343SLEEP.-ARTIFICIAL CESOPHAGUS.

treatment. The second case followed such an unusualcourse that it is difficult to attribute the result , o

anything except the treatment employed. The

symptoms came on after an operation for appendicitis,and on the fourth day the patient had stercoral

vomiting and hiccup. There was no result from anenema. Administration of bile relieved the symptomsand kept them in abeyance until the tenth day.On that day he had no vomiting, and only slightabdominal distension ; his pulse-rate was 70;he felt well, read the paper and smoked; yet a

laparotomy showed " an absolute obstruction by anomental band about six inches from the ileo-csecalvalve." In the third case, again, the condition mayquite well have been acute dilatation of the stomachor obstruction due to adhesions, which as every surgeonknows, often recover spontaneously with the subsidenceof the pathological process in the right iliac fossa.Very remarkable, however, is one of the failures.A woman of 65 was operated upon for strangulatedhernia, but the surgeon did not relieve the obstructionas he did not detect a strangulated loop " in the otherhalf of the bilocular hernial sac." With completemechanical ileus this patient was for 16 days keptalive and remarkably fit by means of bile injections.

Undoubtedly the procedure merits further inquiryand trial, but it is to be hoped that investigators willbe alive to the fact that (as Mr. BROCKMAN shows) sym-ptoms of true mechanical obstruction may be maskedto such an extent that operative relief is delayeduntil it is incapable of saving the patient’s life.

Annotations.

SLEEP.

" Ne quid nimis."

ONE of the sessions of a recent neurological congressat Paris was devoted to the subject of sleep in itsnormal and pathological aspects.l Since the funda-mental work of Pieron in 1912, knowledge of sleephas advanced mainly in two ways : Pavlov’s experi-mental researches have led to the conception of aninhibitory mechanism, and clinical observations,especially on cases of lethargic encephalitis, havebrought new evidence in favour of the existence of aregulating centre. The openers of the discussion-Dr. A. Tournay and Prof. J. Lhermitte-had evidentlybeen much influenced by these newer contributionsto the subject. Dr. Tournay, in dealing with thephysiological side, first referred to the state of themuscular and sensory systems and of the vegetativefunctions during sleep, and then discussed thecharacteristics and variations of sleep, its immediatecauses, and the nervous mechanism by which it isinduced. The somatic musculature, he said, seemsto be more or less relaxed, but its relaxation is notuniform or constant. In children sleeping with theirfists closed a degree of contraction of the flexors ofthe fingers has been observed. It must be notedalso that the masticatory muscles are in a state oftonus and that the sphincters preserve their function ;contraction of the orbicularis oculi helps to keep theeyes closed ; the eyeballs are turned upwards andoutwards by muscular contraction and the activityof the circular fibres of the pupil causes myosis.Tendon reflexes are in general diminished. Babinski’ssign and the defence reflexes are present. Sensationis in general diminished, the threshold of excitabilitybeing greatly increased ; hearing is the sense leastaffected. Breathing is slower and deeper, inspirationbeing -longer and deeper, and expiration relativelyquicker than in the waking state, and ventilation isdecreased. The heart’s action is slower by reason

1 Presse Médicale, July 13th.

of a longer diastole and the blood pressure is slightlyreduced.The outward appearances of sleep do not warrant

more than a presumption that the patient is sleeping.How can it be told that a man is really asleep ?Pieron defined the sleeping state as " the absenceof spontaneous dynamic activity and of voluntaryreactions adapted both to the nature of the excitantsand also to the diverse circumstances of place andtime." To this Dr. Tournay adds the occurrenceof the phenomena already mentioned and theirreversal by the application of a moderate stimulus.This condition of being relatively easily aroused andrestored to the waking state distinguishes the sleeperfrom the man who is in a coma or toxic stuporosestate. The depth of sleep has been studied by meansof graduated auditory stimuli. In most subjects sleepattains its maximum depth about the end of the firsthour and thereafter the depth decreases more or

less regularly till the moment of waking. But thereare some people in whom the pattern is of an invertedtype. The sensory side of thought preserves itsactivity during the time of falling asleep, but the motoror verbal side comes under the influence of sleep muchmore quickly. The persistence and perversion ofsensory impressions produces " images hypnagogiques"which occur during the time of falling asleep and arenot the same as dreams.The immediate cause of sleep seems to be an inhibi-

