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—formstance, that things will all seem much less alarming alarming

at the next visit. He emphasises that there must be the fexpression of

" an inner good will for the patient." The

important thing, he says, with an acutely tense nervous Ipatient (often a woman) is " to recognise that she I

despises herself for being so afraid, and that she badlywants to be understood, tolerated with uncritical patience,and not hurried." Dr. Kitching doubts whether this firststate of relaxed suggestibility should be called hypnosisat all.The second stage, of deep hypnosis, can be reached, it

is variously estimated, by 10-40% of people. The patientreally cannot open his eyes, and anaesthesia can be

produced by suggestion. This stage is suitable for dentalextractions. The third stage, hypnotic coma, resemblesdeep surgical anaesthesia, and is associated with total

spontaneous amnesia. Major surgery can be done onpatients in this stage, but probably less than 10% of

people, Kitching thinks, can reach it. It has the advantageof bringing the autonomic functions of the patient underthe influence of the operator : peristalsis, and the

progress of labour, have both been modified directly bysuggestion to patients in hypnotic coma, and salivationhas been reduced in dental operations. It is not impos-sible that haemorrhage could be checked in the sameway.

Dr. Kitching’s experience contradicts the commonbelief that ready subjects of hypnotism are all of low

intelligence. He finds that, once the procedure andthe reasons for using it have been explained to them,intelligent patients cooperate better than dull ones. Butthe truth is that hypnotism, though it is convenient andiimoouous in honest hands, carries a good many practicaldifficulties. Not many practitioners have the temperamentand interest to become skilled hypnotists ; not manypatients respond well enough to undergo treatment

painlessly; and the chances of the two meeting are, ashe says, rather remote. Chemical an2esthesia offers auseful if imperfect short cut to the desired end.

1. Anderson, C. M., Frazer, A. C., French, J. M., Gerrard, J. W.,Sammons, H. G., Smellie, J. M. Lancet, 1952, i, 836.

2. Almy, T. P. Ann. intern. Med. 1950, 34, 1041.3. Adlersberg, D., Colcher, H., Drachman, S. R. Gastroenterology,

1951, 19, 674.4. Jones, C. M. Int. Congr. intern. Med. 1952, p. 9.5. Badenoch, J. Brit. med. J. 1952, i, 356.6. Cooke, W. T. Lancet, 1953, ii, 425.

HYDROCORTISONE IN THE TREATMENTOF SPRUE

IDIOPATHIC steatorrhoea is usually well controlled bya high-protein diet with a restricted fat intake andadministration of haematinics such as folic acid andvitamin B12. In some cases, however, the patient’scondition gradually deteriorates until eventually hedies. Such a patient may from the start have not

responded to the usual therapy, or else the disorderhas been well controlled for many years before gettingout of hand. A few such cases may be controlled bya rigid gluten-free diet,l but many others are unaffectedby this diet.

Since the role of the adrenal cortex in intestinal

absorption has created much interest, it was naturalthat corticoid therapy should be tried in idiopathicsteatorrhoea. Almy’s 2 report of a successful result wasfollowed by that of Adlersberg et al.,3 who obtainedsatisfactory results in five cases with both cortico-

trophin and cortisone. Chester Jones,4 who had equallysatisfactory results in ten cases, concluded that this treat-ment was sometimes outstandingly successful. Badenoch,5at Oxford, was not so enthusiastic about the results withcortisone, while Cooke,6 at Birmingham, obtained

encouraging results with corticotrophin. It is evidentthat corticoid therapy does not cure the disorder.In occasional patients it brings about long-continued

remissions; in the majority relapse ensues fairlysoon after treatment is discontinued, but mainten-ance doses can be carried on for long periods withsatisfactory control of symptoms. 7 It has also becomeevident that some patients will respond to intravenousadministration of corticotrophin, but will relapse when,instead, cortisone is given by mouth.

Adlersberg et al. have now reported their resultswith hydrocortisone (compound F) in seventeen patients.Two forms of this steroid were used-the acetate and thefree alcohol-and these two substances were clinically" titrated" against corticotrophin and oral cortisone.The results were quite clear-cut. Hydrocortisone acetate,given in two courses by intramuscular injection and fivecourses by oral administration, caused almost immediaterelapse in every patient, even though the dosage washigher than the effective dosages of corticotrophin,cortisone, or the free alcohol. The results with thefree alcohol form of hydrocortisone, however, were

similar to those with cortisone and corticotrophin ; andthe free alcohol had the advantage that it was effectivein small doses without producing undesirable side-effects.Such an attribute is valuable, for side-effects are sometimes so troublesome as to cause the drug to be with-drawn before an effective therapeutic level has beenreached.

