WHEELS WITHIN WHEELS

199 in the majority relapse ensues fairly f soon after treatment is discontinued, but maintenthat must be the there emphasises " an the ance doses can be carried on for long periods with inner will for The of good patient." expression I control of symptoms.7 It has also become important thing, he says, with an acutely tense nervoussatisfactory patient (often a woman) is " to recognise that she Ievident that some patients will respond to intravenous despises herself for being so afraid, and that she badly administration of corticotrophin, but will relapse when, wants to be understood, tolerated with uncritical patience, instead, cortisone is given by mouth. and not hurried." Dr. Kitching doubts whether this first Adlersberg et al. have now reported their results state of relaxed suggestibility should be called hypnosis with hydrocortisone (compound F) in seventeen patients. Two forms of this steroid were used-the acetate and the at all. free alcohol-and these two substances were clinically The second stage, of deep hypnosis, can be reached, it " titrated" against corticotrophin and oral cortisone. is variously estimated, by 10-40% of people. The patient really cannot open his eyes, and anaesthesia can be The results were quite clear-cut. Hydrocortisone acetate, produced by suggestion. This stage is suitable for dental given in two courses by intramuscular injection and five extractions. The third stage, hypnotic coma, resembles courses by oral administration, caused almost immediate the dosage was deep surgical anaesthesia, and is associated with total relapse in every patient, even than the effective of amnesia. can be done on corticotrophin, dosages higher Major surgery spontaneous patients in this stage, but probably less than 10% of cortisone, or the free alcohol. The results with the people, Kitching thinks, can reach it. It has the advantage free alcohol form of hydrocortisone, however, were of bringing the autonomic functions of the patient under similar to those with cortisone and corticotrophin ; and the free alcohol had the advantage that it was effective the influence of the operator : peristalsis, and the of both been modified have labour, directly by in small doses without producing undesirable side-effects. progress suggestion to patients in hypnotic coma, and salivation Such an attribute is valuable, for side-effects are some times so troublesome as to cause the drug to be withhas been reduced in dental operations. It is not imposdrawn before an effective therapeutic level has been sible that haemorrhage could be checked in the same reached. way. Dr. Kitching’s experience contradicts the common WHEELS WITHIN WHEELS belief that ready subjects of hypnotism are all of low Ttiis book," says Mr. W. Grey Walter, D.sc., in his intelligence. He finds that, once the procedure and foreword to The Liviitq Brain, " is intended for general the reasons for using it have been explained to them, for those who are interested in themselves and intelligent patients cooperate better than dull ones. But reading, other creatures." Though many of us fall into his second the truth is that hypnotism, though it is convenient and and most of us into his first, the assertion may class, iimoouous in honest hands, carries a good many practical difficulties. Not many practitioners have the temperament provoke some to reply (like the tragedian asked for change of half a crown) " While regretting that I am and interest to become skilled hypnotists ; not many you, none the less I thank you for the patients respond well enough to undergo treatment unable to obligeFor the book is very hard going : nor is compliment." painlessly; and the chances of the two meeting are, as this the fault of the subject-matter. True, the entirely he says, rather remote. Chemical an2esthesia offers a exposition for the common reader of what we now know useful if imperfect short cut to the desired end. about the living brain would tax even the most limpid stylist ; and limpid is precisely what Dr. Grey Walter HYDROCORTISONE IN THE TREATMENT is not. He is, however, a number of other agreeable OF SPRUE allusive, literary, sophisticated, tanIDIOPATHIC steatorrhoea is usually well controlled by things-a,musing, in simile, and-whenever he choosesapt gential, a high-protein diet with a restricted fat intake and explicit. (His very luxuriance sometimes betrays him administration of haematinics such as folic acid and into inaccuracy : " Pekin man’s acquaintance with the In some cases, however, the patient’s vitamin B12. last of the dinosaurs " must surely have been of the condition gradually deteriorates until eventually he slightest, seeing that the species missed each other by dies. Such a patient may from the start have not But despite his decorated many a million years.) responded to the usual therapy, or else the disorder manner he contrives here to tell the common man, and has been well controlled for many years before getting even the common doctor, much that they otherwise out of hand. A few such cases may be controlled by have little chance of hearing about recent research on the a rigid gluten-free diet,l but many others are unaffected living brain ; and it is a strange new world. by this diet. the aspects of it which most impress the newSince the role of the adrenal cortex in intestinal comer are the number and variety of techniques now in absorption has created much interest, it was natural use for studying the brain’s activities-any one of which, that corticoid therapy should be tried in idiopathic it seems, if explored fully, would occupy the lifetimes steatorrhoea. Almy’s2 report of a successful result was of many generations of searchers. Electro-encephalofollowed by that of Adlersberg et al.,3 who obtained graphy supplies such abundant data that " only rarely satisfactory results in five cases with both cortico- does an observer use more than one-hundredth of one trophin and cortisone. Chester Jones,4 who had equally per cent. of the available information." Changes in the satisfactory results in ten cases, concluded that this treat- electrical activities of the brain, besides being traced ment was sometimes outstandingly successful. Badenoch,5 laboriously by pens for later study, can be observed at Oxford, was not so enthusiastic about the results with as a series of flashing points, by means of immediately cortisone, while Cooke,6 at Birmingham, obtained the toposcope. In this instrument electrodes deliver the encouraging results with corticotrophin. It is evident electrical changes in the brain to 22 small cathode-ray that corticoid therapy does not cure the disorder. arranged in the display console to give " a kind of In occasional patients it brings about long-continued tubes, Mercator’s projection of the brain." The flashing shuttles of Sherrington’s " enchanted loom " are there 1. Anderson, C. M., Frazer, A. C., French, J. M., Gerrard, J. W., Sammons, H. G., Smellie, J. M. Lancet, 1952, i, 836. visibly in action, and their behaviour can be photographed 2. Almy, T. P. Ann. intern. Med. 1950, 34, 1041. 3. Adlersberg, D., Colcher, H., Drachman, S. R. Gastroenterology, 7. Colcher, H., Drachman, S. R., Adlersberg, D. Ann. intern. 1951, 19, 674. Med. 1953, 38, 554. 4. Jones, C. M. Int. Congr. intern. Med. 1952, p. 9. 8. Adlersberg, D., Colcher, H., Wang, C. Arch. intern. Med. 1953, 5. Badenoch, J. Brit. med. J. 1952, i, 356. 92, 615. T. 6. Cooke, W. 9. London : Gerald Duckworth. 1953. Pp. 216. 15s. Lancet, 1953, ii, 425. al rming —formstance, that things will all seem much less alarmingremissions;

