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most liberal allowances for all energy outputs. Thenitrogen metabol sm was normal and protein foodexerted its ord nary specific dynamic action. Theincrease in metabol sm may reach 100 per cent. abovethe normal ; 15 per cent. to 25 per cent. above normalmay be considered mld and above 50 per cent. severe.He considers that the basal metabolic rate will notgive a true idea of how ill the patient is, as the nervousphenomena and the degree of thyroid st mulation byno means run parallel. On the other hand, the basalmetabolic rate may give the differential diagnosisbetween hyper- and hypo-thyroidism. H. S. Plummerand W. M. Boothby have shown that administrationof iodine removes all the clinical symptoms of exoph-thalmic goitre, though the metabolic rate remains high.The theory formulated to account for these facts isas follows : Some chem’ cal appears in the body that iscapable of over-st mulating the thyroid ; the resultingexcess of thyrox n leads to increased metabolism whichmay reach a high figure without causing the patientany symptoms of d stress. These cases Plummer calls" compensated hypertrophies." In the next stagecompensation fa Is because the available iodine isinsufficient and the thyroxin produced is thereforeimperfect and causes nervous symptoms. The adminis-trat’on of iodine to such cases restores them to thecompensated group and the symptoms disappear.Adenomata of the thyroid affect the product"on ofthyroxin in d Nerent ways. The tumour may itselfproduce the hormone or may stimulate the gland toincreased product on. In other cases the adenomaseems to depress the thyroid activity, while in about35 per cent. it has no effect. The basal metabolicrate may help the surgeon to determ’ne whether, andhow extensively, he shall remove the growth. Removalusually brings the metabolic rate back to normal ifthere has been aberrat’on due to its presence. Tooliberal removal of gland substance with the tumourcauses hypothyroidism. Regular estimation of thebasal metabol c rate after operat on would oftenenable the doctor to give thyroid medicat’on beforeserious symptoms of hypothyroidism appeared. Thediagnosis of hypothyroidism may be almost mpossiblefrom symptoms alone, and many cases of ndeterminate" unfitness " would be cleared up by a basal metabolicrate investigat on, which would also be a valuableguide to dosage. It is also an unbiased proof of thevalue of treatment. Valuable statistics could beobtained if all the patients in a hospital were to haveroutine est’mat ons of metabolism and the variouslines of treatment were compared. The interaction ofthyroi d and p tu tary make basal metabolic rateestimations of value in hypophyseal condit ons. Inacromegaly the rate may be increased or decreased,and when it has become subnormal organotherapy maybe very useful. In long-standing cases of Frohlich’ssyndrome the rate may be much lowered. Cliniciansknow that large quantities of pituitary are toleratedif they can be comb’ned with thyroid, and the thyroiditself stimulates p’tu’tary function, but a watch mustbe kept on the metabolism if the thyroid is to be givenwithout danger of harm.

RESPIRATORY PHYSIOLOGY ON EVEREST.

A CONTRIBUTION by Mr. Howard Somervell to theSeptember number of the Journal of Physiologydescribes the results of alveolar air analysis during the1924 attempt to climb Mount Everest. Alveolar airwas collected in football bladders from severalmembers of the party at three different heights abovesea level, and the samples were taken down to thebase camps and analysed. The altitudes were

14,300 ft.. 16,500 ft., and 23,000 ft., and the most re-markable feature of the results was the low respiratoryquotient at 23,000 ft., which was due to the smallvalue of CO in the alveolar air. At a great heightbreathing is so rapid (almost 50 respirations to theminute) that the C02 is washed quickly out of thealveoli. It appears that at 23,000 ft. the (COg—0,)

1 Iowa State Medical Society Journal, 1924.

percentage is smaller by some 3 per cent. than at14,000 ft. During actual motion upwards the pulse-rate was 160-180 per minute, and sometimes evenmore. The pulse was regular in rhythm and of goodvolume, but all who went above 27,000 ft. were foundto have dilated hearts which took from one to three-weeks to recover. During climbing the respiration-rate-was about 50-55 per minute, and when a height ofnearly 28,000 ft. was reached 7-10 complete breathswere needed for every single step forward and upward.Breathing quickly and deeply at a great height is veryeasy owing to the low density of the air. In 1924 non&of the party was affected mentally by the altitude,.as in 1922 ; minds were clear and tempers and resolu-tion fairly good even at 28,000 ft. ; but the simplesttasks-cooking a meal, fetching snow for melting, ortaking a photograph-were found very irksome. Atthe highest camp (26,700 ft.) appetite was profoundlyaffected, and it was with difficulty that meat was eatenat all. Chocolate and biscuit were managed as a duty,and only pemmican soup and coffee were taken withany real relish, for in th high dry air liquids were thefirst need. The three weeks acclimatisation and theextra height seem not to have altered the colour indexof the blood and the blood pressure appeared to beunaffected.

