unwise to have a heavy meal shortly before retiring to sleep, pace the advice of past teaching. In the former case, mental or muscular effort is hampered by the want of blood in the organs thus dragged into function; and in the latter, the anaemia of the brain produced by the operation of the digestive tissues is just one of the effects which it is desirable to secure to induce sleep. The meal, of course, must not be an injudicious one, which, by producing discomfort in the process of sleep-digestion (Pavlow), disturbs such sleep, and in the awakening moments leads to the development of dreams or nightmares.

Discussing a second factor in the causation of sleep, Dr. Harris touched upon a matter which is of vital importance to the national health, and more especially to that part of the national life which is spent in large cities. Sleep may be induced by the diminution or absence of sensory stimulation arriving through such channels as the eye, hearing, or common sensation. No doubt we can get over the almost day-like illumination of many a town or city bedroom by the use of blinds at night, but how can we with the "open window" shut out the fiendish noises which are created alike by cats and dogs, and by the bawling rowdy boys and girls who, to their own. undoing as well, are allowed to make night hideous? Dr. Harris is quite right when he points out that in our slavish worship of "freedom of the subject" we tolerate a licence to make these unnecessary noises in our public thoroughfares. These acts of rowdyism should be treated as misdemeanours as rigorously as any other public nuisance.

A third factor in the production of sleep is the relative diminution of psychic activity. Not only is sleep impossible to the child after the excitement of a party or a pantomime, but in the same way insomnia is one of the frequent possessions of those who, by necessity or by custom, pursue mental work to within

a few moments of the hour of retiring. A certain well-known divine, who was asked how he managed to preserve his health and vigour to a ripe old age, explained it on the ground that a 10 p. m. he refused to worry about anything. And, lastly, Dr. Harris brings to our notice the physiological belief that sleep in its periodic recurrence in the night hours-a recurrence which in a normally balanced individual persists in some cases undisturbed throughout life—may be but an expression of chemical influences which, hitherto unsuspected, have at last been given their due prominence. Perhaps far too much has been said of the periodic activity of our nerve centres, which, on the one hand, are capable of producing the rhythmic discharge of cardiac energy familiar to us all at least in the pulse-beat, and on the other, by rhythmic reservation of energy, bring about that filling of the capillaries of the skin which is held by some to be such a regular accompaniment of sleep. The tendency of modern thought is to view these recurrent changes rather as the effect of recurrent causes, such as the manufacture in unknown recesses of the body, of "fatigue toxins". Sleep, then, becomes but an expression of the relative increase or concentration of these suspected, but undemonstrated agencies, and insomnia may, in the absence of the other three groups of causes, be merely due to an absence, or, curiously but yet. truly enough, to an excess of them.

THE STETHESCOPE.

In his new volume, "Rewards and Fairies," Mr. Rudyard Kipling reintroduced such a charming collection of ancient silhouettes in "Puck of Pook's Hill." The new series of ghosts of the past include Laennec and Nicholas Culpepper, the great herbalist. René Théophile Hyacinthe Laennec was born. in 1781 in the beautiful old Breton town of Quimper, and on the north side of the noble cathedral stands his statue.

Laennec was a surgeon in the Republican army in 1799 and served in the Morbihan. Mr. Kipling's sketch of the father of auscultation has charm and interest, and if he has taken liberties with facts we do not suggest that he has exceeded the romancer's license. If we accept Forbes's careful biography of Laennec implicitly-and it was written immediately after the physician's death, being compiled from such excellent sources as the memoirs by Kergaradec and Bayle, supplemented by notes. contributed by Laennec's cousin-the true story of Laennec differs from Mr. Kipling's presentment. From these biographers it seems proved that after 1799 Laennec was occupied in Paris at the clinic of La Charité, and up to 1818 was busily engaged in a constant output of important writings. In 1818 he broke down in health, probably from incipient phthisis, to which he ultimately succumbed in 1826. In 1821 he returned to Paris and resumed his post on the staff of the Necker Hospital. Mr. Kipling represents him as a prisoner in England at some date subsequent to the battle of Assaye, and describes him as experimenting with wooden stethoscopes (shaped liked trumpets) in a Sussex village. Laennec in his great treatise describes vividly his first use of an impromptu stethoscope, which consisted of a roll of paper, and the incident, he states carefully, occurred in 1816. The early history of the stethoscope is on the whole well authenticated. introduction to Laennec's "Diseases of the Chest" (second edition, 1826) various kinds of materials are mentioned as employed by the discoverer paper, wood, glass, even goldbeater's skin-but they all had a cylindrical form, and there remains no doubt as to the final shape in which Laennec left the stethodiameter and 12 inches long, perforated scope, a cylinder of wood 11⁄2 inches in by a bore three lines in diameter, and

In the

hollowed out at one end into a funnelshaped cavity of the same depth as the external diameter of the cylinder. The late Sir George Burrows rescued from the wards of St. Bartholomew's Hospital the remains of such an instrument, which had been the property of Dr. Bond, afterwards Regius professor of medicine at Cambridge. Burrows and Bond were two of the first to study auscultation at St. Bartholomew's, when they were serving as clerks to Dr. Latham in 1827. Burrows's instrument had one part missing when it found its way into the Museum of St. Bartholomew's in 1887, and no instrument maker in London could be found capable of restoring it, but a complete example was accidentally discovered at Westerham! in Kent by Mr. A. Maude, and this is now in the same museum. The construction of these models corresponds exactly with Laennec's own description.

