599

ment could be removed from them they would be classified asLaennee A or B, or post-necrotic.’’

(3) There is no doubt about the frequency of hepaticsiderosis in Africans in most parts of the Union. It does tendto disappear in the Southern Cape 9 and in PortugueseEast Africa, although all arguments in relation to inade-

quate diet apply equally forcefully in those regions, andmoreover the incidence of cirrhosis in Africans and Colouredsin the Southern Cape and in Portuguese East Africa as

high as elsewhere in the Union. Incidentally our students herehave for long been taught how to distinguish between Africanvisceral siderosis and haemochromatosis.

(4) I doubt whether many in this country would agree withthe view of Gillman and his associates that acute infectious or" epidemic hepatitis is uncommonly seen clinically amongstUnion Africans, though of course proof of the viral nature ofthese clinical cases and confirmation of the viral aetiology ofpost-necrotic cirrhosis of the liver in Union Africans await theintroduction of a satisfactory objective test for present orpast virus hepatitis. It is possible that malnutrition maypredispose the liver if damaged by other factors towards thedevelopment of cirrhosis, though no clear proof of this exists.

B. J. P. BECKER.University of the Witwatersrand,

Johannesburg.

9. Thomson, J. G. Personal communication.

INTRAVENOUS ADMINISTRATION OFMETHYL PHENIDATE

REGINALD GRAHAM.Birmingham Accident Hospital.

SIR,—Methyl phenidate (methyl-1 phenyl-2 piperidylacetate, Ritalin ’) has been administered intravenouslyafter an anaesthetic to 100 outpatients with the primaryobject of speeding recovery and removing all trace ofhangover.The dosage was about 20 mg. per 10 stone body-weight.

The anaesthetics used were thiopentone, nitrous oxide andoxygen, trichlorethylene, and pethidine ; and the durationof operation was generally less than an hour.Though the awakening-time was not notably advanced,

when consciousness was fully regained patients appearedfull of zest and bright, and had a very good appetite.There were 2 exceptions.No antagonism was found to alcohol, nor to the clouding

following chlorpromazine ; but the effect of methylphenidate on muscle-tone when chlorpromazine was usedproved interesting.A year ago a combination of chlorpromazine and pethidine

was used in conjunction with a thiopentone/nitrous-oxide/oxygen system to afford a smooth anaesthetic in the

elderly over periods up to three hours. When the patient hadbeen returned to the ward, he presented one of two pictures :either he was sufficiently recovered to object to the presenceof an airway, but completely oblivious to the dangers of hisown obstructing tongue ; or there was noisy breathing(probably due to spasm of pharyngeal muscles) with obviouslyenlarged veins and an off-pink colour. Administration ofmethyl phenidate rectified this undesirable aspect of therecovery in about three minutes. It was also found to speedthe return of normal muscle-tone in powerfully built patientswho showed muscle fibrillation, stertor, and cyanosis followingthe use of thiopentone, nitrous oxide and oxygen, and tri-chlorethylene.A notable side-effect was wakefulness without loss of

analgesia.An elderly woman, after an extensive operation on the

humerus, remained awake the entire night, but was com-fortable and content, and slept well the following night. Thiseffect lasted sixteen hours in one case, and then sedativeswere granted. But when the wakefulness was limited to anhour or two, there was the satisfaction of knowing that thepatient could look after himself in the event of vomiting andwas ventilating adequately.

Sympathetic stimulation was not observed. The

hypotension that often follows the administration of

chlorpromazine was not affected. It would appear thatthe outstanding feature of the intravenous use of methylphenidate in anaesthetic practice is that it is a powerfulbarbiturate antagonist.

I am indebted to the writings of J. Van de Walle (Paris)concerning the use of intravenous methyl phenidate, andshould like to thank Ciba Laboratories Ltd. for providing, Ritalin’ in a form suitable for intravenous administration.

1. Gregg, A. Bull. N. Y. Acad. Med. February, 1941.

MEDICINE AND THE HUMANITIES

A. P. CAWADIAS.

SIR,—In his paper on Medical History (Aug. 31) Dr.Agnew tells us that the University of Adelaide has screated a readership in humanities for medical students.This is a bold and necessary step and let us hope thatthe example of Adelaide will be followed by otheruniversities.

In fact humanistic culture is as important as naturalscientific culture for the practice of medicine. Asphysicians we have to act upon men and as man is body,mind, and spirit, we cannot limit ourselves to the studyof the basic medical natural sciences, physiology,pathology, nosography, but we must also know thehuman mind in its various manifestations embodied inthe term " culture," a knowledge developed in psychology,sociology, and history. More than that, we must takeinto consideration the human spirit, that mysteriouspower that makes us aware of our uniqueness, our

liberty, our creativity, and directs us towards transcendentvalues. Such knowledge, if we can use that term, isembodied in the lofty thoughts of the great philosophersand religious leaders. Psychology, sociology, history, andphilosophy constitute the humanities, that is the sciencesreferring to the real human characteristics, the humanmind and the spirit, whereas the physical sciences,physiology, pathology, and nosography, deal with the

aspect of man common with other natural beings.History of medicine is the great link between the physicalmedical sciences and the humanities.Some time ago that great medical educator, Alan

Gregg, 1 was writing " How meagre the cultural baggage,how callow the manners, how unexercised the imaginationand the sympathies of our medical students must remainif we do not open for them the resources of Humanismfor the enrichment of their training. How can we expectsuch a one to have the spiritual values that will enablehim to combine effectively with patients in the bewilder-ment, loneliness and anxiety of illness."

SEX IN ANENCEPHALUS

SIR,—In anencephalus there is a striking excess ofaffected females. Various explanations have been sug-gested for this finding, such as selective affection offemales, disproportionate embryonic or early fœtal

mortality of affected males, &c. However, in view ofrecent findings on aberrations of sexual differentiation inman the possibility should be explored that an error ofsexual differentiation may underly the apparentlydisturbed sex-ratio in this condition. During the lasttwenty months one of us (A. E. C.) has studied theexternal and internal sexual differentiation of 12 anen-

cephalic babies (4 males, 8 females) born at QueenCharlotte’s Hospital, London, and determined the statusof the nuclear sex chromatin. In each case the " nuclearsex " agreed with the post-mortem findings of theanatomical sex. As, however, the anencephalic defectis variable, and only some of the defects may be associatedwith anomalous sexual differentiation, we feel that studyof further material will be necessary to confirm the

findings of our limited sample. In view of the relative

rarity of anencephaly we would be grateful for the helpof colleagues who see such cases. We would suggest thefollowing investigation :

(1) Nuclear sex determination on skin or " sexable " internal

organs.