tion of cortical processes ; according to Pavlov," internal inhibition of conditioned reflexes and sleepare one and the same process." Sleep as a pathologicalcondition is to be distinguished from coma and thestupor produced by certain intoxications ; realsleep as a symptom of a diseased state is seen chieflyin two conditions, narcolepsy and encephalitislethargica. Narcolepsy (sudden onset of sleep so

that the patient, if standing, falls down) is a symptomwhich may arise without known cause or may followencephalitis or trauma, and there is considerableevidence that it occurs as a result of damage to thegrey matter in the floor of the third ventricle,especially in its anterior (hypothalamic) portion.The study of encephalitis lethargica suggests thatprolonged sleep may be brought about by inflammationaffecting some structure in the anterior part of themid-brain, and it may be that in this region there isconvergence of paths leading to and from higher sleep-controlling centres. ____

ARTIFICIAL ŒSOPHAGUS.

THE condition of an otherwise healthy personcondemned to a fistula life on account of an occludedgullet is a pitiable one. Since Cesar Roux, of Lausanne,inaugurated the attempt 20 years ago, there have beena score of cases in which a successful attempt has beenmade to replace the stenosed oesophagus by anartificial tube extending from pharynx to stomachin the thoracic integument. Dr. A. Fonio reports, 1from the hospital of Langnau, near Berne, the resultafter eight years of such an oesophageal plastic opera-tion which has enabled the patient to sit at table and eatlike an ordinary person. The history of the casedates back to the year 1908 when after a domesticquarrel the woman swallowed some crystallinepermanganate of potash and developed a stricturenear the cardia which gradually became impermeableso that for ten years she was dependent on fluidintroduced through a gastric fistula. In 1919 Dr.Fonio, in a series of operative measures extendingover 17 months, succeeded in improvising a functionaloesophagus. In the first stage a piece of thoracicintegument 22 x 8 cm. was converted into a skin-lined tube. In the second a piece of transverse colon15 cm. in length was isolated, with retention of itsarterial supply-colon being chosen in order to avoidthe danger of gangrene experienced when a loop ofjejunum is used for the purpose-to intervene betweenthe stomach and the lower end of the skin tube. Ifwe understand Dr. Fonio aright, it is important to1 Schweizerische medizinische Wochenschrift, July 30th, 1927.

344 MEDICAL MUNITIONS IN WAR.

retain the peristaltic action of this colon tube in the (

downward direction. Finally, the upper end of the skin tube was sutured to the cut cesophagusthrough an incision in the neck, the thyrohyoid <

muscles being sewn into the upper edge of the incisionin order to open widely the mouth of the skin tubeat the moment of swallowing. Some minor difficultiesand accidents were overcome to such effect that in1921 food after mastication was delivered with J

lightning rapidity down the air-filled tube directlyinto the stomach via the section of colon. No retrac-tion or retention occurred at any time in the loweror middle sections of the tube. Between 1921 and1927, however, the development of a calcareous goitreresulted in gradual closure of the upper end of theskin tube and the necessity of reverting to the gastricfistula ; after removal of the goitre patency wasrestored and the patient returned well nourished to herfactory work. The only respect in which she does notnow possess normal function is that she cannot vomit.The net result is a striking achievement in plasticsurgery although the indications for its employmentmay not be frequent. It is obviously only applicablein non-malignant stricture, and Roux, who firstdevised the technique, gave it up later in favourof early and patient stretching of the stricture bythe passage of metallic sounds. Biologically theoperation is of interest, as it affords an examplein later life of the method so familiar in embryonicdevelopment of the production of tubular structuresby the tucking in of superficial layers of cells.

PROSPEROUS MEDICAL SCHOOLS IN AMERICA.

NEW endowments and gifts have recently madepossible the extension and improvement of researchand teaching in various American medical schools.The campaign of the " half century committee "of Johns Hopkins University resulted in a total ofseven million dollars from 3992 subscriptions, and theGeneral Education Board of the Rockefeller Foundationhave given million dollars for a medical libraryat the same University. The new library will assemble50,000 volumes from various departmental libraries,some of which are now a mile or two apart. Thebuilding is to be in the Italian Renaissance style,three stories high, and will house 400,000 volumes.It will be dedicated to Dr. William H. Welch, the firstdean of the medical school and now director of theSchool of Hygiene and Public Health. The medicalschool of the University of Pennsylvania is raisinga fund of three million dollars, of which nearly one-halfhas already been subscribed. This school has justannounced the organisation of a new department ofpathology which is to be under the direction of Dr.Eugene L. Opie. The medical schools at Albanyand Detroit have each completed new six-storybuildings which will replace their former domiciles. ’,The teaching hospital at Detroit, now called theDetroit General Hospital, recently opened a milliondollar extension. A million dollars has been receivedfor the foundation of a new radiological institutefor the Washington School of Medicine. The institute,besides providing facilities for research, will offertreatment with radium and X rays. In New Yorkcity a neurological institute is projected which willcost a million and a half, of which more than halfhas already been pledged. Western Reserve is raisingsix millions for a medical centre and is already startingto build a new pathological institute. Of these largesums of money a part is provided by the wealthyfoundations peculiar to America, but a considerableproportion comes from the alumni of the Colleges them-selves. How this is made possible is revealed by aquestionaire recently sent out from the University ofOklahoma School of Medicine to 304 of its graduates.Of the majority who replied the monthly income issaid to range from$300 to$4000, with an averageof$1100. Most of these graduates are practisingmedicine in their home State. The State medical

