure up the idea of a fairy godmother-in-law, and what she might have done to wreck the scenario.

One of the interesting features of Perrault's story is the tracking down of Cinderella through the loss, at a second royal ball, of a glass slipper which she had shed at the stroke of midnight, when her godmother's spell ended. The notion of a glass slipper must always strike one as unnecessarily stupid. It is supposed that when Perrault wrote of it he was really thinking of une pantoufle de vair, meaning one of fur, but in his original text he undoubtedly wrote une pantoufle de verre, meaning one of glass. The error became embedded in all our versions of the Cinderella story, and we have to admit that it adds glitter to the pantomime.

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Words and actions

When I use a word, explained Humpty Dumpty, "it means just what I choose it to mean — neither more nor less". This reasoning, with its massive lacunae, is popular among politicians, lawyers and advertising agents. And the sorry state into which this attitude has plunged our world is encouraged by our modern culture, in which commercial gain is ranked far above truth and morality, so that children grow up having scant respect for unequivocal language. Hence our paradise of spin-doctors.

It is becoming obvious that personal responsibility for acts and attitudes of both positive and negative nature is difficult to establish. For pharmacists as professional people this is an important challenge. Once a bureaucratic atmosphere is permitted to envelop our daily work we become ready to explain that "it's not my fault, I'm only doing what I am told." This may be good enough for a civil servant or someone in a military organisation; it is not good enough for a pharmacist. He or she has special expertise that can be used to help or to harm, and must use informed discretion.

According to the dictionary, responsible means "accountable to another for something" or "capable of fulfilling an obligation or trust". Therefore it carries a powerful social impact, governing our relationships with our friends, neighbours and relatives. And responsibility may be either personal or collective. The philosophical implications of collective responsibility are complex and open to endless argument, whereas those of personal responsibility are relatively clear-cut and under the control of conscience, a factor that moves persons but not committees or governments.

Despite his notorious cynicism, George Bernard Shaw had a sound point when in 'Man and superman' (1903) he wrote: "Liberty means responsibility. That is why most men dread it."

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Falling elderly

A paper published in the New England Journal of Medicine for 2 January from the Yale University School of Medicine examines the clinical problem of falls of elderly persons and their connection with medication. It states that more than one third of people aged 65 or more suffer a fall each year, and half of them have recurring falls. About one in 10 falls results in serious injury such as fractures, soft-tissue injuries or head injuries, accounting for 10 per cent of emergency hospital visits.

Most falls result from interactions between long-term or short-term predisposing factors. Factors include arthritis, depression, cognitive impairment, failure of vision, muscular co-ordination and sheer muscle weakness, but important ones to be considered include the taking of four or more prescription medicines. There is a clear relation between falling and the higher number of medicines taken. Risks associated with different classes of drugs are variable. The classes showing the greatest increase in fall rate include serotonin-reuptake inhibitors, tricyclic antidepressants, neuroleptics, benzodiazepines, anticonvulsants and antiarrhythmic medications.

It has been noted that the rate of falling of elderly patients is greatest during the month following discharge from hospital. Episodes of acute illness or exacerbations of chronic illness also add to the frequency.

Strategies to prevent falls include cutting medication to a minimum, which is not always practicable. Psychotropic medications require special attention, since many falls are associated with them.

Particularly for those with balance or gait problems, attention should be paid to the removal of loose rugs in the home, the adoption of safer footwear, the use of non-slip bathmats, adequate home lighting at night and the addition of stair rails where necessary. Education of the patient and his or her family in precautions to be observed is important.

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