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medicine. The more extensive our knowledge of thedifferences in biochemical make-up between differentnormal individuals becomes, the more likely are we tobegin to understand why people react differently fromone another in similar environments, and why somepeople are more susceptible than others to particulartypes of clinical disorder. The idea of diathesis is an oldone in medicine, but it has always been nebulous.Studies of the sort discussed here may in the future

provide a firm scientific basis for this old-establishedbelief.

1. Expert Committee on Mental Health. Tech. Rep. Ser. Wld Hlth Org.1951, no. 42, pp. 5, 19, 20, 21.

2. Expert Committee on Mental Health. ibid. 1952, no. 48, pp. 16, 26, 33, 38.3. Alcohol and Alcoholism: report of an expert committee, ibid. 1955, no. 94,

p. 7.

Varieties of Alcoholism

WHAT is alcoholism ? When ten years ago the WorldHealth Organisation’s Alcoholism Subcommittee heldits first session it suggested as an

" ad hoc and pro-visional " definition " any form of drinking which in itsextent goes beyond the traditional and customary’dietary’ use, or the ordinary compliance with the socialdrinking customs of the whole community concerned,irrespective of the ætiological factors leading to suchbehaviour and irrespective also of the extent to whichsuch ætiological factors are dependent upon heredity,constitution or acquired physiopathological and meta-bolic influences ".1 A year later, at its second session,the subcommittee considered it " more appropriate touse the preceding definition to define the term’ excessivedrinking’". It now defined alcoholics as " thoseexcessive drinkers whose dependence upon alcohol hasattained such a degree that it shows a noticeable mentaldisturbance or an interference with their bodily andmental health, their inter-personal relations, and theirsmooth social and economic functioning; or who showthe prodromal signs of such developments. They there-fore require treatment." 2 The subcommittee went onto distinguish two categories of alcoholics: the " habitualsymptomatic excessive drinkers" or " non-addictive

alcoholics ", and the " addictive drinkers " or " alcoholaddicts". The main difference between these two

categories consists, as E. M. JELLINEK explained in anappendix to the report, in the occurrence only amongalcohol addicts of loss of control over alcohol intakeafter several years of excessive drinking. Loss of controlindicates the onset of the third or crucial phase in thedevelopment of addiction, resulting in further drinkinguntil the point of intoxication or sickness. JELLINEK feltthat, " strictly speaking, the disease conception attachesto the alcohol addicts only, but not to the habitualsymptomatic excessive drinkers ".2Two years later a W.H.O. Expert Committee on

Alcohol and Alcoholism concluded that there was,besides loss of control, another criterion that might serveto distinguish "true" alcoholism—i.e., "inability to stopdrinking."3 Whereas loss of control was found chieflyin predominantly spirit-drinking countries—such as theU.S.A.—inability to stop drinking was more characteris-tic of alcoholism in predominantly wine-drinking coun-

tries, such as France: the drinker taking alcohol day-in,day-out, from morning till night without necessarily (oreven generally) getting drunk. Each of these two drink-ing patterns could be found in all countries, but oftenwith one so much the commoner that the other might beoverlooked. And, as JELLINEK later pointed out,4 " inmany countries problems of national magnitude arisemore from other types of drinkers than from the steadyexcessive symptomatic drinkers with or without addictivefeatures ". The problem of alcoholism seems to varyfrom country to country.

JELLINEK, whose work has been mainly responsible forclarification and progress on this complex issue, hassummed up his present views.5 Alcoholism, he nowconcludes, is not a specific but a generic term. It is a

fairly broad genus with a large number of species, thevarious alcoholisms described in different countries

having only two features in common—drinking, and thedamage (to individual and/or society) resulting from it.The genus can therefore be defined only vaguely; buttaking into account ætiology, elements of the alcoholicprocess, and type of damage, JELLINEK tabulates five ofthe most common species of alcoholism, which he callsby the first letters of the Greek alphabet.As regards ætiology, psychological vulnerability,

varying from slight psychological deficits to outrightneurosis or psychosis, is present in all species. The roleof physiological vulnerability is hypothetical: physio-pathological elements may possibly be important in thedevelopment of the addictive process. Finally socio-cultural elements, such as the attitude towards drinkingand drunkenness, and economic elements, among themthe price of alcoholic drinks, play varying parts in thedifferent species.Among the elements of the alcoholic process,

JELLINEK considers first acquired increase of tissuetolerance: this is present to a slight extent in all regulardrinkers, but its rapid development to a high degree maybe a major element in the process of addiction—thatis, physical dependence. JELLINEK discusses the mainaddictive features—i.e., besides acquired increasedtissue tolerance, an increase of the dose, withdrawalsymptoms, and craving. The addictive process is

coupled either with loss of control with unimpairedability to abstain after a bout or with inability to abstaineven for twenty-four hours but without loss of controlover the amounts ingested. Dependence in the variousspecies of alcoholism may be psychological or physical—though in certain species there is neither, but insteaddependence on social custom such as heavy weekenddrinking. Nutritional and physical habits may greatlycontribute to the damage in some species.

Alcoholism is usually described as a progressivecondition, but JELLINEK points out that only in the twotrue addictive species of alcoholism is there progressionfrom social drinking over various stages 2 to eventualloss of control and/or inability to abstain. In other

species of alcoholism progress consists merely in thedevelopment of manifestations of chronic alcoholism.