journal, in commenting on these results, wonders howmuch of the incomes are derived from the profession

of medicine and how much from investments in oil.If one could believe such prosperity to be shared bygraduates from other schools the source of theirendowments would not be difficult to discover.

MEDICAL MUNITIONS IN WAR.

THE United States of America have already arrangedfor the prompt supply of the surgical instruments whichwould be needed by the Army should large-scale warfareever break out again.’ France is similarly planningahead, for, as M. R. E. H. Salkin2 points out in a recentarticle, surgical instruments are just as important asmunitions, and the medical department must settlein peace-time their patterns, the number that willbe wanted, and the depots in which they are to bestored and looked after. It must also arrange fortheir repair in war and for the replenishment ofstocks without interference with national production.A census of the surgical instrument industry inFrance has, therefore, been taken. The instrumentsare made at three chief centres : Paris, Nogent(Haute Marne), and Thiers (Puy-de-Dome). In Parisare particularly produced instruments of precision;at Nogent knives, scissors, and forceps ; at Thiersbistouries and cutting instruments. It is in thesecentres replacements will in war-time be made ; repairswill be done in other large manufacturing centres.Sufficient quantity of the various grades of cruciblesteel, the raw material of the instruments, must beplanned for. In 1000 parts of steel 10 to 7 partsof carbon are required for bistouries, 5 to 4 for chisels,burrs, and the like, 3-5 for forceps. Stainless chromesteel is being examined and has given good results sofar, but has not yet been officially adopted. Theindustry is carried on largely at home or in smallworkshops, but sometimes in factories, and arrange-ments are being made to give it more protection.France exports at present three-fifths of her production,especially to the Latin countries. English steel, thewriter admits, is excellent, but he finds the Englishsurgical instruments a little large and less delicatelyfinished than French. France is, however, backwardin suture needles and dental equipment, though theseare being encouraged. Surgical instrument makingshould, he concludes, be scheduled as a nationalindustry. ____.

RED CELL AND H&AElig;MOGLOBIN NORMALS.

THE statement that the average number of redcells in the human being is 5,000,000 per c.mm. forthe male and 4,500,000 per c.mm. for the femalehas figured in all text-books of medicine and in mostspecial works on the blood and its diseases for the last75 years. Its tacit acceptance is, as we have alreadypointed out,3 something of a mystery. Probablyit will outlast the century, and this in spite of thefact that everyone accustomed to performing bloodcounts habitually encounters figures far outside thisrange in normal persons. In 1926 E. E. Osgood 4showed that for normal men the figure should be inthe neighbourhood of 5,500,000 per c.mm. ; thesame author, in collaboration with H. D. Haskins,.has now investigated the blood of normal womenbetween the ages of 18 and 30, and agair it is foundthat the hallowed text-book statements are wide ofthe truth. Using a carefully standardised technique,these workers find that the average red cell count inhealthy women between the ages stated is 4,800,000per c.mm., 90 per cent. of their subjects giving readingsbetween 4,300,000 and 5,300,000. As regards thehaemoglobin percentage, Osgood showed in hisinvestigations upon the blood of males that theaverage weight of haemoglobin is actually 15-76 g.per cent., while the majority of methods in use in thiscountry and in America are based upon an assumed13.8 g. per cent. Curiously enough, the average

1 THE LANCET, 1926, ii., 1230.2 Arch. de M&eacute;decine Militaires, April, 1927, p. 332.

3 THE LANCET, 1926, ii., 191.4

Osgood: Arch. Int. Med., 1926, xxxvii., 685.5 Osgood and Haskins: Arch. Int. Med., 1927, xxxix., 643.