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that she subsisted principally upon soups and soft food. The pain was worse at times during each day, but not always at the same time, being periodic for several days, and then irregular.

The best of the several treatments used was, internally, a threegrain powder of equal parts of sulphate of quinia and prussiate of iron given at intervals of two hours, with an external application of aconite liniment, the parts being covered from the air.

The anti-periodic would arrest only the periodicity, and the aconite .would ease the pain temporarily but would also inflame

the eye.

After varied success for two months everything was abandoned but the application of cocaine, one grain to a drachm of water, applied with a camel's hair pencil. In a few weeks she was well and has had no further trouble.

II. The second case was that of a gentleman aged about sixtyfive, who had been very much exposed to the weather during the past winter and whose nervous system was very much unstrung, caused by severe sickness in his family and also by some financial reverses.

On applying for treatment he presented a weary, haggard expression, and instead of being of his usual disposition-rather jovial—he was so irritable that he would hardly answer questions without flying into a passion. Without particularizing, I would say that his digestive system was disordered, the skin, kidneys and bowels not acting properly; and all accompanied by an intense burning pain over the surface of the scrotum and the inside of the thighs. On examination no eruption was visible, but appeared later on in the case. He would have cold extremities in the forenoon and then burning in the afternoon, lasting into the night, but not much febrile action accompanying

At that time I considered the disease entirely constitutional and so directed the remedies, aided by such external applications as the mild zinc ointment, Hamamelis, etc. The internal treatment had the effect to improve him in a general way; but ointments and washes made him wild with burning, which only hot, moist cloths relieved. In a few weeks he passed out of my hands and began taking patent blood-medicines, and putting on everything he could hear of.

Some six weeks since he returned, and now by the use of welldirected internal remedies, aided by the free use of cocaine externally, he is on the road to recovery, and is in part, about well. Every lotion and ointment that I used, except cocaine, would fairly set him wild.





The prevention of conception is not only a sociologic problem of importance, but it is of interest in a medical sense. I shall not refer to operative measures for sterilizing women, but only discuss the mechanical devices for preventing conception.

These can be divided into two groups—one used by men, the other by women. The latter are of greater medical interest because of their increasing popularity and their influence on the general health. These devices are constructed after the manner of a pessary, and are intended to grasp the portio vaginalis in such a way as to occlude the external os and prevent the entrance of the spermatozoa into the uterus.

In preventing conception these devices are unreliable, as skilled hand is required to place them in proper position. Their supposed efficacy is enhanced by the fact that they are used by individuals whose intercourse is sterile, from occluded tubes, endometritis, epididymitis, or prostatitis. But these considerations are of only individual interest. The fact that these devices may be dangerous to both parties gives the subject a general medical interest.

The occlusive pessaries used in preventing conception consist of a rubber ring with a central diaphragm, the latter modified in various ways, or the whole pessary is formed of soft rubber, in the form of a cap with a thickened rim, the latter firmly grasping the cervix. As a rule such pessaries are inserted after the menstrual period and left in position until the next menstrual flow. This practice is a menace to the health of both sexes. Gynecologists know that certain vaginas do not tolerate soft rubber; it causes an intense congestion with profuse secretion.

Pathogenic germs are always present in the vagina, but their virulence and viability are greatly reduced. A change in the environment alters their virulence; in a few generations they may become so virulent as to excite an inflammation which varies in character with the germ. A copious catarrhal secretion may undergo decomposition when retained and awake the potential virulence of these germs. Such an altered secretion may infect the male urethra, or cause an ascending inflammation of the female pelvic organs. Such cases have been observed in which gonorrheal THE PREVENTION OF CONCEPTION—KOLISCHER.

*Read before the Chicago Medical Society


infection could be certainly excluded. I append a few cases which support these views.

The wife of a physician married for eight years had borne three healthy children, when one of the above mentioned contrivances was used. The husband, perfectly familiar with the modern professional views concerning gonorrhea, and aware of the importance of truth in this matter, emphatically denied ever having had any infection. He willingly submitted to all kinds of examinations, which proved the truth of his statements. I had occasion to examine the wife repeatedly and carefully, as I conducted all the confinements. Never up to the time of the above mentioned incident was there any infection. The soft rubber cap was introduced after menstruation and kept there until the next period, and daily irrigations were used. In the second month of the use of the pessary the wife noticed a rather offensive discharge, while pain in her right side set in. Shortly afterwards the husband appeared in my office very much concerned, having noticed a purulent discharge from the urethra ; this discharge appeared the day following the last intercourse. The pain during urination was slight. That the urethritis was not gonorrheal was proven by microscopic and culture tests. The short incubation and the disappearance of the discharge inside of a few days without treatment confirmed the diagnosis of a non-specific process. The examination of his wife showed a typical vaginitis with a copious cream-like secretion. In removing the cap, quite an accumulation of pus in its cavity was found. Cervicitis was present, the right parametric tissue infiltrated and sensitive, the right ovary enlarged and painful. The removal of the pessary and antiseptic flushings and the four times repeated cleaning of the cervix with formalin caused the prompt disappearance of all symptoms.