7. Colcher, H., Drachman, S. R., Adlersberg, D. Ann. intern.Med. 1953, 38, 554.

8. Adlersberg, D., Colcher, H., Wang, C. Arch. intern. Med. 1953,92, 615.

9. London : Gerald Duckworth. 1953. Pp. 216. 15s.

WHEELS WITHIN WHEELS

Ttiis book," says Mr. W. Grey Walter, D.sc., in hisforeword to The Liviitq Brain,

" is intended for generalreading, for those who are interested in themselves andother creatures." Though many of us fall into his secondclass, and most of us into his first, the assertion mayprovoke some to reply (like the tragedian asked for

change of half a crown) " While regretting that I amunable to oblige you, none the less I thank you for thecompliment." For the book is very hard going : nor isthis entirely the fault of the subject-matter. True, theexposition for the common reader of what we now knowabout the living brain would tax even the most limpidstylist ; and limpid is precisely what Dr. Grey Walteris not. He is, however, a number of other agreeablethings-a,musing, allusive, literary, sophisticated, tan-

gential, apt in simile, and-whenever he chooses-explicit. (His very luxuriance sometimes betrays himinto inaccuracy : " Pekin man’s acquaintance with thelast of the dinosaurs " must surely have been of theslightest, seeing that the species missed each other bymany a million years.) But despite his decoratedmanner he contrives here to tell the common man, andeven the common doctor, much that they otherwisehave little chance of hearing about recent research on theliving brain ; and it is a strange new world.

Perhaps the aspects of it which most impress the new-comer are the number and variety of techniques now inuse for studying the brain’s activities-any one of which,it seems, if explored fully, would occupy the lifetimesof many generations of searchers. Electro-encephalo-graphy supplies such abundant data that " only rarelydoes an observer use more than one-hundredth of one

per cent. of the available information." Changes in theelectrical activities of the brain, besides being tracedlaboriously by pens for later study, can be observedimmediately as a series of flashing points, by means ofthe toposcope. In this instrument electrodes deliver theelectrical changes in the brain to 22 small cathode-raytubes, arranged in the display console to give " a kind ofMercator’s projection of the brain." The flashingshuttles of Sherrington’s " enchanted loom " are therevisibly in action, and their behaviour can be photographed

200

as a permanent record, or checked against a pen tracingmade simultaneously. In 1946 it was found that theinformation contained in E.E.G. records could be greatlyincreased by subjecting the brain to rhythmic stimu-lation-particularly by flickering a bright light in theeyes, whether these are open or closed-and it becamenecessary to devise an instrument (the electronic strobo-scope) to deliver the flashes accurately at different rateswithout shortening their duration. Flicker can evoke,in 3-4% of normal people, E.E.G. responses indistinguish-able from those previously regarded as diagnostic of

epilepsy; and in some people these responses are

associated with faintness, feelings of swimming in thehead, jerking of the limbs in rhythm with the light, orunconsciousness. Since flicker is encountered in ordinarylife by anyone driving a car past a set of railings orthrough an alley of trees when the sun is low and thelight is coming through in level shafts, this observationhas immediate practical significance : it may accountfor some accidents. Another effect of flicker is to producevivid illusions of moving patterns, often in bright colours.This happens when the subject’s eyes are closed. Norm-ally when the eyes are closed, the E.E.G. records the alpharhythm, which disappears when the eyes are opened ;and which may therefore be a scanning mechanismsearching for a pattern, and relaxing as soon as a patternis found. Dr. Grey Walter draws an analogy fromtelevision, where a space-pattern is converted for trans-mission into a time-sequence of impulses by the scanningmechanism of the camera. The bizarre experiences ofthose exposed to flicker he likens to the interferencewith the scanning process which would result from

illuminating the television studio with flickering light :the screen would then show blobs of light darting giddilyabout. He postulates similar confusion in the brain,where " the conflict between the two time patterns, theinherent scanning rhythms of the brain, and the flicker,produce a brain storm as wild as any distortion on thetelevision screen."

