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weight, the work being based upon studies of basalmetabolism in infancy ; but even such exact studiesmay be misleading if we concern ourselves too exclu-sively with the energy value of the food supplied.The importance of supplying nutriment for growthrather than for energy expenditure is certainly amongstthe most pressing of the problems of the dietetics ofinfancy. In this respect it is surprising how frequentlyone still finds the term " protein " alone employed indiscussions on the nitrogenous requirements of theyoung child. Griffith, in an otherwise excellent article,has made no mention whatever of the amino-acidsupon whose presence or absence the whole suitabilityof many foods depends. The tendency of modernphysiology is to show that the amino-acids are theultimate units from which the protoplasmic moleculeis built up, and the absence or deficiency of one

particular type of amino-acid in any protein may resultin an inability on the part of the organism to constructnew protoplasm-just as the absence of a particulartype of tile may make impossible the construction of amosaic pattern. It is possible that herein lies thesuccess of such work as that recently reported3 byF. Tweddell, who, by the addition of egg-yolk tothe milk, secured considerable improvement in thecondition of marasmic babies.

NA’e have recently had occasion to consider thetherapeutic possibilities of B-vitamin with specialreference to its application to infant-feeding. It isnot here our purpose to discuss the chemical composi-tion of the vitamins ; whether they be indeed amino-acids. or whether they be substances whose beneficentaction is due to some direct effect on the living cells,it is clear that they possess a value altogether beyondtheir possible calorie worth, and are probably essentialin the diet of any growing organism. The interestthey are causing amongst those occupied with prob-lems of baby feeding is evidenced by the rapidlyincreasing literature dealing with the subject : bypursuit of close lines of investigation we may arriveultimately at a system of infant feeding establishedupon a truly scientific basis.

THE SPIRIT-LEVEL IN CHEST EXAMINATIONS.

ONE of the most accurate methods of detectingdifferences in the expansion of the chest on the twosides is to hold a spirit-level horizontally against themiddle of the chest and to note the movement of thebubble in this instrument while the patient breathes.Like many other useful devices, this simple procedure

has not enjoyedthe popularity itdeserves; per-haps it is toosimple to bepopular. InH ygiea for June

last, Dr. C. E.’

Waller, under theheading " Retar-datio Medica,"describes the use

of this instrument in the examination of the chest,and its special value in demonstrating lagging of theleft side of the chest as a result of certain nervousimpulses. The ends of the instrument are heldbetween the first finger and thumb of the examiner’shands, the remaining three fingers of each hand beingpressed against the patient’s chest above the spirit-level at points equally distant from the centre of thechest and at the same level on the two sides. Thesesix fingers being placed in the infra-clavicular fossae,the instrument is set at the horizontal on the com-pletion of expiration, and the movements of the bubbleare watched as the patient inspires. Under normalconditions the expansion of the two lungs may be sosymmetrical that the chest moves as if it containedonly one lung. But if the patient is nervous, and thisi-s so often the case as to be the rule rather than the

3 Medical Record. 1921, p. 935. 4 THE LANCET, 1921, ii., 1228.

exception, the condition which Dr. Waller callsretardatio medica-i.e., lagging of the left side of thechest-is observed. The phenomenon can be demon-strated on many healthy persons, and has to bediscounted in estimating the significance of otherforms of asymmetrical breathing. Thus, there maybe pleurisy, pneumonia, or cavitation on the rightside, tending to produce respiratory lagging on thisside. But if the patient is subject to retardatiomedica, it may be sufficiently marked to neutralisethe effect of the pleurisy on the right side. Or itmay diminish the lagging on the right side but notneutralise it altogether. On the other hand, if theleft side of the chest is diseased, the retardatio dueto this cause is apt to be exaggerated by retardatiomedica ; it may therefore be advisable to wait tillthe retardatio medica has passed off before gaugingthe degree of retardation due to organic disease onthe left side. The value of the spirit-level can bedemonstrated in a case of hsemoptysis when thephysician wishes to learn from which lung the bloodcomes. But unless he is alive to the significance ofretardatio medica, he may fail to detect the retardationwhich haemorrhage from a lung sometimes provokes.

TREMOR DURING ANÆSTHESIA.