THE INFLAMMATORY "PELVIC

MASS."

Lipman, in the Journal of Obstetrics and Gynecology of the British Empire, deals with local inflammatory disease of the female genital organs, that is to say, with inflammations of the uterus and adnexa, and the pelvic cellular tissue, for it is any or all of these structures when involved in an inflammatory process which come to constitute the inflammatory "pelvic mass." In particular terms the mass is a metritis, salpingoovaritis or a cellulitis, single or combined, unilateral or bilateral, together with intraperitoneal adhesions and exudate. All degrees of the process occur, from the unilateral small deposit to the complete "choked pelvis," where the viscera are no longer discrete, and the pelvis is occupied by a single firm undifferentiated mass.

Out of 832 cases treated in hospital, one-fifth have been instances of inflammatory disease of the uterus and its

adnexa. In the extension of the disease the viscera become involved. The "mass" is either within or without the peritoneum, the site depending largely upon the nature of the infection. Within the mass itself any stage of the inflammatory process may be discovered, from lymph exudate and oedema to necrobiosis and tissue necrosis and pus, either as a pyosalpinx or ovarian abscess.

The organisms that are chiefly pathogenic in the female genital tract are the gonococcus, streptococcus, and tubercle bacillus. The two first invade the genitalia from below, the last attacks from above, its primary pelvic focus being the Fallopian tube. These three infections occasion the "inflammatory mass," but are clinically distinct, and can be distinguished one from the other. The gonorrhoeal variety of the "inflammatory mass" has a history of purulent leucorrhoea and urinary disturbance, with pus in the urethra and Bartholinian ducts, or perhaps a granular vaginitis or catarrhal. Such evidences may persist for years untreated, and the resulting mass will be a salpingo-ovaritis and may be of any size. It is frequently pelvic and not large, or bilateral with the uterus recognizable between; often it occupies the pouch of Douglas and the uterus is not greatly displaced. The streptococcal variety has a history of childbirth or abortion; if acute the fever is high, there is pain, and usually a unilateral mass in the pelvis fixed to the pelvic wall. The mass is of any size and the uterus is often greatly displaced.

The tuberculous variety is associated with failing health and some menstrual depravity. The mass is bilateral, elastic, and rounded, little nodosities may be found in the isthmian portion of the tube, the uterus is not much displaced. Where tuberculosis is suspected the von Pirquet reaction is often valuable. In 164 operative cases, 113 were gonorrhoeal, 19 tuberculous, 17 streptococcal, and 15 of mixed infection. More than half of the

cases escaped operation and did well with rest and palliative measures. The writer operated upon 164 cases of inflammatory "pelvic mass"; he considers that where the infection is streptococcal operation is contraindicated, though drainage may be established or abscesses evacuated. In gonorrhoeal cases operation cannot be undertaken during the acute stages. Later posterior colpotomy with complete tunnelling of the "pelvic mass" is a wise, curative, and conservative measure. Extirpation of the dis

eased organs should only be made as a last resource. In tuberculous lesions the process is progressive and should be dealt with as soon as possible. Extirpation is the only cure.

TREATMENT OF BRONCHIAL
ASTHMA.

August Goldschmidt, in Muenchner Med. Wochenschrift, starting with the admission that it is impossible at present to effect a permanent cure of bronchial asthma by medicines, records the results. which can be obtained by a few drugs in this affection. He leaves alone the question of the physical treatment of asthma, since this requires institutional treatment. In the first place, he believes that 1 per cent solution of morphine with 1 per 1,000 solution of atropine sulphate gives the best results during an acute attack. He advises not less than 1 c.cm. of the solution injected subcutaneously. He is doubtful whether it is advisable to use adrenalin for this purpose.

If the attack can be dealt with very early, von den Veldon's theobromine preparations do good service. He prefers the following prescription: R Caffeine valerianic. 0.25 gram; theobromin. sodiosalicyl. 0.5 gram. M. Ft. pulv. Sig.: One or two powders to be taken during the attack. If the attack has been set going by an attack of bronchitis, iodides. appear to answer well by removing the secretion. He prefers the sodium salt.