Concurrently with all this, the new science of cyber-netics has been contributing information about the

processes of learning. The electro-mechanical creaturesdescribed here are the outcome of a growing under-standing of the process of feedback-the automaticgoverning devices which enable machines (or for thatmatter reflex circuits) to regulate and stabilise theiractivities. The invention of the thermionic valve hasmade it possible to construct a reasonably trustworthyimitation of a reflex circuit, and hence to devise suchmock-biological creatures as the goal-seeking and self-

regulating Machina labyrinthea which can find its wayhome along its rails, coping with 63

"

choice-points,"and which-once it has achieved a successful return-will ever afterwards go directly home without error ; or

another maze-learning creature, " a sort of electro-mechanical mouse that fidgets its way out of confine-ment " ; or M. sopora which only stirs when disturbed,and " then methodically finds a comfortable position andgoes to sleep again." More elaborate still in its repertoireof behaviour is M. speculatrix, which explores its environ-ment ceaselessly except while it is "

feeding " (i.e.,getting its batteries recharged), scans the horizon forlight signals, and moves towards light of moderate

intensity, avoids bright lights, material obstacles, andsteep gradients, and does many other things which whenwe see them in animals we attribute to awareness.

From this background of new devices and all the

possibilities for fresh research which they open up, Dr.Grey Walter goes on to discuss the ability of the brain,alone among organs, to learn and to remember. Theseattributes have been illumined by another machine CORA,the conditioned reflex analogue, which grafted on toM. speculatrix gives 31. docilis, the easily taught machine.This he has conditioned to come to a whistle, by blowing

a short blast and showing it a light until it has establisheda " sound means light " response ; or has equally easilytaught that " sound means trouble " by blowing thewhistle and kicking the shell a few times until the machineshows the response " sound means dodge." But if amachine which has learnt such responses is subjected toconflicting stimuli (kicked when it is advancing in a" sound means light " response, for instance) it will

give up its attempts to oblige and will lose the power ofaction-a neurotic response with which we are familiarin living animals. Moreover, it can be treated alongorthodox psychiatric lines: by switching off all circuitsand switching them on again, or by disconnecting a circuitaltogether-by sleep, shock, or surgery, in fact. Thismachine, too, has taught something about three types ofmemory: the extension of the neural stimulus thatensures that when you step on a tack your foot, reflexlywithdrawn, does not at once come down in the same place;the gradual accumulation (as in a condenser) of dataabout neutral and specific stimuli; and the evocablememory, perhaps maintained by electrical oscillations.

Dr. Grey Walter passes on to discuss personality, andalso sleep, surveying the contemporary neurobiologicalscene, as he goes, and tracing its relations with theneighbouring fields of theoretical and applied psychiatry.It is a remarkable feat to have covered so much groundand conveyed so much information in so brief a space;and if the book is not fully satisfying that is mainlybecause it brushes so many philosophical problems, butnever broaches them. Indeed in this respect Dr. GreyWalter behaves very much like M. speculatrix skirting amaterial obstacle ; and he might well claim that, beingconditioned as a scientist rather than a philosopher, hecan do nothing else. This would hardly relieve thereader’s disquiet, however. Civilisation seems to havebeen in safer hands when learned men were conditionedto be both.

1. Playfair, L. Proc. roy. Instn G.B. 1865, 4, 431.2. See Lancet, Jan. 2, 1954, p. 35.3. Müller, E. A. Quart. J. exp. Physiol. 1953, 38, 205.4. Lehmann, G., Müller, E. A., Spitzer, H. Arbeitsphystologie,

1950, 14, 166.

HOW HARD CAN MAN WORK?

WEEKEND gardeners know that they can work at arate which they could not possibly keep up if theylaboured day after day and week after week. How hard cana man be expected to work regularly throughout the year?Nearly a century ago Playfair,l who based his viewson the experiences of rural postmen and of infantrymen,suggested that throughout the year no man could douseful work on six days of the week equivalent to morethan a 20-mile walk a day or a 14-mile march with a60-lb. pack, without the risk of breaking down. This

problem has more recently been studied by the MaxPlanck Institute for the Physiology of Work, atDortmund.2Muller 3 suggests that to prevent evidence of fatiguein a man doing physical work for eight hours a day,the intensity of the work and the duration of the restpauses must be adjusted to give an over-all rate of energyexpenditure of not more than 4 kcal. per min. (a netfigure which does not include the energy of basalmetabolism, amounting to just over 1 kcal. per min.).This he calls the endurance limit (E.L.) ; it is equivalentto walking continuously on the level at 3-8 m.p.h.Carrying a load of 50 kg. at 2-5 m.p.h. requires twice asmuch energy and can only be kept within the E.L. ifrest pauses equal the working time. For work involving12 kcal. per min. rest pauses equal to double the workingtime are necessary. Muller’s suggestion involves a

working capacity of 240 kcal. per hour and 1920 kcal.per day.

During the late war, Lehmann, Muller, and Spitzer 4made an extensive survey of energy expenditure in