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matosis peritonei: each was given an injection oftritium-labelled water, either intraperitoneally or intra-Tcnously, and samples were then removed at intervalsup to 24 hours. Whatever the route of administration,equilibrium between the ascitic fluid and the plasmawas reached in 8-10 hours. From the slope of the

equilibration’curves it was calculated that between 40%and 80% of the total volume of the ascitic fluid enteredand left the peritoneal cavity each hour. A simplecalculation shows that a patient with 6 litres of asciticfluid-a by no means uncommon amount-turns over58-115 litres per day.The remarkable absorptive capacity of the peritoneum

is confirmed by both investigations. The difference inthe turnover rate of protein and water, as shown bythese experiments, is undoubtedly a function of moleculesize. This is further suggested by the recent experimentsof Whipple et al.3 who used labelled albumin and

globulin in dogs with ascites. The rate of transfer ofthe relatively smaller albumin, across the peritonealmembrane was, in terms of weight, at least three timesas fast as that of the larger globulin.

It is evident, as Prentice et al. point out, that with aturnover capacity of more than 100 litres per day thebalance between inflow and outflow from the peritonealcavity must be delicately controlled. A 1% deficit inoutflow could rapidly lead to a clinically significantdegree of ascites. Moreover, since ascites was presentdespite the apparently unimpaired absorptive capacityof the peritoneum, it is clear that the formation of asciteswas probably due to greatly increased inflow. This con-clusion agrees with that reached by workers at the MayoClinic 4 who attribute ascites formation to the grosslyexcessive production of hepatic lymph caused by intra-hepatic sinusoidal congestion. Moreover, as Prenticeand his colleagues emphasise, this conclusion leads tothe conception of a reabsorption threshold which mustbe exceeded before ascitic fluid can accumulate. Factorssuch as the renal retention of sodium and water, andchanges in the osmotic pressure of the plasma proteins,which are known to influence the development of ascites,may operate through their effect upon this threshold,as well as upon the direct formation of the fluid byfiltration in the highly permeable hepatic sinusoids.

3. McKee, F. W., Yuile, C. L., Lamson, B. G., Whipple, G. H.J. exp. Med. 1952, 95, 161.

4. Gray, H. K. Ann. R. Coll. Surg. Engl. 1951, 8, 354.5. Manchester Guardian, March 10.6. Horsley, J. S. Narco-Analysis. London, 1943.7. Grinker, R. R., Spiegel, J. P. Men under Stress. Philadelphia,

1945.8. Sargant, W., Slater, E. An Introduction to Physical Methods

of Treatment in Psychiatry. Edinburgh, 1948.

NOTHING BUT THE TRUTH

AT the trial in Belfast this month of a young R.A.F.clerk who was charged with murder, statements made by-the accused man while under the influence of sodium

thiopentone were put forward by a psychiatrist who wascalled as an expert witness by the defence. This medicalevidence was accepted by the court, and the jury, afterdeliberating for two hours, found the accused guilty butinsane.5 In Britain such evidence has not previously beenaccepted in a murder trial.Sodium thiopentone is a quick-acting barbiturate

commonly administered for anaesthesia during minorsurgical operations or for inducing anaesthesia. Likesodium ajnylobarbitone (’ Sodium amytal’) it has beenincreasingly used in psychiatry during the past twentyyears, for during the precomatose stage or duringemergence from unconsciousness inhibitions are abolishedor lessened, and this phase can be prolonged by slowintravenous injection of the drug. As in hypnosis, thereis some dissociation and the subject is more than

ordinarily suggestible ; the intravenous administrationof barbiturates for " narco-analysis " and for " narco-synthesis "7 is based on this. Sargant and Slater 8

approve of this use of barbiturates for diagnosing psy-choses, both in depressives and catatonic schizophrenics.and for diagnosing and treating neuroses. In the acuteneuroses of war they found it valuable in treating func-tional amnesias and conversion symptoms of recent andabrupt onset, and for the abreaction of emotionallycharged experiences. 9 Henderson and Gillespie 10 suggestthat the value of narco-analysis has been overrated :

" Its chief usefulness is in the rapid recovery of memoryin psychogenic amnesia. It is more certain to work than

hypnosis and gives, therefore, more confidence to the doctor,but with sufficient patience and time, the same and probablybetter results can nearly always be obtained with persuasion,without either hypnosis or narcotisation. The method givesthe patient something tangible that he understands moreeasily than the purely psychological method of approach, andit has in consequence considerable value as a vehicle of

suggestion."

They admit, however, its value in discriminating betweenhysterical and epileptic fugues and between psychogenicamnesia and amnesia due to brain injury.