THE tremor which is sometimes seen duringanaesthesia, generally when ether is being used,although not a serious symptom, may cause muchinconvenience to the surgeon. It is rarely evidentwhen narcosis is deep. Commonly it is started bysome alteration in position, particularly of the lowerlimbs. Physiologically it appears to be of the natureof a reflex clonus. At the hospital of Vestervik,Sweden, a number of observations’ have been madeby Dr. T. Rietz, which led him to attribute thephenomenon to cerebral excitation brought out bythe narcotic circulating in the blood. He conceivedthe idea that, if this were the true causation, pressureon the carotid might influence the symptoms. Tryingthis treatment he found that out of 33 subjects whodisplayed the tremor, this was immediately stoppedin 19, imperfectly in five, and the pressure was with-out effect in five. The pressure must be strong, hesays, and sometimes bilateral. Pressure exertedelsewhere, for example, on the brachial plexus, waswithout effect, and Rietz believes therefore that theresult achieved by compression of the carotid is notdue to reflex from the painful stimulus caused, butto actual pressure on the artery. It is permissible todoubt whether the symptom deserves the treatment.In most instances the tremor is quickly overcome ifnarcosis is deepened and the faulty position tem-porarily rectified, or if ether is given up in favour ofchloroform for a few moments. But the observationis of physiological interest, and deserves furtherattention.

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PALPABLE RADIAL ARTERY.

THOUGH palpability of the radial artery is con-

sidered an important sign in assessing the conditionof the vascular system, its frequency and the condi-tions under which it is observed do not appear tohave been much investigated. Sir Clifford Allbutt,in his great work on " Diseases of the Arteries,"states that palpable radials are frequent in those whodo heavy physical work. In the JJ1 edical Journal ofAustralia of Dec. 3rd, 1921,Dr. G. C. Willcoeks has pub-lished an important paper based on the examinationof the radial arteries of 104 healthy soldiers and77 ex-soldiers suffering from neurasthenia. Of theformer, whose ages ranged from 18 to 50 years, theradial artery was found palpable in 85 per cent. ; in15 per cent. it could not be distinguished from thesurrounding tissues, but in six of the men a thickforearm or proximity of the vessel to the flexortendons prevented a definite conclusion as to whetherthe vessel could be palpated or not after the radialpulse was obliterated. In 13 per cent. the artery felt

1 Bull. Société de Biologic, Dec. 17th, 1921.

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very thick. Of the neurasthenics 92 per cent. hadpalpable radials, and in 8 per cent. the artery couldnot be felt. In 40 per cent. the artery was muchthickened. In the majority of the men there was noobvious difference between the arteries on the twosides. Of 87 soldiers with palpable radials 48 hadsome infectious disease since childhood, and 40 wereunder the age of 26 years. The artery was markedlypalpable in healthy soldiers of 18, 19, and 22 years.In only three men was there a history of alcoholism,and these had palpable radials. In 25 healthysoldiers under the age of 22 years it did not seem thatheavy work could have been responsible for the

palpable radials. It has been stated that spasm orhypertonus may render the radial artery temporarilypalpable, but it was difficult to believe that hyper-tonus could be the cause in so many men. In threecases an endeavour was made to eliminate spasm byimmersing the forearm in water as hot as could beborne, but the radials remained just as palpable.They were more frequently and more markedlypalpable in the neurasthenics, especially in thosewhose symptoms were of long standing. The

systolic blood pressure (taken with Lauder Brunton’ssphygmometer) in healthy soldiers was about 130--0.The pressure differed little in those whose arterieswere markedly palpable, just palpable, or not palpable.The pressure did not vary with the palpability of theartery, or at all constantly with age.

THE HISTORY OF HUMAN DISSECTION.

IN his first professorial lecture 1 at Lyons Dr. A.Latarjet told the history of anatomical investigation,paying eloquent tribute to his master, Testut, whomhe succeeds in the chair of anatomy. The student ofto-day is so much engaged in gathering in the latestviews, that he can spare few moments to listen to theecho of the voices of the past. ’Tis true, ’tis pity,and we must make the best of it, but the studentsof Lyons should be grateful for the glimpse giventhem of the great antiquity of the science they study.Prof. Latarjet distinguished three great periods inanatomy : his first period extending from remotetimes to the downfall of the Western Roman Empire ; -,his second, including Harvey, from the thirteenth tothe seventeenth centuries, a period marked byincreasing perfection in knowledge of detail, technique,and application of experimentation ; the third, theage of evolution, of scientific grouping and blendingof biological sciences, of study of human races withthe wider application of anatomy to clinical andpathological conditions. The large part played byFrance in the two later periods was naturally andjustly insisted upon. England, which scarcelyentered the world of medicine before the thirteenthcantury, may herself claim a preponderating share inthe same periods, although we fear that many ofthe names of the men who wrought so well are

