rial, but especially to give to its surfaces the results caused by the secondary effects of heat and moisture, results well known to the profession, in the external use of poultices, the vaginal douche, etc.

This, for some years, we have been accustomed to avail ourselves of, by the use of double metallic tubes, as, for example, the intrauterine douche, and in cystitis. However advantageous, the instruments caused pain and suffering, while they are more or less difficult and dangerous of introduction.

With the double rubber tubes, these disadvantages are almost completely avoided. The applicability of such tubes readily suggests itself as very wide and varied.

First, in the diseases of the bladder, the 18 is sufficiently small to enter the adult male bladder, unless the passage thereto is constricted. Even with a considerably enlarged prostate, it enters quite easily, and the benefit of the continuous current is very speedy and marked.

The relief comes, not only from the washing out of mucus and decomposing urine, and destruction of bacteria, but continued, as has been my habit, for one-half hour, night and morning, at the temperature of about 100° F., the congestive thickening and vascular supply of the mucous membrane are greatly diminished, the prostatic irritability is largely held in control, and permanent improvement ensues. In hemorrhage from ulcerations or other processes, the results are even of greater value. In illustration, I cite, briefly, the following case. Mrs. T., aged 64, always well until within one year. Noticed trouble in passing water about six months since. Micturition frequent and painful; sediment thick and ropy. About a month before consultation began to pass bloody coffee-colored urine, and clots were usually in the deposit. Despite every attention of the family physician, she grew steadily worse, until at visit, and for two weeks preceding, had been in bed. Is thin, very anæmic, and feeble. It was apparent the patient could not much longer sustain the continued loss of blood. A careful examination revealed no evidence of renal complication, but there was a contracted bladder, with thick walls, a roughened surface, and hemorrhage was increased after examination. Retained catheter for a considerable period, to allow of complete rest of organ, but without benefit. Used hot-water current one hour, without lessening the hemorrhage, although it gave no suffering; then arranged for its continuous use at a carefully regulated temperature of 100°,

slightly carbolized, which was continued for about forty-eight hours, after which the bladder was allowed to be emptied voluntarily. There was no return of the hemorrhage; the urine remained free from pus and mucus. Rapid convalescence followed, which has continued for more than six months.

In acute cystitis, the results have been even more gratifying. In the large class of cases, where the uterus has become the receptacle of septic and decomposing materials, the tubes have proved of very great value. After childbirth, I have found the larger sizes the most convenient and advantageous. Their introduction is easier, as a rule, and the clots and débris come away with greater readiness. The intra-uterine douche under such circumstances has appeared to me of such service that it may challenge comparison in beneficial results with the vaginal douche, as recommended by Dr. Emmet, which has been found of such marked advantage in uterine and pelvic inflammations, that already it has generally won the confidence of the profession. Hitherto intra-uterine injections have been usually considered as dangerous, because a free return current has not been secured, and, on this account, even in the most marked cases of septic poisoning from decomposing materials retained in the uterus, the removal of the cause is undertaken only exceptionally. Guided by the dogmatic conservatism of the past, and the fear of patent Fallopian tubes, many a patient has been allowed to die.

In narrowing of the rectum, from inflammatory conditions of the pelvic organs, the relief and benefit have been in every case most marked. In these instances the tube enters the colon, and the water is left, without strain upon the intestinal wall, at a point above the inflamed or involved part; not only is the large intestine emptied of its gas and contents, and the tenesmus and pain removed, but the poulticed effect of the continuous current is very efficacious in reducing the congestive and inflammatory processes.

The comfort and advantage have been equally marked after various pelvic surgical operations, where gaseous distensions are often so troublesome. In one case, where I removed the uterus and both ovaries, this procedure commenced upon the second day, was not only painless, but of such service that it was continued until convalescence was assured.

The use of the double current through such a soft flexible tube renders it easy and effectual to cleanse the pleural cavity

in empyema, to wash out long irregular sinuses, deep gunshot wounds where necrosis of tissue must follow the track of the bullet, and frequently shreds of clothing, small pieces of bone, etc., are retained.

In nutritive enemas I have felt that considerable gain has followed by the introduction of the fluids thus high in the transverse colon, and can but recommend their use for further trial. The subject of the absorption of nutrient enemata has deservedly occupied the attention of the profession, and is invested with a new interest by the recent statements of a number of independent observers, that something of a reversed peristaltic action takes place. It has been even claimed that the entire intestinal tract may be permeated by injections. The impression would seem logical the higher the enemata can be safely and conveniently carried, the more surely will the restorative processes be aided thereby.