Prof. Jean Lhermitte 11 favours the use of thiopentonein criminal cases only for the detection of malingering(" narco-diagnosis") but not for obtaining informationabout the guilt of the accused (" narco-analysis ").There seem to be two main problems connected with theuse of a " truth drug " in criminal investigations : the

question of medical ethics, and the question of the

reliability of evidence thus elicited. Probably few wouldobject to its use for the purposes of the defence only,though the accused might be at some disadvantage if itwas revealed at his trial that he had refused to submit to

narco-analysis. The question of reliability is usefullydiscussed by Gerson and Victoroff.12 Using intravenoussodium amylobarbitone, they investigated the possi-bilities and limitations of narco-analysis in 17 maleneuropsychiatric patients who had refused to admit tocrimes or antisocial conduct concerning which irrefutableevidence was available from other sources ; they pointedout to the men that no information divulged would beused in charges against them. They emphasise the

importance of establishing the best possible rapport withthe subject and of obtaining a full history of his past lifeand of the incidents and circumstances leading up to thehidden material. The men were not warned until a fewminutes beforehand that they were to have amylo-barbitone ; it was then explained that it would makethem sleepy and enable them either to remember for-gotten episodes or to talk more freely to the doctor.6 patients submitted readily, but the remainder showedsuspicion or resistance. Anaesthesia was prolonged, andthe most material was obtained ’during emergence.Confessions were obtained from all subjects, but thesewere subsequently repudiated in 8 cases. Gerson andVictoroff agree with Henderson and Gillespie 10 that thereis often fantasy and falsehood in the material divulged ;and they point out that narco-analysis may provide thesubject with a welcome opportunity of " recovering hismemory " or of informing on an associate. They believethat statements obtained by means of narco-analysis,with the subject’s permission, could be useful in estab-lishing guilt or innocence, weeding out those who confessfalsely to crime, and exposing malingerers. They suggestthat ultimately submission to narco-analysis may bemandatory in the investigation of certain crimes, just as,in the U.S.A., the taking of fingerprints, premaritalWassermann tests, the reporting of venereal diseasecontacts to the board of health, and blood or urineanalysis of suspected alcoholics, have been enforced ;9. Sargant, W., Slater, E. Lancet, 1940, ii, 1.10. Henderson, D. K., Gillespie, R. D. Textbook of Psychiatry.

London, 1950.11. Lhermitte, J. Report of the Société International ede Crimino-

logie, Paris, 1951.12. Gerson, M. J., Victoroff, V. M. J. crim. Psychopath. 1948, 9,

359.

586

but they would like more investigations of the validityof narco-analysis as a method of interrogation, andmore discussion between the psychiatrists and the

lawyers of the ethical problems involved.

1. Sturnick, M. I., Gargill, S. L. New Engl. J. Med. 1952, 247, 829.2. Bishop, P. M. F., Kennedy, G. C., Wynn-Williams, G. Lancet,

1948, ii, 764.3. Bishop, P. M. F., Richards, X. A., Neal Smith, D. J., Perry,

W. L. M. Ibid, 1950, i, 848.4. Bishop, P. M. F., Richards, N. A., Perry, W. L. M. Ibid, 1951,

i, 818.

NEW ŒSTROGENS FOR OLD

THE cestrogens are used widely and sometimes indis-criminately. By a biochemical freak, oestrogenic effectsare produced not only by naturally occurring substancesbut also by some compounds, such as stilboestrol, withvery different formulae ; and the number of these

synthetic forms steadily increases. Among them thedimethylpentanoic acid derivatives of "allenolic acid "(6-hydroxy-2-naphthalenepropionic acid) have been foundto possess considerable oestrogenic activity. Judged bytheir effect on the vaginal smear in the female castratedrat, they are more patent than oestradiol when given byinjection ; and they seem to be effective, though lessnotably, when given by mouth. When injected into thespleen of castrated cats they are not destroyed by theliver as are the natural cestrogens.

Sturnick and Gargill 1 have used one of these allenolicacids-riamely, the methoxy derivative of the dimethyl-pentanoic acid series (’ Vallestril ’) in treating 32 women,of whom 28 had menopausal symptoms, 3 postmeno-pausal osteoporosis, and 1 (a young woman) pustular acne.(A man with bony metastases from a prostatic carcinomawas also included in their series.) They formed the opinionthat vallestril was effective in many cases where othercestrogens had failed and singularly free from toxiceffects and complications, especially uterine bleeding. In9 of the women vaginal smears were examined daily ;but the evidence of benefit consisted mostly in relief ofsymptoms, principally hot flushes. Unfortunately thismethod of clinical assay can never be regarded as verysatisfactory, for the average patient is unlikely to keepan honest or accurate record of flushes day after day.Most doctors know well how little of the medicine which

they prescribe is swallowed by the patient after the firstfew doses ; and the better the psychological integrationof the patient the less likely is she to continue to remem-ber or bother to take it. The same applies to diaryrecords of symptoms. Other factors, such as the sym-pathetic interest of the doctor prescribing a new prepara-tion and spontaneous remissions also undermine the

accuracy of such observations as these ; profound effectscan even be produced by treatment which is impressiveonly for its pharmacological nonsense. Moreover, themenopausal patient is at best an unstable observer whoseresponse level is liable to alter as time goes on.

