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THE CAUSATION OF THIRST.
842 careful inquiry into the family histories did not reveal any hereditary tendencies, heredity has played an important part in a number of the recorded cases, as in the family reported by Dubreuil-Chambardel, in which the grandmother, mother, and two daughters all had exophthalmic goitre ; and in that described by Souques and Lermoyez, in which there were seven cases. In several instances, as in those reported by Gaucher and Salin, Hazen and Rost, syphilis was thought to be the underlying factor, but in none of Dr. Heiman’s cases was there any history or evidence of that disease. Of the three cardinal symptoms of exophthalmic goitre-tachycardia, exophthalmos, and enlargement of the thyroid gland-Barret states that tachycardia is the first to develop in children. The exophthalmos is usually less marked in children than in adults, though it is rarely missing. In Barret’s series it was absent in only eight cases. The basal metabolism test, which is the most important diagnostic guide, was performed in Dr. Heiman’s cases, and showed that the degree of severity of the symptoms and signs corresponded with the degree of elevation of the metabolism rate, the results before treatment being in the first case 12 per cent., in the second case 20 per cent., and in the third case 52 per cent. Dr. Heiman maintains that the most rational treatment of exophthalmic goitre is, first, a regimen of strict physical and psychical rest for a period of 6-10 If the patient then shows no improvement weeks. a short stage of X ray treatment should be employed. If there is then no response, thyroidectomy should be performed. Considerable improvement took place in one of Dr. Heiman’s cases in which partial thyroidectomy was carried out. In the other two cases, in which rest was the only treatment, the improvement was less striking.
THE CAUSATION OF THIRST. THE sensation of thirst, so familiar yet vague and elusive, has often aroused the curiosity of the investigator, and at least two theories arecurrent to explain its origin. Thirst might be due primarily to loss of water from the tissues in general, the actual sensation being a secondary local reference to the pharynx ; or it might be a consequence simply of loss of water from the mucosa of the mouth and pharynx, and independent of the general state of the tissues. Some well-known facts point to the one theory and some to the other. Thus, the rapidity with which thirst is quenched by drinking water or by such devices as the sucking of a lemon, or the antidipsic button used by soldiers in arid climates, both of which promote a flow of saliva, point to the local desiccation theory ; so does the thirst familiar to the nervous orator, or that engendered by atropin. An experimental investigation by G. T. Pack,l of Yale, gives further support to this view. He sought to learn whether pilocarpine, by promoting a flow of saliva, exerted an antidipsic effect, and found that it did. Rabbits deprived of water for a sufficient period were offered water for a certain length of time and the amount consumed was noted. Similar rabbits treated with pilocarpine took much less water even in double the time ; yet the general desiccation of the tissues would probably, if anything, have been greater after pilocarpine than before, on account of the flow of digestive
juices.
While all these facts seems to be arrayed in favour of the local desiccation theory of the origin of thirst, there is a not inconsiderable body of evidence in favour of the general tissue-desiccation theory. For instance, thirst can be allayed or prevented by intravenous or rectal injections, or by the administration of water by a stomach tube. Again, the thirst of diabetes or of chronic polyuria is not assuaged by pilocarpine. Mere wetness or dryness of the mucosa of thelmoiith and pharynx is therefore not the only factor. Pack’s rabbits, although they took less water 1
Amer. Jour. Physiol., 1923, lxv., 346.
z,
in a given time with than without pilocarpine, nevertheless frequently took some water; thirst was reduced but not abolished. A compromise between the two views would be not unreasonable. Local drying apparently always produces thirst; local drying would obviously be greatly accelerated and would reach the sensation-point sooner if there was a generalised desiccation ; sensations arise first from the pharynx because, though normally moist, its opportunities for drying are greater than in other mucous membranes, owing to its forming part of the respiratory tract, and possibly also being endowed with end-organs sensitive to drying.
special i
THE LISTER WARD IN THE ROYAL INFIRMARY OF GLASGOW. CONSIDERABLE feeling has been aroused both in and beyond Glasgow by the recent decision of the managers of the Royal Infirmary to demolish the Lister Ward, the workshop in which that great surgeon evolved his antiseptic treatment of wounds. The ward forms part of the old Lister block, which was left intact in the precincts of the present Infirmary when the plans were published in 1907, and it stands The entire some 60 feet from the new building. block has been condemned, but public sentiment finds expression in a petition, already signed by large numbers among the medical profession and the laity alike, that at least the first storey-the Lister Ward-should be retained as a memorial of one to whose fame Glasgow is proud to have contributed. The reason for the managers’ decision appears to be three-fold : that the ward is not suited to modern requirements of surgery, that the space occupied is essential for light and air, and that to retain the ward would affect the symmetry of the Infirmary forecourt. To these utilitarian, hygienic, and aesthetic grounds for total demolition is added the cost of reconstructing the ward when the upper storeys are removed. All four arguments are ably disposed of by Mr. James A. Morris, F.R.I.B.A., in his pamphlet entitled, "A Humble Plea for the Retention of the1 Famous Lister Ward in the Royal Infirmary, Glasgow." On the purely technical side of these questions expert advice must prevail, but the main issue at stake in the public mind is one which has again and again been a matter of controversy in recent years, and which amounts to this : is it justifiable in present-day circumstances to sacrifice a part (however small) of a modern conception to sentiment, and to honour a great pioneer of progress by an act of conservatism ? If the continued use of the ward should in any way impair any patient’s chances of recovery, then to protest against its demolition would be folly ; but it was those who had the most direct interest in the well-being of their patients-the medical staff of the Tnfirmary-who were the first to sign a petition pleading for the retention of the ward. Surely, then, even at a small financial outlay, and, it may be, at the expense of the hypersensitive aesthetic taste of a few, it is justifiable-nay more, it is a civic duty, to preserve this historic battlefield in the age-long fight against disease, as an inspiration for those who follow after. THE LONDON SCHOOL OF DERMATOLOGY. FOR a long time it has been realised that dermatology in London has suffered from want of concentration and combined effort. Each of the large London hospitals has its dermatological department, for which, as a rule, one physician alone is responsible. St. John’s Hospital for Diseases of the Skin provides a centre where there is ample material, and where there are also considerable facilities for concerted teaching, but up till now these various interests have been working independently. During the last few months negotiations have been proceeding between the medical staff of St. John’s Hospital and other 1 Glasgow: Maclehose, Jackson and Co.