at the next visit. He

though

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permanent record, or checked against a pen tracing made simultaneously. In 1946 it was found that the information contained in E.E.G. records could be greatly increased by subjecting the brain to rhythmic stimulation-particularly by flickering a bright light in the eyes, whether these are open or closed-and it became necessary to devise an instrument (the electronic stroboscope) to deliver the flashes accurately at different rates without shortening their duration. Flicker can evoke, in 3-4% of normal people, E.E.G. responses indistinguishable from those previously regarded as diagnostic of epilepsy; and in some people these responses are associated with faintness, feelings of swimming in the head, jerking of the limbs in rhythm with the light, or unconsciousness. Since flicker is encountered in ordinary life by anyone driving a car past a set of railings or through an alley of trees when the sun is low and the light is coming through in level shafts, this observation has immediate practical significance : it may account for some accidents. Another effect of flicker is to produce vivid illusions of moving patterns, often in bright colours. This happens when the subject’s eyes are closed. Normally when the eyes are closed, the E.E.G. records the alpha rhythm, which disappears when the eyes are opened ; and which may therefore be a scanning mechanism searching for a pattern, and relaxing as soon as a pattern is found. Dr. Grey Walter draws an analogy from television, where a space-pattern is converted for transmission into a time-sequence of impulses by the scanning mechanism of the camera. The bizarre experiences of those exposed to flicker he likens to the interference with the scanning process which would result from illuminating the television studio with flickering light : the screen would then show blobs of light darting giddily about. He postulates similar confusion in the brain, where " the conflict between the two time patterns, the inherent scanning rhythms of the brain, and the flicker, produce a brain storm as wild as any distortion on the television screen." Concurrently with all this, the new science of cybernetics has been contributing information about the processes of learning. The electro-mechanical creatures described here are the outcome of a growing understanding of the process of feedback-the automatic governing devices which enable machines (or for that matter reflex circuits) to regulate and stabilise their activities. The invention of the thermionic valve has made it possible to construct a reasonably trustworthy imitation of a reflex circuit, and hence to devise such mock-biological creatures as the goal-seeking and selffind its way regulating Machina labyrinthea which can home along its rails, coping with 63 " choice-points," and which-once it has achieved a successful returnwill ever afterwards go directly home without error ; or another maze-learning creature, " a sort of electromechanical mouse that fidgets its way out of confinement " ; or M. sopora which only stirs when disturbed, and " then methodically finds a comfortable position and goes to sleep again." More elaborate still in its repertoire of behaviour is M. speculatrix, which explores its environment ceaselessly except while it is " feeding " (i.e., getting its batteries recharged), scans the horizon for light signals, and moves towards light of moderate intensity, avoids bright lights, material obstacles, and steep gradients, and does many other things which when we 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. These attributes have been illumined by another machine CORA, the conditioned reflex analogue, which grafted on to M. speculatrix gives 31. docilis, the easily taught machine. This he has conditioned to come to a whistle, by blowing as a

