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a-globulins of the plasma and an increase in the

y-globulins ; since some antibodies are included amongthe y-globulins this is considered to be a favourableeffect. The drug has a strange and deceiving actionon the erythrocyte-sedimentation rate. After a few

days of treatment there is usually an. impressive fallto normal levels. This action is non-specific andoccurs in patients with and without tuberculosis. The

change in sedimentation-rate in patients receivingTBI-698 therefore rather loses its significance as anindex of their progress.The evaluation of any drug in the treatment of

tuberculosis is difficult unless it can exert an impressiveeffect on the miliary or meningeal forms. Theother clinical types wax and wane without anyspecific treatment. The evaluation of TBI-698 in theGerman cases is further complicated by the nutritionalcondition of the patients, many of whom were

repatriated prisoners-of-war, at the start of treatment.Moreover, in many areas X-ray films were scarce

and paper film had to be used. It seems certain thatTBI-698 has no effect on tuberculous meningitisor miliary tuberculosis, but 90-100% of the cases oflaryngeal tuberculosis treated have shown consider-able improvement ; pain, dysphagia, and hoarsenessdisappear in a few days and complete healing isobserved in most cases after six to eight weeks.Tuberculous enteritis, which seems to be commonin German sanatoria, responds favourably, althoughthe drug has to be continued for a long time andrelapse may occur after its withdrawal. It should be

pointed out, however, that the diagnosis of tuber-culous enteritis was often based on radiologicalfindings only. Many of the patients with pulmonarytuberculosis were in a deplorable physical conditionat the start of treatment and it was very difficult totell how far their improvement was the effect of

good food and nursing rather than of specific chemo-therapy. The German workers are enthusiasticabout the results in pulmonary patients, but HINSHAWand McDERMOTT are more sceptical, though theygrant that the improvements are " suggestive " ofsome drug effect. The German and Americanobservers agree that the drug is most likely to have afavourable effect in fresh exudative non-destructive

types of pulmonary tuberculosis, and that its actionon pulmonary lesions is neither as dependable noras rapid as streptomycin’s. In Germany the economicfactor is important because TBI-698 is much cheaperand more readily procured than streptomycin or

p-aminosalicylic acid. German workers claim to haveobtained good results in patients with cavities bymeans of - local treatment and Monaldi drainage ;local treatment of tuberculous empyemas is also saidto be effective. In tuberculosis of the genito-urinarytract and tuberculous sinuses, fistulae, and abscesses,HINSHAW and MCDERMOTT say that TBI-698 rarelyeradicates the tubercle bacilli completely and theresults cannot compare with those of streptomycin.Even if we fully accept the enthusiastic German

reports, there is no question of TBI-698 replacingstreptomycin. Its clinical activity seems to be on apar with that of p-aminosalicylic acid, and its toxicityresembles that of the arsenicals used in syphilis.But in spite of its toxicity it can be safely given for longperiods under careful medical supervision, and the

results, even on the most conservative view, callfor further carefully controlled investigations. Plansare under way for the manufacture and clinicalevaluation of TBI-698 in America, and trials willno doubt be conducted in this country, preferablyunder the auspices of the Medical Research Counciland by workers who have had experience with bothstreptomycin and p-aminosalicylic acid.

Men and WomenIT is no sinecure to be human ; but, even allowing

for the difficulties, we cannot claim to have mademuch of a hand of it so far. MARGARET MEAD/considering mankind anthropologically, hints that

by taking thought we might do better ; and especiallythat men and women, as complementary partnersrather than rivals, might each make a better con-tribution to our society. What should be man’scontribution, what woman’s ? We have so longthought of attributes as either male or female, so

long assigned one group of tasks to men and anothergroup to women, and so often protested when eitherinvades the territory of the other, that few of us

stop to ask what is fundamental behaviour in eithersex. Miss MEAD, in an attempt to identify thisfundamental behaviour-the essential differences,rather than the learnt differences, between thesexes-has compared seven Pacific peoples : the

tranquil harmonious Samoans ; the prudish toilingManus people ; the paternal altruistic undernourishedArapesh ; the laughing hating cannibal Mundugumor ;the Tchambuli, among whom women are unadornedand managing, and men decorative dilettantes ; -,,and the Balinese-musical, ritualistic, incapable ofenduring warmth of feeling-who have turned alllife into an art.

