814

trichiasis are present surgical correction is still imperative.Whether drugs other than chlortetracycline are equallyeffective is uncertain; but Reinhards et al. cite J. G. Scottas having obtained satisfactory results from chlorampheni-col applied intermittently for three consecutive days eachmonth for a year in schoolchildren in South Africa.The short-term intermittent treatment of trachoma

advocated in this report is a radical break from the tradi-tional methods, which involved years of constant treat-ment ; and much interest attaches to the suggestion byReinhards et al. that intermittent treatment is effectivebecause it spreads the therapy over different phases ofrelative activity and non-activity of the virus. Now thatthe virus of trachoma has been isolated-and apparentlyestablished from the increasing number of successfulinoculations in volunteers 18-this hypothesis and muchelse besides has become open to experimental trial.

ALCOHOLIC v. NON-ALCOHOLIC CIRRHOSIS

IT has long been recognised that hepatic cirrhosis is nota disease entity but the scarred stage resulting from manydifferent pathological processes, themselves the result ofdifferent aetiological factors.19 Nevertheless, in some

patients the hepatic disease is clearly part of a recognisabledisease entity, such as hsemochromatosis or Wilson’s dis-ease. In others, gross overindulgence in alcohol plays asignificant but ill-understood part, while in yet others nocorrelation can be established and the process can at

present only be regarded as cryptogenic. These two formsof the disease constitute the great majority of the cases inGreat Britain and the U.S.A., but their relative incidencediffers strikingly between the two countries. A group of35 alcoholic cirrhotics in the Boston City Hospital hasnow been carefully compared with a group of 35 non-alcoholic cirrhotics in Hammersmith Hospital, London. 20

Striking differences between the two groups of patientswere revealed. Thus males were twice as numerous asfemales among the alcoholics, but only half as numerousin the other group. Malnutrition, and especially a defi-ciency of dietary proteins, was clearly established in 26of the Boston patients but was insignificant among thepatients at Hammersmith. Clinically the outstandingfeatures of the alcoholic patients were those attributableto hepatic failure, such as jaundice and hepatomegaly, incontrast to the non-alcoholic group in which portalhypertension and its associated features of splenomegalyand gastrointestinal haemorrhage were predominant.Other features related in some obscure way to hepaticfunction, such as gynxcomastia, parotid-gland enlarge-ment, and Dupuytren’s contracture, were found lexclusively in the alcoholic patients; while leucopeniaand thrombocytopenia were almost confined to the non-alcoholics.The differences in the morbid anatomy of the liver

were equally striking and consistent between the two

groups. In alcoholic cirrhosis the liver was enlarged, butin the non-alcoholics small: mean weights 1806 and 1055g., respectively. On the other hand the regenerationnodules in the non-alcoholic patients were almost threetimes the size of those in the alcoholics: diameters 9-0 and3-5 mm., respectively. Fatty infiltration, a conspicuousfeature of the alcoholic liver both at biopsy and at

18. Collier, L. H., Duke-Elder, S., Jones, B. R. ibid. 1958, 42, 705; ibid. 1960,44, 65. Smith, C. H. ibid. 1958, 42, 721.

19. Karsner, H. T. Amer. J. clin. Path. 1943, 13, 569.20. Summerskill, W. H. J., Davidson, C. S., Dible, J. H., Mallory, G. K.,

Sherlock, S., Turner, M. D., Wolfe, S. J. New Engl. J. Med. 1960,262, 1.

necropsy, was virtually absent in the non-alcoholics.These and other changes indicate that the cirrhotic liver inalcoholic patients typically shows the features of diffusehepatic fibrosis, while that in the non-alcoholic patientsconforms to the picture of postnecrotic scarring withnodular hyperplasia.The results of this detailed study have thus convinc-

ingly shown that the cirrhosis associated with alcoholismis in general clinically and anatomically distinguishablefrom cryptogenic cirrhosis. Unfortunately, the study hascontributed little to our knowledge of the pathogenesis ofthe former or the xtiology of the latter. The findings do,however, accord with the view that fatty infiltration is astage in the development of alcoholic cirrhosis, and thatnutritional deficiency is not unimportant in its patho.genesis.21 It is also apparent that at least in this countryalco.holism is not the main cause of cirrhosis; but whether themain cause is the virus of infective hepatitis is uncertain.The most important conclusion to be derived from this

study is that the prognosis differs between the two typesof disease : the outlook of the alcoholic is far better, especi-ally if the patient can be induced to improve his nutritionand curtail his consumption of alcohol.

EVOLUTION OF PSYCHIATRIC RESEARCH

THE extraordinary rate of progress of psycho-pharmacology and neuropharmacology over the past tenyears indicates that psychiatry has entered on whatRostow might call the " take-off " phase of development.Recent work has taken two complementary forms. Thefirst has been the direct investigation of the metabolism ofpsychotic people in an attempt to find abnormalities ofvarious kinds; and some rather patchy progress has beenmade in this direction. The second has been the study ofbasic neurochemical and neurophysiological mechanismswhich may underlie psychoses; at present this is likelyto prove the more fruitful course. This work, in turn,takes two forms. The first is the careful comparison ofthe " model " psychoses with natural psychoses byobjective psychological and psychopharmacologicalmethods. The second is investigation of the mode ofaction of the drugs producing a

" model " psychosis.We still know very little of how drugs such as lysergic

acid diethylamide (L.S.D.), mescaline, and amphetamineact at biochemical, physiological, and pharmacologicallevels. We do not know the metabolic fate of the bulk ofthe mescaline that enters the body; we do not knowwhether it acts on the brain directly or through somemetabolite, or whether it interferes with the metabolismof some other substance in the body; we know very littleabout its action on cerebral enzymes, neuronal activity,synaptic transmission, and the electrical activity of thebrain; and only the initial phases of its structure/activityrelationship have been worked out. Very little more isknown of the mode of action of L.s.D. An excellent reviewpublished by the World Health Organisation 22 includesan article by E. Jacobsen, who surveys the actionsand interactions of ataractic and hallucinogenic drugs.(Two appendices give useful lists of these drugs and theirstructural formulae.) The clinical use of ataractic drugs isdiscussed by N. S. Klein, and of L.S.D. by R. A. Sandison.

21. Himsworth, H. P., Glynn, L. E. Lancet, 1944, i, 457.22. Bull. World Hlth Org. 1959, 21, no. 45.

Sir JAMES KILPATRICK, dean of the London School ofHygiene and Tropical Medicine and formerly director-generalof R.A.F. Medical Services, died in London on April 4.