4. Jellinek, E. M. World Health, Geneva, 1957, 10, 4.5. Jellinek, E. M. Canad. med. Ass. J. 1960, 83, 1341.

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Only the first two species, representing addiction in thestrict pharmacological sense, and termed " gamma"alcoholism (involving loss of control) and " delta "alcoholism (inability to abstain) are regarded byJELLINEK as diseases. Two other species (" alpha " and"

epsilon " alcoholism) may be symptoms of underlyingdisorders. Finally, " beta " alcoholism results fromcertain cultural drinking patterns, which in conjunctionwith poor nutritional and physical habits are responsiblefor the development of complications (chronicalcoholism) and is neither a disease nor a symptomof a disease.

Delta alcoholics predominate in France, gammaalcoholics in the U.S.A. As far as this country is con-cerned, published studies deal almost exclusively withthe species now termed by JELLINEK gamma alcoholics;but GLATT’S6 work suggests that other types of alcoholicsmay not be very uncommon here. Some of JELLINEK’Sresearches have greatly influenced work in this country.Thus the Jellinek formula, providing an estimate of theprevalence of chronic alcoholism, underlies the usualestimate of 86,000 chronic alcoholics in England andWales/ and his concept of the developmental process ofalcohol addiction 2 has been found by GLATT to applyalso to alcohol addicts in this country.

6. Glatt, M. M. J. clin. Pract. 1961, 15, 153.7. Glatt, M. M. Lancet, 1959, ii, 397.8. Hansard, Feb. 17, 1961, col. 1917.

Annotations

EXCEPTIONAL CHILDREN

MANY families in this country contain exceptionalchildren. Unfortunately some of them are exceptionalbecause they are mentally or physically handicapped.Their need of help is recognised, and to some extentprovision is made for their education. There are specialschools, for instance, for backward children, deaf children,blind children, spastic children. There are some, thoughprobably too few, residential places. No-one would dis-pute that these vulnerable children have a special claim onthe community and that we still have not done enough forthem. There is, however, it was lately suggested in theHouse of Commons, another, smaller, group of excep-tional children whose needs are still unrecognised-children of outstanding intelligence in families wherethere is not money to provide special educational

opportunities.Last month on the adjournment Mr. Philip Holland e

drew attention in the House of Commons to the difficultiesof a father of limited means who had a 9-year-old sonwho was said to have an I.Q. of 171 whom he was anxiousto send to a boarding-school with a high teacher/pupilratio. Mr. Holland pointed out that the only provisionin the State educational framework for exceptionallygifted children was a permissive regulation which alloweda local authority to make a grant out of its own funds. Inview of the many claims on their resources, authoritiescould not be blamed for showing a certain reluctance touse these powers. But the country urgently needed first-class scientists, and he thought that we should no longerrely on " a passive permissive permission " to meet theneeds of the " raw material in its earlier stage of develop-ment". If local authorities were reimbursed for any

grants they gave to children of high intellectual calibre,they might be less inhibited in making contributions. Thescope for help of this kind was shown by the reply ofMr. Kenneth Thompson, parliamentary secretary to theMinistry of Education. He said that there might be as manyas 25,000 children in England and Wales in each age.group with an i.Q. of somewhere between 138 and 171.But he was uncertain about the wisdom of providingspecial schools for supernormal as well as subnormalchildren.

Perhaps neither the solution nor the problem emergedclearly from the debate, and a more helpful approach is tobe found in Dr. C. 0. Carter’s suggestion,9 based on sur.veys by the Eugenics Society of 250 families with at leastone child of high intelligence. The surveys showed thatmore than a quarter of these families would have liked atleast one more child and some would have liked several.As it was, they were a little below replacement-rate. Themain obstacle to increasing the size of the family was lackof money. Dr. Carter believes that we are too apt to

regard the amount of national talent as fixed, and in hisview it would be a good investment actively to encourageour promising families to have more children (instead ofrather ineffectually urging our problem families to havefewer). Four possible methods of population promotionare increased family allowances, increased educationalgrants, help with housing, and increased income-taxallowances for children. Of these, educational grantshave Dr. Carter’s support, for they could be used selec-tively to help to enlarge families of promise. He wouldlike all children over sixteen judged suitable for full-timetraining to receive a grant sufficient to meet their living ex-penses. Part of the allowance would go to the mother to in.crease her ordinary family allowance, but Dr. Carter sensiblybelieves that it is important that part should go to theteenager, so that he does not feel that he is being a burdento hard-pressed parents or find himself at too great adisadvantage among his wage-earning contemporaries inthe milk bar.

9. Carter, C. O. Eugen. Rev. 1961, 52, 197.10. Thudichum, J. L. W. A Treatise on the Chemical Constitution of the

Brain. London, 1884.11. Jepson, J. B. Times Sci. Rev. 1961, no. 39; p. 18.12. Lancet, Feb. 25, 1961, p. 444.

METHIONINE AND SCHIZOPHRENIA

SEVENTY-SEVEN years ago Thudichum 10 suggested thatthe psychoses resulted from production of abnormalchemical substances in the body; and he believed thatthe time would come when their production could becontrolled. Unfortunately, the only real success has beenin preventing the effects on the brain of excessive amountsof phenylethylamine-and then only if the diagnosis ismade early in life. Diagnosis depends on the detectionof phenylketonuria; and, as Jepson 11 has pointed out, bythat time, though the amine can be inactivated rapidly,great cellular damage may have been done.Many workers hope that further investigations into the

effects of the hallucinogenic (or " psycholytic ") drugs,such as lysergic acid diethylamide, may throw some lighton the mechanism of the psychoses, in particular ofschizophrenia, and may suggest possible therapeuticmethods. Results so far have been both conflicting anddisappointing. 12A report from the United States on the action of

/-methionine in schizophrenia, though not conclusive,indicates another approach. In a small but carefullydesigned study of 12 chronic schizophrenic patients,