In the second case the husband married after a successful treatment and a cure of chronic gonorrhea. The wife became pregnant shortly after the wedding, and in due time was delivered of a healthy child. Labor and lying-in period were uneventful, and husband and wife enjoyed perfect health until about a year after the confinement, when the use of a preventive soft-rubber pessary was commenced. After this pessary was in the vagina for about three weeks, the husband was suddenly attacked by urethritis. The accused intercourse took place about twelve hours before the discharge was noticed. Examination of the woman revealed copious discharge from cervix and vagina, erosions on both lips, and a change of the cervical mucous strand to a yellowish mass. Search for gonococci gave a negative result. The discharge from the male urethra proved non-gonorrheic, but extension of the inflammation to the posterior urethra and prostate set in the week after the first symptoms appeared, and it took four months to cure the patient. All the time microscopical examinations and culture tests failed to show gonococci. The extension of the inflammation to the posterior urethra and appendages is somewhat similar to the well known phenomenon, that every time a gonorrheal reinfection takes place the posterior urethra becomes involved. This incident proves at the same time how serious even a non-specific purulent infection of a urethra is, which has once been subject to gonorrhea. The symptoms in the woman were mild and subsided under antiseptic flushings and ichthyol.

In the third case both marital partners have had a chronic gonorrhea. The husband has shreds in the urine, mostly consisting of mucus and a few pus cells. Gonococci show up occasionally, especially after alcoholic excess. The symptoms in his wife did not exceed the presence of a chronic urethritis and cervicitis. In the secretions of both gonococci could be found. Repeated bimanual palpation failed to reveal changes at the uterine appendages. Both parties felt quite comfortable until the husband, in order to get rid of the frequent urinary calls, underwent an energetic treatment of his chronic gonorrhea. This treatment, consisting in dilatations, instillations, etc., cured, according to his physician's opinion, the chronic process. The husband, afraid on account of his improved condition that his wife might become pregnant, following the suggestion of his family physician, had his wife use a soft-rubber pessary.

In about six weeks the wife was taken with a serious attack of inflammation of the uterine appendages and pelvic peritonitis. She said in her history that shortly after the pessary was inserted she noticed an increase of leucorrhea, which inside of two weeks turned into a yellowish flow. The conclusion seems not farfetched that the irritation of a foreign body helped along the development of an ascending gonorrhea, or may be that a "mixed infection" took place on account of the decomposition of the retained secretion.

To sum up the prominent features of these cases, which are reported at some length, because they are the most typical and best observed of a series of similar cases, I may say this: The use of soft-rubber caps as preventive pessaries is always a dangerous meas

The practice of leaving it in the vagina during the interval between two menstruations is to be condemned. If they are used at all, they must be removed at short intervals and effective anti



septic douches should be regularly employed. These rubber caps may produce inflammatory catarrhs in pelvic organs that have never been attacked by a specific infection. The secretion of such inflammation may cause a non-specific urethritis in the male. These pessaries are especially dangerous in cases in which the tissues are weakened and made susceptible for new infection by a previous gonorrhea, and they are apt to increase the virulence of a latent gonorrhea.



Carbuncle is a species of boil, appearing most frequently in persons who have passed the meridian of life, and whose vitality is lowered by the impairment of the function of one or more of the great emunctories of the body. The retention of effete matter in the blood, and the consequent lowering of its vitality, are no doubt the principal exciting cause. The inflammation accompanying is of the asthenic type, and this is the more marked the farther the carbuncle departs from the character of the ordinary phlegmon. If a healthy state of the blood existed in the patient the inflammation would remain localized and circumscribed as it is in the common boil; but in carbuncle the low vitality and consequent inflammatory condition of the blood causes the inflammation to spread rapidly to contiguous parts, going through the various stages to complete stasis and sloughing. One of the marked peculiarities of carbuncular inflammations is to spread to contiguous parts and successively to involve fresh tissues. In this respect it has some striking resemblance to phlegmonous erysipelas as well in the progress of the inflammatory actions as in the constitutional condition which precedes and also accompanies it.

The carbuncle may appear at first as a small pustule and not excite for the time being any suspicion of its virulent character. A small blister will, however, presently appear on its surface, which, being scratched or burst, exudes an ichorous and corroding discharge. A hard cake forms, spreading rapidly to contiguous parts, and successive crops of little blisters next come out from the size of a pin-head to that of a split pea, which, upon being opened, will be found to cover a small orifice extending down to a slough underneath, with a similar discharge to the one first mentioned. As the slough forms underneath, the color of the skin passes from

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