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LEFT-HANDEDNESS AND LEFT-EYEDNESS.

IN his " new interpretation " of left-handednessMr. Parson sets out on an adventure which has.attracted so many investigators previously that hisbook of 180 pages 1 contains 40 pages of bibliography,which is still incomplete. Briefly stated, his theoryis that " eyedness " precedes " handedness." The" master eye " of the popular imagination determineswhich shall be the dominant hand, and as mostpeople are, for some still unknown reason, right-eyed, right-handedness follows, since on account ofour physical configuration we can thus aim morenaturally and effectively by bringing the object, the-hand, and the macula of that eye into line. Theargument is attractive, and by means of a simpleapparatus called a manuscope the author was ableto support it in examining 608 right-eyed children,only 4 of whom proved to be left-handed. Thenon-agreement with the formula in one of theseexceptions he attributes to a defective right eye.It was found, however, in another case, that it wasthe left eye that was weak. Still, the relationshipat the time of examination seems to be established.It was when of 257 left-eyed children only 32 " con-fessed " to being left-handed, that the investigationbecame more complicated. This leaves 225 left-eyeddextrals to be accounted for. " Having found,’"Mr. Parson writes, " that of the hundreds of childrenexamined, virtually all the right-eyed are at Lhe sametime right-handed, we are justified in believing thatthe natively left-eyed, irrespective of their presentmanual preference, were originally left-handed." Butare we really justified ? As there were 257 left-eyedchildren in a total of 877 examined, it follows that,barring accidents, 29-3 per cent. of the whole must benatively left-handed. Bardeleben, in 1914, attackingthe problem, apparently on Mendelian principles,had come to the conclusion that the number of left-handers who changed to right-handedness was

26 per cent. of all children. This number corresponds.closely with the 225 left-eyed dextrals, who were25-7 per cent. of the total number of children examined,and so far Mr. Parson’s argument finds strikingsupport. But can we be sure that no converted left-handers should be numbered among the right-eyeddextrals ? The author’s attitude towards his four-right-eyed sinistrals (who, he says, claim to be left-handed) scarcely suggests that converted left-handersamongst the right-eyed would be welcomed, if found,by the investigator. Lacking information on this,however, we can go no further. To return to the257 left-eyed subjects, we find that Mr. Parson states

1 Left-handedness: A New Interpretation. By Beaufort SimsParson. New York : The Macmillan Company.

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that only 32 "confessed" " to being left-handed.A moderate proportion of the others certainly.admitted one or two left-handed activities, butnothing is said as to left-handed tendencies ina majority of the cases. According to Mr. Parson theodd activities referred to " give a hint as to what-more detailed investigation of each case might havedeveloped, had time and circumstances permitted."But the validity of his theory depends entirely uponthe result of such a detailed investigation. It issuggested that training in infancy and early childhoodhas altered the habit of using the preferred left hand.There is no doubt that such an influence is almostinvariably exercised, but, as we have pointed out, it ispossible that of the 608 right-eyed dextral childrenmany would have used the left hand apart from thesame parental influence. Is it even certain that.a single left-handed activity is an unfailing sign ofa thwarted complete sinistrality ? The author goeson to say, ’* the original bias may in some cases beso slight that in infancy a change might take placewithout the conscious exertion of any special correc-tive effort on the part of parents." Here two separateproblems are involved : The cause for the originalbias, and the origin of the elders’ disapproval ofa bias to the left side. The former may or may nothave a physical basis, but the latter undoubtedlyintroduces a psychological factor. Why is the childof tender age coerced or coaxed, consciously or uncon-sciously, into the preferential use of the right hand ?What enables it to cling tenaciously to one or moreleft-handed activities, when for all else it becomesright-handed ? Is " eyedness " in any way responsiblefor the survival of any particular form of activity ?It is obviously useless to ask the individual why hedeveloped the habit of using the left hand in the firstinstance. He started too early for him to rememberanything about it. The technique of psycho-analysis,however, may throw some light on the question.Mr. Parson’s book certainly carries the problem ofleft-handedness to a higher plane of inquiry than domany of the previous works on the subject.

ADOLPHE SMITH.