In certain chronic diseases of the large intestine I have been confident of the benefit secured by the continuous use of hot water; and, although I have not as yet had occasion to use water thus applied in dysentery, either hot or cold, it would seem that a trial thereof might be thoughtfully recommended.

The longer tubes are of easy application for the evacuation of the stomach. Said a friend, "they are not introduced, they are swallowed;" at least almost equally easy do they enter the stomach,-in marked contrast with the ordinary stiff tube of the stomach pump. A tube of this character, and an ordinary rubber syringe, are all that are necessary for the speedy and effective emptying of the stomach; and feeding by this means is, in like manner, easily accomplished. This I have had recourse to in a number of instances with children as well as adults.

The modus operandi is too simple to require detailed description. For the secondary effects the siphon is the simplest and most convenient method, from a height sufficient to insure a slow but continuous current. Usually it is well to lengthen the ends by connections of rubber tubing as deemed convenient.

Although I have written in an exceptionally enthusiastic manner, I assure the profession I have kept within the limit of the seeming just deductions from my experience in these directions, lest it might appear that I was a partial and untrustworthy witness for truth. I am convinced results will confirm more of good than I have indicated.

CAN WE MAKE A POSITIVE DIAGNOSIS OF PREGNANCY PREVIOUS TO THE OCCURRENCE OF THE AUDIBLE SOUNDS OF THE FETAL HEART AND THE DETECTION OF THE FETAL MOVEMENTS?

BY JOSEPH TABER JOHNSON, M.D.,

DISTRICT OF COLUMBIA.

PLAYFAIR and other writers tell us that while the other symptoms generally relied upon are of importance in leading us to suspect pregnancy, and in corroborating and strengthening our opinion, they do not of themselves justify a positive diagnosis. Leishman' speaks of the great importance of an early and a correct diagnosis; but almost in the same breath says that "no combination of merely probable signs will suffice." "In addition to these, however imposing their array, we must, in every case, have one, at least, of the certain signs before we can with all confidence assert that the woman bears a living child. As these certain signs do not appear until the latter half of pregnancy, our certain diagnosis would, therefore, be considerably delayed.

Most of the writers on midwifery and medico-legal medicine state that pregnancy cannot with any certainty be detected until the movements of the foetus are perceived within the womb. Beck, in the sixth edition of his Medical Jurisprudence, says we should never give a positive opinion until six months have elapsed, and while many authors could be cited who agree with Beck, a majority, and among them Velpeau, say that a positive diagnosis is impossible until four complete months have elapsed.

The diagnosis, then, of pregnancy previous to quickening becomes a question of very great importance in jurisprudence, as well as in the social and domestic relations of life. There is, perhaps, no question in obstetrics or gynæcology of equal im

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portance which is so difficult of solution. Our text-books dismiss the subject without definite instructions how to perfect an early diagnosis. We are taught to rely upon signs which, when they are all present and corroborate each other, are considered presumptive evidences by some, probable by others, and uncertain by all.

We have little authority for pronouncing any of the digestive, nervous, mammary, pigmentary, vaginal, or cervical disturbances or changes in the blood, urine, or milk as distinctly pathognomonic during the first half of utero-gestation.

When a patient comes to us with a history of the cessation of the catamenial flow for one or two months, some nausea in the morning, and a darkened areola, we are too much in the habit of jumping to a conclusion that she is pregnant, and commencing forthwith to calculate the time of the expected accouchement. The number of errors in diagnosis made upon this unreliable evidence, recorded in our medical journals and society transactions, is truly surprising.

In glancing over the records in the great library of the Surgeon-general's office at Washington, one is struck not so much with the lack of newly discovered evidences of early pregnancy, as with the reports of cases of mistaken diagnosis, in which the fact is lamented that no certain guide exists to aid us in perfecting a diagnosis in these very important and troublesome cases.

My attention was attracted to this subject during the past year by two cases which gave me considerable anxiety, and one of them no little mortification.

A lady of refinement and high social position presented herself at my office, about a year ago, with the following statement: She desired to join a party of friends who were to travel in Europe for six months. Her husband had important business to transact, and while he was occupied she expected to derive much pleasure in sight-seeing with other members of the party. She feared, however, that she might be six weeks' preg. nant, and, if her fears were well founded, did not wish to undertake the fatigues of the journey. It had been the dream of her life to visit Continental Europe, and now, that her ardent hopes were about to find their very pleasant realization, she was almost crazed at the prospect of disappointment. She had, I found upon examination, several of the usual signs of pregnancy upon which we are taught to rely in making our diagnosis of that