unknown to present-day students. Harvey-" YourAnatomist," as he styles himself in addressing hisCollege-occupies a position which is unique. Judginghis work by its results, it has had more influence onmedicine, in the large sense, than any other : it swungthe ship round on a different course. Had Galen,writing on the heart valves described by Erasistratus,but seen the truth by intuition, it is impossible toimagine what the science of medicine might havebeen like to-day. Harvey, howev er, was not the firstanatomist to use experimental methods, althoughProf. Latarjet appears to suggest this when heassigns such " new methods " to the time of Harvey,Aselli, and Pecquet. Galen would still rank to-dayamong leading exponents of experimental physiologyby his boldness, clearness, and judgment, but hispreconceptions closed his eyes to much that - wasbefore him ; like us he only saw that which he wasprepared to see. It was owing to Galen’s experi-mental work on dogs and swine that his anatomicalviews of the human subject were mingled with those

1 Paris Médical, Nov. 26th, 1921.

properly belonging to the structure of such animals,but we doubt whether Prof. Latarjet is justified indenying that Galen or others of his age practisedhuman dissection. Le Clere holds the reasonableopinion that Galen certainly, if only occasionally,dissected the human body. The remark of Senecaabout physicians opening bodies to ascertain causeof death, and the record of Hesychius that " Hermo-genes, the rhetorician, having died was dissected,"are in proof of human dissection in ancient times.Nor is there any special reason for thinking that theopportunities open to Herophilus in the earlyPtolemaic time became obnoxious to the laterPtolemaic spirit. When this line came to an end,however, and Egypt became a Roman province, nodoubt popular feeling as well as Roman law went,against the practice. Hence the difficulties which Galenhad to surmount, as is apparent from his writings.In Arabian medicine there was no practice of dissec-tion. It was occasionally undertaken at Byzantium,where the Eastern Empire still lingered gorgeously,but the religious forces were strongly against itsrecognition, and it was probably only performed insecret. During the pre-Renaissance period swine werein extensive use for anatomical teaching, and even aslate as the sixteenth century we know that Berengarius.gave his first anatomical demonstration on the bodyof a hog in the house of Albertus Pius. Religiousobstruction was potent before the days of the moreliberally-minded Popes ; yet it is hard to believethat the wider views of the Benedictines, for example,which led them to foster the growth of the school ofSalernum, did not at the same time show them thenecessity of studying the structure of man-thesubject of the science of medicine, as old Mondinushas it. The same Mondinus, writing in the fourteenthcentury, gives the first manual for human dissection,referring on occasion to the pig by way of contrast.There are hidden rooms in some of the old universitiessaid to have been used for human dissection, andrecent research suggests that certain malefactors werehanded over alive for this purpose during the fifteenthcentury. It may, in fact, be said that humandissection was practised from the thirteenth century,when the law of Frederick II., regulating the trainingof medical men (1213), insisted on a course of humananatomy and provided for the same. Ever sincedissection has been a recognised road to knowledge.

PRIMARY TUBERCULOUS PERICARDITIS.

ALTHOUGH some authorities have categoricallydenied the occurrence of a primary isolated tubercu-lous pericarditis, apart from glandular or other lesions,from time to time cases are reported in which aclinically primary pericarditis has been establishedpost mortem, being found to be associated with noother discoverable trace of tuberculosis elsewhere.In a paper recently published, Dr. Carl A. I3edblom, iafter briefly abstracting eight such cases reported inthe literature since 1897, gives details of a case per-sonally observed at the Mayo Clinic. In this patient,a man of 36, the clinical diagnosis was based on thechronicity, the recurrence of effusion after repeatedaspiration, the history of recent exposure to tubercu-lous infection, and the absence of any other recognis-able disease. Pericardiotomy was performed underlocal anaesthesia, partly in the hope that an openoperation might prove curative on the analogy of asimple laparotomy in tuberculous peritonitis, and2000 c.cm. of sero-purulent fluid were evacuated.Although guinea-pig inoculation of the exudate gavea negative result, a section of the pericardium,examined microscopically, showed unmistakabletuberculosis. Immediate relief was obtained fromthe operation, but there was a recurrence of theeffusion, and six weeks later pericardiotomy was againperformed, and a similar quantity of fluid evacuated.Convalescence from this second operation was com-plicated by thrombo-phlebitis of the right jugular

1 The Surgical Clinics of North America, October, 1921.