short blast and showing it a light until it has established " sound means light " response ; or has equally easily taught that " sound means trouble " by blowing the whistle and kicking the shell a few times until the machine shows the response " sound means dodge." But if a machine which has learnt such responses is subjected to conflicting 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 of action-a neurotic response with which we are familiar in living animals. Moreover, it can be treated along orthodox psychiatric lines: by switching off all circuits and switching them on again, or by disconnecting a circuit altogether-by sleep, shock, or surgery, in fact. This machine, too, has taught something about three types of memory: the extension of the neural stimulus that ensures that when you step on a tack your foot, reflexly withdrawn, does not at once come down in the same place; the gradual accumulation (as in a condenser) of data about neutral and specific stimuli; and the evocable memory, perhaps maintained by electrical oscillations. Dr. Grey Walter passes on to discuss personality, and also sleep, surveying the contemporary neurobiological scene, as he goes, and tracing its relations with the neighbouring fields of theoretical and applied psychiatry. It is a remarkable feat to have covered so much ground and conveyed so much information in so brief a space; and if the book is not fully satisfying that is mainly because it brushes so many philosophical problems, but never broaches them. Indeed in this respect Dr. Grey Walter behaves very much like M. speculatrix skirting a material obstacle ; and he might well claim that, being conditioned as a scientist rather than a philosopher, he can do nothing else. This would hardly relieve the reader’s disquiet, however. Civilisation seems to have been in safer hands when learned men were conditioned to be both. HOW HARD CAN MAN WORK? WEEKEND gardeners know that they can work at a rate which they could not possibly keep up if they laboured day after day and week after week. How hard can a man be expected to work regularly throughout the year? Nearly a century ago Playfair,l who based his views on the experiences of rural postmen and of infantrymen, suggested that throughout the year no man could do useful work on six days of the week equivalent to more than a 20-mile walk a day or a 14-mile march with a 60-lb. pack, without the risk of breaking down. This problem has more recently been studied by the Max Planck Institute for the Physiology of Work, at Dortmund.2 Muller 3 suggests that to prevent evidence of fatigue in a man doing physical work for eight hours a day, the intensity of the work and the duration of the rest pauses must be adjusted to give an over-all rate of energy expenditure of not more than 4 kcal. per min. (a net figure which does not include the energy of basal metabolism, amounting to just over 1 kcal. per min.). This he calls the endurance limit (E.L.) ; it is equivalent to 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 as much energy and can only be kept within the E.L. if rest pauses equal the working time. For work involving 12 kcal. per min. rest pauses equal to double the working time 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 Spitzer4 made an extensive survey of energy expenditure in a

a

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.