6d.
THE CAUSATION OF THIRST. THE sensation of thirst, so familiar yet vague and elusive, has often aroused the curiosity of the investigator, and at least two theories arecurrent to explain its origin. Thirst might be due primarily to loss of water from the tissues in general, the actual sensation being a secondary local reference to the pharynx ; or it might be a consequence simply of loss of water from the mucosa of the mouth and pharynx, and independent of the general state of the tissues. Some well-known facts point to the one theory and some to the other. Thus, the rapidity with which thirst is quenched by drinking water or by such devices as the sucking of a lemon, or the antidipsic button used by soldiers in arid climates, both of which promote a flow of saliva, point to the local desiccation theory ; so does the thirst familiar to the nervous orator, or that engendered by atropin. An experimental investigation by G. T. Pack,l of Yale, gives further support to this view. He sought to learn whether pilocarpine, by promoting a flow of saliva, exerted an antidipsic effect, and found that it did. Rabbits deprived of water for a sufficient period were offered water for a certain length of time and the amount consumed was noted. Similar rabbits treated with pilocarpine took much less water even in double the time ; yet the general desiccation of the tissues would probably, if anything, have been greater after pilocarpine than before, on account of the flow of digestive
juices.
While all these facts seems to be arrayed in favour of the local desiccation theory of the origin of thirst, there is a not inconsiderable body of evidence in favour of the general tissue-desiccation theory. For instance, thirst can be allayed or prevented by intravenous or rectal injections, or by the administration of water by a stomach tube. Again, the thirst of diabetes or of chronic polyuria is not assuaged by pilocarpine. Mere wetness or dryness of the mucosa of thelmoiith and pharynx is therefore not the only factor. Pack’s rabbits, although they took less water 1
Amer. Jour. Physiol., 1923, lxv., 346.
z,
in a given time with than without pilocarpine, nevertheless frequently took some water; thirst was reduced but not abolished. A compromise between the two views would be not unreasonable. Local drying apparently always produces thirst; local drying would obviously be greatly accelerated and would reach the sensation-point sooner if there was a generalised desiccation ; sensations arise first from the pharynx because, though normally moist, its opportunities for drying are greater than in other mucous membranes, owing to its forming part of the respiratory tract, and possibly also being endowed with end-organs sensitive to drying.
special i
THE LISTER WARD IN THE ROYAL INFIRMARY OF GLASGOW. CONSIDERABLE feeling has been aroused both in and beyond Glasgow by the recent decision of the managers of the Royal Infirmary to demolish the Lister Ward, the workshop in which that great surgeon evolved his antiseptic treatment of wounds. The ward forms part of the old Lister block, which was left intact in the precincts of the present Infirmary when the plans were published in 1907, and it stands The entire some 60 feet from the new building. block has been condemned, but public sentiment finds expression in a petition, already signed by large numbers among the medical profession and the laity alike, that at least the first storey-the Lister Ward-should be retained as a memorial of one to whose fame Glasgow is proud to have contributed. The reason for the managers’ decision appears to be three-fold : that the ward is not suited to modern requirements of surgery, that the space occupied is essential for light and air, and that to retain the ward would affect the symmetry of the Infirmary forecourt. To these utilitarian, hygienic, and aesthetic grounds for total demolition is added the cost of reconstructing the ward when the upper storeys are removed. All four arguments are ably disposed of by Mr. James A. Morris, F.R.I.B.A., in his pamphlet entitled, "A Humble Plea for the Retention of the1 Famous Lister Ward in the Royal Infirmary, Glasgow." On the purely technical side of these questions expert advice must prevail, but the main issue at stake in the public mind is one which has again and again been a matter of controversy in recent years, and which amounts to this : is it justifiable in present-day circumstances to sacrifice a part (however small) of a modern conception to sentiment, and to honour a great pioneer of progress by an act of conservatism ? If the continued use of the ward should in any way impair any patient’s chances of recovery, then to protest against its demolition would be folly ; but it was those who had the most direct interest in the well-being of their patients-the medical staff of the Tnfirmary-who were the first to sign a petition pleading for the retention of the ward. Surely, then, even at a small financial outlay, and, it may be, at the expense of the hypersensitive aesthetic taste of a few, it is justifiable-nay more, it is a civic duty, to preserve this historic battlefield in the age-long fight against disease, as an inspiration for those who follow after. THE LONDON SCHOOL OF DERMATOLOGY. FOR a long time it has been realised that dermatology in London has suffered from want of concentration and combined effort. Each of the large London hospitals has its dermatological department, for which, as a rule, one physician alone is responsible. St. John’s Hospital for Diseases of the Skin provides a centre where there is ample material, and where there are also considerable facilities for concerted teaching, but up till now these various interests have been working independently. During the last few months negotiations have been proceeding between the medical staff of St. John’s Hospital and other 1 Glasgow: Maclehose, Jackson and Co.
6d.