It might be thought that we and these diversepeople at least had in common the fundamental

experiences of birth and suckling ; but even thesecan vary. True the abrupt change from the perfectcomfort of the womb to the multiple troubles anddiscomforts- of life outside is a universal experience.But it is one thing to be born in the warmth of anobstetric theatre, and to be lapped at once in cottonwool, and another to be dropped on cold wet leavesin a leaky hut and to lie there for five minutes whileyour mother ties the cord. The experience maydiffer for the sexes as well as for races ; for if, asMiss MEAD suggests, girls have keener skin sensitivitythan boys, then the experience of birth in any societymay be different for each sex. In other ways-fromthe mother’s handling, from her voice-the childwill early begin to learn the pattern of its own sex ;and her method of suckling it will colour its first

opinion of human behaviour. The loving -Arapeshsuckle children tenderly. The Mundugumor womendislike both childbearing and children ; the childis never fed until he cries, and then he is made towait. His mother stands beside him to feed himwhere he lies, and gives the breast grudgingly. This

early struggle for the bare means of life must helpto fashion this angry avid cheerful people, amongwhom every male is at war with every other-evenwith his own young sons.

1. Male and Female. London : Gollancz. 1949. Pp. 477. 18s.

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In lightly clad societies the bodies of males andfemales are taken for granted. The small Balinese

girl early learns that she is female, and has only towait to become a mother ; and the boy accepts thisas something she will achieve which he never can.The girl child in our own civilisation has no such

certainty, nor does the boy usually think of her as apotential mother ; he is far more likely to regard heras ari incomplete and partial male-as she is also

apt to regard herself. " The difference between thesexes that is forced home on children in our worldof walled-in self-contained flats," as Miss MEAD says,has to do with differences in occupation, in dress, inprivilege. All women do not have babies, but mostmen don’t have to wash dishes." (That, of course,is in America.) In some of the Pacific societies,however, appreciation of women’s childbearingcapacity goes very deep as a cause of envy to theother sex-envy expressed in initiation ceremoniesat which adolescent boys are reborn symbolicallyof men, not of women.The outward manifestations of sex-the deep voice,

hairy chest, great height, or heavy musculaturewhich some societies regard as manly, and the bigbreasts (or conversely the small high breasts) whichare felt to be particularly womanly-are not directlyrelated to fertility. Differences in appearance-between the large " manly " man and the small

rabbity man, the billowing " motherly " woman

and the boyish girl-are differences not in repro-ductivity but in biological type. The small rabbityman is quite often more fertile than the large muscularone ; and if he had been bred among a people,like the Arapesh, where men are small, kindly, andunassuming, nobody would have questioned hismanliness. Small breasts lactate as well as, and some-times better than, heavy ones : one type is not moreessentially feminine than the other. We might gain,Miss MEAD thinks, by recognising that among our ownpeople-or anyhow among Americans, for whom sheis primarily writing-there are many biologicaltypes. We should then cease to expect all men andwomen to conform to standard types of behaviouror to follow a rigid set of occupations. The boy withartistic leanings would not be suspected of effeminacy,and the girl who shows a greater need to take thingsapart than most other little girls would not be

reproached. " In such a world," says Miss MEAD,66 neo child would be forced to deny its sex member-ship because it was shorter or taller, or thinner or

plumper, less hairy or more hairy, than another, norwould any child have to pay with a loss of its sex

membership for the special gifts that made it, thougha boy, have a delicate sense of touch, or, though agirl, ride a horse with fierce sureness."

Applying her method of observation and deductionto her own people, Miss MEAD reminds us how manycultures have gone to the making of Americans.

They have no single traditional pattern to follow,no small closed tribe hedged and comforted bycustoms. " Every home is different from everyother home, every marriage, even within the sameclass, in the same clique, contains contrasts betweenthe partners as superficially striking as the differencebetween one New Guinea tribe and another." Evenin America, however, there are some patterns ofbehaviour .which mould the child. Boys and girls

are consistently urged towards success-urged tomake good, get on, be happy, be fulfilled, be theideal. Some feel keenly the discrepancy betweenthe real and the ideal, asking themselves " Am I

getting on enough ? "

or " Am I as happy as I ought

to be ? " In adolescence they have to learn the

exigent routine of "

dating." To be a good date-popular and sought after by your own set-is to bea success. To choose to be solitary when you havebeen asked to go out is to be selfish and lacking ingood sportsmanship.