He does not like pyrenol as well as the ordinary iodine, but when the patient does not take the latter well sajodin may be used.

The treatment of asthma apart from the acute attack consists chiefly in giving atropine or some substitute. He is, however, of opinion that both when given by the mouth or subcutaneously, the well-known intoxication symptoms occur frequently. Fickler has recently reported a case of atropine mania in an asthmatic. A less dangerous method of application consists in applying it by means of a nasal inhaler.

His prescription is as follows: R Alypin. nitr. 0.3 gram, eumydrin. nitr. 0.15 gram, glycerini 7 grams, aq. dest. 25 grams, ol. pini pumil. 1 drop. M.D.S. To be inhaled from the spray apparatus (Tucker's). Since alypin produces some hyperaemia, it is advisable to add 8 to 10 drops of a 1 in 1,000 solution of adrenalin or suprarenin to each 10 c.cm. of the solution. As the adrenalin does not keep well, it is not wise to mix it with the spray solution, but to add it fresh each time. The prescription given above can be made up for 35c (according to the German scale of charges). It has answered well in six out of seven cases.

PROPHYLAXIS IN OBSTETRICS. Summarizing an excellent article in the British Medical Journal on this topic, A. W. Russell presents the following conclusions:

1. Contracted pelvis is mostly a legacy of the rickety infant. Much can therefore be done by way of prevention if enlightened attention is paid to the feeding and hygiene of the baby from birth.

2. The education and physical culture of the growing girl must be supervised. This is specially important at the onset of puberty and during adolescence.

3. The young woman should understand her functions, and in her work

should be protected from debilitating influences.

4. The young wife, and especially the expectant mother, should receive the further information that is necessary for her guidance in relation to the sexual functions and the preparation for motherhood.

5. As to the complications of pregnancy it does not seem to be generally realized by the busy practitioner out of how trifling ailments overlooked the most serious troubles arise, and how much special obstetrical studies have in recent years contributed to their more scientific treatment. I refer you to what I have already said about pernicious vomiting of pregancy, which so often develops out of the ordinary digestive disturbances, and eclampsia which results from renal or hepatic disorders which have not been looked for or have been left untreated. In the antepartum haemorrhages, too, it has been clearly shown by statistics that if the condition is properly diagnosed under aseptic precautions and the patient put under the care of a skilled obstetrician at any early stage before she has been carelessly handled, the chances of the mother and child are infinitely better. The same remark applies to the early diagnosis of really dif ficult cases of contracted pelvis or marked disproportion between the sizes of the child and the pelvis.

6. With regard to the process ul labour I desire to give fresh emphasis to several points.

(a) Abortion or miscarriage is really a miniature labour and should receive at least the same prophylatic care as ordinary labour. The mother needs to be taught this otherwise and earlier than by the unhappy lesson of a weakening haemorrhage or a septic infection.

(b) The induction of premature labour has still a place among obstetric operations, but it must be done after careful, and even repeated, examination

under an anaesthetic, so that the pregnancy may be allowed to run as near the full term as is consistent with spontaneous delivery. When this is done the results are most satisfactory, as I can testify from a recent series of cases conducted on these lines in the Glasgow Maternity Hospital. It has been a great advantage to Glasgow to have its new maternity hospital with abundance of room, so that apart from simply providing for labour when it comes on, patients may receive prematernity treatment, and may be admitted, as now frequently happens, for the proper investigation and treatment of complications arising during pregnancy. This has proved itself a great boon, alike to the practitioner and to the patient, and not the least important of the cases that need such consideration are the patients who can thus be saved from operative procedure later on by the induction of premature labour under favourable conditions.

(c) When we come to consider prophylaxis in relation to full-time labour it is difficult to select points for emphasis, and I shall confine my attention to difficult labour in relation to the use of the forceps and to the scope of modern operations.

The forceps should be considered a surgical instrument, and its use a surgical operation. As a consequence the sterilization of instruments and the disinfection of all parts of operator, nurse, and patient, that are liable to be touched, should be thorough, and this asepsis should be maintained. In this way there is some hope of avoiding the septic infection that so frequently results from handling. The forceps should never be used without distinct indications on the part of the mother or child of the need for it, and delay in the labour is very rarely a reason in itself. The use of the forceps should always be preceded by a careful measurement of the pelvic cavity, so far, at least, as to gauge the

Two-inch nails are driven into a small board at intervals of an inch for about two feet. This board when tied to the bed or nailed to the wall gives a means of lowering or raising the enema bag. About fifteen feet of medium heavy tubing is attached to the end of an ordinary two-quart enema bag, and a small rubber catheter is joined to the end of this tube. Near the edge of the bed is placed a pan containing two or more gallons of warm water, the temperature of which is about 100 F. Into this pan the tube passes and is coiled so that about twelve