Other methods of assaying potency include the sup-pression of lactation ; but this is almost useless, becausethe experiment cannot be repeated in the same patientuntil after the next pregnancy, and this prevents com-parisons. Vaginal-smear assays in the human are unsatis-factory because the changes take place too slowly to givea reliable guide ; and in castrated animals the results donot parallel those in women, since oestrogen potencyvaries from species to species. For such reasons as these,Bishop’s method of clinical assay

2-4 seems the mostreliable : it consists in determining the minimum dosagesof different cestrogens which cause oestrogen withdrawalbleeding in the same amenorrhceic women. Results mayoccasionally be vitiated by spontaneous menstruation,but this can often be detected by a study of basaltemperatures. The primary effect of all oestrogens is onthe endometrium, and it is here that the potency of aparticular form is most accurately assessed. The effects

on pituitary and thyroid activity, on hot flushes, onvaginal acidity and cornification, and on lactation areless direct.

So far it appears that the potency and toxicity of

cestrogens go hand in hand, and are together related todosage. Hexoestrol, for example, is less toxic than stil.boestrol only in doses that are therapeuticall,B leseffective. If an allenolic acid derivative were found torelieve secondary symptoms of oestrogen deficienenwithout producing the primary effect of endometrial

bleeding it would certainly represent a real advance;and it may yet prove possible to segregate the pharmaco.logical effects of these or some other cestrogens. Mean.while oestrogen therapy directed towards one symptomwill continue to carry penalties in other directions, suchas the suppression of ovulation, menstrual anomalies,postmenopausal bleeding, fluid retention, and nausea andvomiting

1. Proc. Mayo Clin. 1953, 28, 25.2. Handley, R.. Stewart, A. S. R. Lancet, 1952, i, 742.3. Jasper, H. H.. Droogleever-Fortuyn, J. Ass. Res. nerv. ment.

Dis. 1947, 26, 272.

MODERN OUTLOOK ON EPILEPSY" A convulsion is but a symptom," and " the mode of

onset of the seizure is the most important matter in theanatomical investigation of any case of epilepsy." Withthese two quotations from Hughlings Jackson Dalyopened his discussion of the pattern of the epilepticattack in a recent symposium at the Mayo Clinic 1; andhe went on to advise, as did Hughlings Jackson, thatboth site of origin and aetiology of seizure must beconsidered. Modern clinical practice seems gradually tobe catching up with Hughlings Jackson’s views of eightyyears ago. Although his dicta on the subject have alwaysbeen revered, and quoted as a part of neurologicalpietas, they have been slow to diffuse into the generalbody of clinical medicine. Now that we have newmethods of medical and surgical treatment and the

electro-encephalogram (E.E.G.) for more accurate diag-nosis, interest in epilepsy has increased ; and many ofJackson’s observations and the hypotheses derived fromthem are being confirmed and strengthened, both in theclinic and in the laboratory.

Episodic behaviour disorders in epileptic attacks haveattracted renewed attention. Such disorders may at firstseem primarily psychiatric ; but their episodic and

strange nature, and possibly associated neurologicalabnormalities, including E.E.G. changes, may help to

suggest their true origin. When, however, they arise ina setting of constitutional epilepsy, the diagnosis may bemore difficult ; they may largely merge into lack of self-control and other oddities of personality which can hardlybe regarded as specifically "

epileptic "

even whenassociated with some E.E.G. abnormality. The responseof such cases to treatment may sometimes be of diagnosticvalue. Drugs of the hydantoin group may control theseabnormalities of conduct ; and lately ’ Mysoline,’ a newBritish preparation, has been introduced 2 as a treatmentfor all forms of epilepsy, including this psychomotorgroup.With regard also to petit mal, new views are abroad.

In this disorder the bilateral " wave-and-spike "

patternin the E.E.G. at first suggested some generalised cerebralor cortical abnormality. Now, however, this electricalpattern, and indeed some of the clinical features of theattacks, have been reproduced in animals by stimulatinga limited area of the medial intralaminar region of thethalamus,3 and petit mal may be regarded as the " localsign

" of discharge from a specific subcortical area.

There was a tendency to regard the wave-and-spikeE.E.G. pattern as almost essential for the diagnosis of

petit mal ; but it is now usually agreed that " petit mal "

should be-a clinical term that may cover borderline cases