’’

Petting " is almost another

duty, in which the boy is expected to ask more thanhe hopes to be granted, and the girl is expected torefuse him-capably, gaily, and with poise. Thisin itself has unforeseen effects later, when the youngpeople finally seek permanent mates ; for the.girlshave acquired in this exacting game a degree of self-control which makes it hard for them to surrender

fully as wives. Easy divorce, strangely enough, hasadded another anxiety to life ; for it has become a

duty to free the other partner if he or she wishesto be freed, and many a conscientious couple enduresuch self-questioning as " Ought I to give him adivorce ? " " Would he develop more with some-

one else ? " " Would she be happier if she were free ? "

Every quarrel becomes a prospective rupture, everyday renews their solicitous care for the marriagerelationship, lest it grow too brittle to hold together.There are good points about this, of course; butit seems a hard way of doing it compared with theolder method of marrying for good with no escapeexcept through a destructive scandal. However,there is no going back to former patterns ; and MissMEAD hopes that such things as marriage counselling,nursery schools, and housekeeping services may easethe strain on young married couples and help them tokeep together with less emotional tension.

It is impossible to pack into a nutshell the stouttrunk, spreading branches, and innumerable livelytwigs of this vast tree of Miss MEAD’S book ; butit is clear from all she says that American society-and ours too in equally well-defined ways-has notproduced the pattern in which both sexes can make,easily and generously, their full contribution. Boysare made jealous and resentful of girls, girls are madeenvious of boys-a useless rivalry which everygeneration perpetuates afresh. In seeking the funda-mentals of human behaviour she has found one

permanent pattern : in all known human societiesthere is some form of the family ; and it is distin-

guished from the families of other primates by thefact that the male helps to provide food for thefemales and children. Inside this simple patternthere is room for both sexes to live constructivelyas colleagues sharing a task. She outlines the waygenerally rather than specifically. Our mistakesat least are clear.

" Either sex may be distorted by the presence ofthe other sex, or it may be given a fuller sense of sexmembership.... If parents define one child as lesscomplete, less potentially gifted, with less right to befree, less claim to love and protection, or less a sourceof pride to themselves than the other, the child of thatsex will, in many cases, feel envy. If society defineseach sex as having inalienable qualities of its ownbut does not relate those qualities to the reproductive edifferences between the sexes, then each sex may be

proud and strong, but some of the values that comefrom sex contrast will be lacking.... Externally at

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some given period of history and in some set of socialarrangements it may often look as if one sex gainedand the other lost, but such gains and losses mustin the end be temporary. To the extent that womenare denied the right use of their minds, their sonssuffer as well as their daughters.... If our analysisis deep enough and our time perspective long enough,if we hold in mind all the various possibilities thatother cultures hint at or fully embody, it is possibleto say that to the extent that either sex is dis-advantaged the whole culture is poorer, and the sexthat, superficially, inherits the earth, inherits onlya very partial legacy."The implicit conclusion-that sex rivalry is not

a fundamental characteristic of human behaviourbut a learnt pattern, and that if one sex wins bothlose-is the heart of a book alive with promisingnotions. It should indeed be possible, by takingthought, to do better.

Annotations

FAINTS AND FITS

To the public mind, fainting attacks are still a harmlessdisorder, -whereas epilepsy still carries a stigma. Yethow much they may have in common was made clearin the discussion at the Royal Society of Medicinereported on another page.The chief differences are in onset and symptoms. In

a little more than half the cases a major epileptic attackbegins with an aura ; and unconsciousness, stiffness,and twitching follow in rapid succession. In a faint,the retina fails early, then the centres for muscle tone, andconsciousness goes next ; thus the patient experiencesdimness of vision and loss of balance before he loseshimself. Moreover he is nearly always standing ; the

epileptic may get his attack when he is asleep in hisbed. If both disorders always behaved in the classicalmanner, probably no confusion would arise ; but, as

Sir Charles Symonds pointed out, some 7% of faintingpeople twitch or are convulsed, whereas many of thosewho have epilepsy are not convulsed. Faints in child-hood may be supplanted by epilepsy in later years, justas migraine may sometimes be exchanged for epilepsy.For the faint and the fit the essential common factor isan unstable nervous mechanism with the trigger in thecentral nervous system. Some distinguishing markscan be trusted to point to epilepsy, notably the aura,incontinence of urine, automatic behaviour, and perhapsprodromal yawning and biting of the tongue, but theseare not always present. The electro-encephalogramwill not give a cut-and-dried answer, as Dr. DenisWilliams showed. Patients who had faints only andpatients who had fits only both produced bursts of fastwaves, especially in the frontal lobes. But this is onlyto say the two conditions have a common factor, notthat they are identical. The waves reflect some instabilityin the cerebral hemispheres which can be increased byvarious situations and lead to unconsciousness. In

