An Address ON SLEEP AND SLEEPLESSNESS: Delivered to the Dorset and West Hants Branch of the British Medical Association

W. J. Smyth
1923 BMJ (Clinical Research Edition)  
MEDICAL JOURNAL healing of tlle ulcer even in such conditions is a most tedious and protracted process. The operation that I regard with the utmost confidence as thoroughly satisfactory for tlle great majority of cases is gastrectomy. There are very few cases in which it cannot be performed. It is safe to a degree that one could lhardly expect. In the ten years tlle mortality lhas been 1.6 per cent., a shade lower tllan the lowest publisshed death rate from Balfour's operation. The results in
more » ... lhands have been excellent. I have had the following unsatisfactory experience in connexion with it: One patient has died of cancer of the stomacll over five years after the gastrectomv lhad been performed; a second patient developed cancer of the remaining part of the stomach two years later. These two are examples of mistaken diagnosis, both clinical and pathological. One patient had to submit to a secondary operation on account of obstructive vomiting; a long loop had been left between the duodeno-jejunal flexure and the anastomosis of the bowel with the stomacl. This patient subsequently made a perfect recovery. One patient from wlhom I removed a group of tuberculous mesenteric glands at the time the gastrectomy was being performed has had a second operation and another group of glands has been removed; this operation was done three months ago and the patient has since gained 15 lb. in weight. That is all that I can find to bring against the method of gastrectomy. No other operation gives such admirable and uniform results. I have greatly simplified its performance by introducing the " anterior no-loop " method. The jejunum is brought from the flexure across the transverse colon from left to right and applied to the divided stomach so that the proximal part of the jejunum joins with the greater curvatuTe. This method has been followed in every case since June, 1920; there lhas been no deatlh, and not the slightest untoward symptom at any time after operation, early or late. There has never been a recurrence of ulceration (apart from the two cases of carcinoma mentioned above); there has been no return of dyspepsia; there has been no sign of persistent or profound anaemia in any case in this series. I feel, therefore, that I can justly excuse myself for not performing gastrectomy only when the condition of the patient prohibits any major operation, or when the location of the ulcer, or any other of its attributes, renders the operation quite impracticable or disproportionate to the needs of the individual case. And so far as the condition of the patient is concerned I feel fairly confident that by the most watohful care, by the performance of direct transfusion of blood once or oftener, and by the copious administration of glucose, with and without sodium carbonate, so great an improvement may by degrees be brought about thlat anv operation that is required may safely be performed. After all is said and done, that operation for the treatment of chronic gastric ulcer will alone survive which with the smallest risk brings about a complete subsidence of all symptoms, a permanent freedom from any recurrence of the like disease, and immunity from any disorder associated with the operation in consequence of its mechanical or physiological effects. The operation which seems destined to fulfil all these indications is gastrectomy. How is it tllat the surgical mortality is so low? The patients who come for operation are often very ill; they have suffered for years; obstruction with grave inanition may have resulted; and haemorrlhage on one or many occasions may have sapped their strength almost to exhaustion. It is a question of taking pains. I once heard a very distinguished surgeon say that no one could continue to operate upon even simple cases such as inguinal hernia without mortality; one or two miglht die in every hundred. If this view is taken, the practice of the surgeon will justify and sustain it. But if you deal with cases as units, and say, " The last case may yet die, and the next case be a desperate one wbiclh no man can save, but t1is case must not die whatever happens," you will find your practice will go far to vindicate your determined optimism and your confidence. The units saved swell into multitudes. Surgery, after all, is an affair of the spirit; it is a fierce test of a man's technical skill sometimes, but in a grim or long figlht it is above all a trial of the spirit; and there are few thiings that cannot be conquered if a man's heart is set on victory. The lecture was illustrated by a number of lantern slides, many of which were kindly lent to me by Professor hI. J. Stewart, to whom I am greatly indebted not onuly for this kindness hut also for the preparation of the statistics I quote from the records of the post-m7ortenm department of the Leeds General Infirmary. SINCE coming to Bournemnouth twenty-five years ago my professional work has chiefly been concerned witlh patients in the middle and later periods of life. Of these I believe the majority have presented certain decided defects in their nervous system-organic or functional. Of their troubles by far the most frequent has been the symptom of insomnia, and I hope you will bear witlh me when I place before you certain well known physiological facts. SLEEP. Sleep is a mysterious phase of all living things, animal and vegetable. Its causation in man remains an unsolved problem, and therein lies the fascination of the pursuit of-a study so important, for in a true comprehension of its causation must ultimately lie a scientific understanding of insomnia and its treatment. The question of sleep has interested men of all ages. Scripture teems with reference to sleep. Poets have sung its praises, sculptors and painters have found it a fitting setting for beauty; the classical writers-Sophocles, Horace, an:d Ovid-all but worslhipped it; nor did Aristotle nor our own Slhakespeare pass it by in silence. Under normal circumstances we spend roughly one-thiird of our life in sleep. It is a normal condition of the lhuman body occurring periodically, in which there is a greater or less degree of unconsciousness due to inactivity of the nervous systenm, and more particularly of the brain and spinal cord. It may be regarded as the condition of rest of the nervous system, during wlichl there is a renewal of the energy that. has been spent in the hours of wakefulness, for in the nervous system the law holds good that periods of physiological rest must alternate with periods of physiological activity, and, as the nervous system is tlle dominating mechanism in the body, when it reposes all the other systems participate in a general condition of rest. In all vital phenomena rest alternates with activity. The heart muscle as well as the secreting gland lhas eaclh its period of repose. Nervous action involves physico-chemical clhanges of matter and the loss of energy. This is true even of the activity of the brain in connexion with volition, perception, emotion, sensation, and so on, so that the higher nervous centres require rest during which they are protected from tlle stream of impressions flowing in from the sense organs; tllis permits of the elimination of waste products and the recuperation of cerebral structure so as to fit it for furtlher mental activities. Tinte of Sleep. Most people sleep during the. niglht. The silence of the niglht and other circumstances co-operate to bring this about. But the advent of sleep does not necessarily depend on terrestrial phenomena-but rather on bodily conditions. Some animals sleep during the day and prowl about at niglht; some persons have to perform night duty and sleep in the lay; bodily fatigue is the main factor in determining the time of sleep. Just as the sensation of hunaer is referred to the stomacl, thirst to the tlhroat, and breathing to the chest, so sleepiness is referred to the region of the head and neck. A sensation af weight occurs in the eyelids, spasm of the hyoid muscles -auses yawning, and the head droops. A gradual obscuration of the intelligence, depression of general sensibility and 3pecial senses, with general muscular weakness, follow-and Nature's soft nurse steeps our senses in forgetfulness." Sleep having supervened, there are gradations in its completeness. It may be so light that the individual is partly -onscious of external impressions and disordered trains of thouglht. This is the dream state. On the other hand, sleep may be so profound that all psychical phenomena are lbolished. The first couple of hlours are thlose of most jerfect sleep. As the state of awakening approaches, sensi-Aility becomes more acute, and external impressions are
doi:10.1136/bmj.1.3241.226 fatcat:pn3avk4opzdlzdu6snkb3cwg4u