THE death of Mr. Adolphe Smith at Fulham onNov. 9th removes the picturesque figure of an

octogenarian who had met life at many points. Ofbilingual parentage, Mr. Smith was equally at homeon either side of the Channel. He wrote an admirableguide to Hyeres as a health resort, he was intimatewith the small but influential community at Monaco,he was publicly thanked by the French Government forpersonal bravery in the streets of Paris at the time ofthe Commune. His deep interest in the internationallabour movement took him to every continental centrewhere standards of work were under discussion, andfew can have known more of the actual conditions oflife of the people of many countries. It was thisbackground of knowledge and sympathetic outlookwhich gave special value to Mr. Smith’s work asSpecial Commissioner of THE LANCET for 40 years.These commissions were set in motion to inquireinto various defects associated with social machinery,understood in its broadest sense, at a time when noofficial body existed for the purpose. Mr. Smith’sreports included one on the spread of disease by meansof laundrying, in which he found that table napkinsfrom St. James’s-street Club were being dried in aPeckham garret over the bed of a small-pox patient,and another on the contamination of uniforms at theArmy Clothing Depot. This report led to immediatereform. He reported on cholera centres in Europeat the danger-point of 1892-94, preparing maps andstatistics which helped the progress of epidemiology ;for at that time, while the State could legally spendmoney on investigating the few cases of choleraoccurring in this country, there was no official provisionfor making inquiry on the continent. He reportedon the sanitation of a number of continental andAmerican cities, and his revealing survey of theChicago stockyards was used by Mr. Upton Sinclair

in his famous book, "The Jungle." Mr. Smith’sinvestigation into the way of life of East-end tailorshaving resulted in the setting up of a special commissionof inquiry by the House of Lords, he visited 150sweating dens in the provinces, of which the finaloutcome was five large blue-books and the initiation ofmany changes for the better. Articles on the freefeeding of school children which he wrote for us wereused as evidence in the House of Commons debateswhich ended in a measure for provision of meals.

In all these ways Adolphe Smith’s work was oflasting value to the community, but outstanding formedicine were his reports on the conditions ofcontract practice 30 years ago. A general movementagainst the medical man being dragged into contractpractice as if it was a profit-making business came toa head at Cork, where the local profession formed abenefit club to be managed entirely by themselves.Mr. Smith went to Cork and set out in a brief letter toTHE LANCET the stages of the dispute between medicalmen and the clubs, the importation of outside medicalhelp, the way in which first the hospitals and then thedruggists were drawn into the battle against thedemand that bankers, large tradesmen, and well-salaried clerks should be admitted to the medicalclubs upon the same terms as poorer clerks, artisans,and labourers, with a miserable yearly fee to coverattendance upon every member of the subscriber’sfamily. From Cork Mr. Smith went on to Portsmouth,where he examined the dockyard benefit societieswhich admitted infants and juveniles as well as adultsat the uniform rate of 2d. per head per week ;from there, to the medical aid companies at East-bourne, and so on, over the rural and mining areas,with a divergence to Brussels and a final visit toFrance, where he discovered no harm being done tothe dignity and interests of the medical profession bysick insurance companies. In one of these letters hesummed up the position of the club medical officeras the wage-slave of a commercial concern, no longerthe guardian of public health, but the promoter of aprivate business. These articles were issued later asa pamphlet entitled " The Battle of the Clubs," whichwas widely quoted when the proposals for a NationalHealth Insurance Act first came before Parliament.It is remarkable now to recall with what approval Mr.Smith carried out his difficult task. In person heretained throughout life a certain disarming simplicityof demeanour, and his writing gave the impression ofone who observed with candour and who set out hisobservations without prejudice. Among the host ofnameless contributors to our columns none can havehad wider influence on broad social conditions thanAdolphe Smith.

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THE PAINTER AND HIS OCCUPATIONALRISKS.

ATTENTION has often been directed to the occupa-tion of painting mainly on account of risk of leadpoisoning. In this and in other countries committeesof inquiry have deliberated and reported. Then camethe adoption at Geneva of a recommendation thatlead paints should be prohibited internationally foruse inside houses. Action to give force to this recom-mendation has not yet been followed in the differentcountries concerned. The contention has beenadvanced that some, at any rate, of the symptomsamong painters attributed to lead are, in fact, dueto inhaling the fumes of turpentine and other volatilesolvents used in paints. There are grounds foraccepting that these fumes do cause trouble, butthe risk from lead poisoning is hardly thereby mini-mised. Now further trouble is ascribed to these samesolvents by Dr. J. A. Turner, Ohio, U.S.A., whoseinterest was aroused by the occurrence of skin affec-tions among painters under his care. The troubleconsisted in an irritating vesicular eczema on theback of the hands and forearms, which, however,quickly reacted to treatment. He proceeded to

1 Acute Dermatitis Among Painters, by J. A. Turner, Journal ofIndustrial Hygiene, 1925, vol. vii., pp. 293-298.