epilepsy the onset is local, the site of the trouble is in thebrain itself, and the spread is so rapid that the convulsionoften becomes generalised at the start.An epileptic attack can be provoked by emotion or the

sight of some feared scene ( a bleeding wound, a hospital) ;but so can a faint. Cerebral anaemia from whatevercause-heart-block, ventricular standstill, fall of blood-pressure, or occlusion of the carotids-will produceunconsciousness. Dr. Williams disposed of the notionthat damage to the nerve-cells of the brain by ’anoxiamight be the responsible factor in the Adams-Stokessyndrome ; the loss of consciousness is too rapid to makesuch an explanation plausible. He pictured the porridgybrain supported on its tree of blood-vessels : suddenlythey collapse, and the brain collapses with them-a

neurogenic cause for loss of consciousness, secondary toa cardiac disaster. In either epilepsy or syncope theimmediate cause of the attack may be primarily cardio-vascular or primarily cerebral. With postural hypo-tension, a sudden fall of blood-pressure, or haemorrhagethe trouble is primarily cardiovascular ; in epilepsy some-thing goes wrong in the brain. The cardiovascularcauses of loss of consciousness are legion, as Dr. MauriceCampbell was able to show ; but it should be kept inmind that fainting from organic heart-disease is notcommon in practice. The cardiac disorders which produceit, though multiple, are relatively rare.The crux of the discussion, as Sir Charles Symonds

remarked, was Dr. Williams’s new concept that somepeople are more liable to lose consciousness than others,whether from epilepsy or not. This view of things, if

generally disseminated, might do much to make lifeeasier for epileptics.

SIGNIFICANCE OF A RISE IN SERUM-AMYLASE

THE estimation of serum-amylase deserves a largeplace in the diagnosis of acute pancreatitis, for a normallevel rules out this disorder while a very high levelconfirms its presence. A moderate rise may be foundwhen the pancreas becomes involved in an adjacentpathological process, and sometimes in cases of acuteinflammation of the salivary glands or renal‘ failure. Tothese causes Musgrove,lof the Mayo Clinic, has now addeda fourth-free perforation of gastroduodenal lesions,with liberation into the peritoneal cavity of pancreaticamylase which is subsequently absorbed.During 1948 the emergency surgical service at the

Mayo Clinic dealt with three cases in which the serum-amylase levels were raised but the pancreas was subse.quently found to be normal. These cases all had a

perforation high up in the gastro-intestinal tract andsevere generalised peritonitis. Musgrove concludes thatwhen a large free perforation of a peptic ulcer occursduring the phase of active digestion, a large amount of 1gastroduodenal chyme may be poured out into theperitoneal cavity - and the subsequent absorption of

pancreatic amylase will cause a moderate rise in the

serum-amylase. This supposition has been confirmedexperimentally by Pemberton et a1.2 Of 14 dogs withanterior perforations of the duodenum, they found 4,all of which had eaten a large meal 1-2 hours beforeperforation, with high amylase values both in serum andin the peritoneal fluid. The amylase content of their

peritoneal fluid, expressed in arbitrary units based onthe number of mg. of maltose liberated by the amylasepresent in 1 ml. of fluid, was 130-352 units. The other10 dogs, which had no rise of serum-amylase afterperforation, had eaten their last meal 2-3 hours beforeperforation, and their peritoneal fluids contained only23-58 arbitrary units of amylase per ml.-a sixth of theamount in the 4 animals. When the interval between thelast meal and perforation was more than 3 hours theserum-amylase never rose ; when the interval was about2 hours the level was raised a little ; ;’ and when theinterval was only an hour or so there, was alwaysa distinct rise. The site of perforation apparently did hotinfluence the subsequent behaviour of the serum-

amylase. In normal dogs, the intraperitoneal administra-tion of amylase produced a prompt, well-marked, andlong-continued rise in serum-amylase. Further experi-ments showed that an associated pancreatitis or peri-tonitis had no. appreciable effect on the post-perforationserum-amylase level. In 2’ dogs with a persistentlypatent ulcer there was no rise in serum-amylase in theearly hours after a perforation ; but- the level was highat 70 hours after perforation. The explanation of this1. Musgrove, J. E. Proc. Mayo Clin. 1950, 25, 8.2. Pemberton, A. H., Grindlay, J. H., Bollman, J. L. Ibid, p. 5.