SOFT CHANCRE (CHANCROID).

Soft chancre or chancroid is a virulent ulcer. It usually begins within 36 hours after exposure, first as a red spot, but rapidly develops into an ulcer covered with thick yellowish pus. The period of development is about three or four days. Sometimes a week elapses from the time of exposure to the development of the sore, and occasionally the period of incubation is as long as 10 days. A sore appearing within a few days or a week or even as late as 10 days after exposure is usually regarded as a chancroid; but in practice this is not a safe rule, for the reason that many venereal sores are of a mixed character. The inoculations of both poisons may take place at the one and the same spot-the result is a mixed chancre; or if two sores appear, the origin of one may be syphilitic, the other chancroidal. It is therefore difficult, if not impossible, in many cases to determine the character of the disease from the period of incubation or from the appearance or local characteristics of the A mixed chancre is a syphilitic chancre (a hard chancre), while its appearance may be precisely like that of the soft chancre or chancroid. The only safe plan is to regard all venereal sores as suspicious until a microscopical examination can be made to determine if the Spirochete pallida, the organism of syphilis, is present. The mixed chancre, as already stated, is essentially a syphilitic chancre, and the beginning of constitutional disease. Its local effects, however, may be precisely the same as those of soft chancre or chancroid. The ulcer or ulcers (sometimes there are two or more) may remain as small as a pea or grow as large as a quarter, and if it becomes phagedenic (eating) may spread over a large surface of the body. It is also proper to state that a secondary syphilitic sore may appear under the foreskin, as well as at any other place on the body, and that cancer (epithelioma) of the organ may begin as a small ulcer. The latter, however, is a rare disease as compared with the different varieties of chancre.

The most frequent complications of soft chancre or chancroid is inflammation of the lymph glands of the groin (bubo), known to the sailor as "blue balls." Another troublesome and serious complication is the elongation and contraction of the orifice of the foreskin (phimosis), on the inner surface of which the sores may be located. The swelling and tension may be so great as to produce gangrene (mortification). If the foreskin is very tight and pulled back and can not be brought forward again, the condition is known as paraphimosis, which produces great swelling, the same as if a string were tied around the organ, frequently resulting in severe ulceration and destruction of tissue. This condition may also be

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the result if the inflammation and swelling are marked and the

foreskin very tight.

Treatment. The sore should be dried and covered with a small piece of aseptic gauze or absorbent cotton, and later a dusting powder of boric acid may be applied.

If phimosis exists, the cavity of the foreskin should be syringed out with hot water, and if there are sores under the foreskin which can not be reached by the boric acid the cavity should be syringed with a solution of one-half teaspoonful of carbolic acid to one-half pint of hot water. Soft chancres or chancroids appearing at the anus or rectum should be treated by frequent washings of warm water and the application of calomel.

In all cases, wherever the sore is located, cleanliness must be insisted upon, and, as already stated, in nearly all inflammations of whatever character hot water alone is a valuable remedy, and rest in bed is of equal importance. If a lump (bubo) appears in the groin, rest in bed is of the greatest importance. The diet should be light but nourishing. Tincture of iodine, pure or diluted one-half with alcohol, may be painted over the lump, but it is not of much value. Rest is the important thing. If the bubo goes on to suppuration, it should be carefully opened with the point of a sterilized knife (see p. 176) and kept open by a strand of aseptic gauze, which must be frequently changed, and enough aseptic gauze should be placed on top of the wound to absorb the discharges. The soiled gauze should be burned, and the person handling it must be careful to wash his hands in soap and water and in a disinfecting solution. (See p. 217.) The patient's bowels should be moved once a day.

GONORRHEA (CLAP).

Gonorrhea is a specific inflammation of the urethra due to a microorganism called gonococcus. It usually begins during the first week after exposure, sometimes as early as 3 or 4 days, and occasionally as late as 10 days or 2 weeks. The first symptoms are a tickling or itching sensation and a slight swelling about the lips of the orifice of the urethra. A purulent creamy-colored discharge soon appears, and a burning or stinging pain attends the passage of urine. The inflammation gradually extends to the deeper parts of the urethra, and, unless checked by medication, reaches its height about the end of the second or during the third week. The patient may experience great difficulty in passing water. If the inflammation runs very high, abscesses may form in the tissues around the urethra, and swelled testicle and bubo are frequent complications, also painful erections and bending of the organ (chordee). Phimosis or paraphimosis occurs if the foreskin is tight or becomes involved in the inflammation.

If phimosis occurs, and if the cavity of the foreskin is not thoroughly and frequently washed out, " venereal warts" are apt to form. True gonorrhea, if carefully treated, gradually subsides and recovery may take place in from four weeks to two months. A urethral discharge that recovers in a few days or a week is probably a simple urethritis.

Gonorrhea is urethritis (inflammation of the urethra), but urethritis is not necessarily gonorrhea.

Prevention.-This disease is not as serious an affection for men as for women. In man it may in time cause a stricture of the urethra, which, if neglected, may be followed by retention of urine and disease of the kidneys, or sterility may result if both of the spermatic ducts become permanently closed. These sequelæ are, however, rare, and men usually get well without permanent injury, but it often takes a long time to cure them. The acute symptoms generally subside within a few weeks, but a slight discharge may be present for months or years. This discharge may be noticed only occasionally, as after drinking beer or severe muscular exertion. No man should ever marry as long as this discharge is present and until he is pronounced cured after a careful examination by a competent physician, as he may convey the disease to his wife.

Gonorrhea in women is a very serious complaint, as the gonococcus is liable to travel up into the womb and extend from there to the ovaries and peritoneum (the serous membrane lining the abdominal cavity). It often produces a severe inflammation of these structures, resulting in the formation of abscesses and adhesions which bind the organs together in one mass. This causes sterility and invalidism, due to constant suffering. Most of the operations performed on the reproductive organs of women are for the relief of conditions following gonorrhea.

Treatment. Rest in bed, light diet, plenty of water to drink, regularity in eating and sleeping. Keep the bowels open by taking a moderate dose of Epsom salt in the morning. Avoid strong coffee and tea, all stimulants, and greasy articles of food. Keep the body and mind at rest. Bathe frequently in hot water. Be very careful not to carry any of the pus from the urethra to the eyes. (Gonorrheal inflammation of the eyes is a serious disease, which not infrequently results in total blindness.)

Injections of silvol 5 parts, water 90 parts; argyrol, 10 per cent solution; permanganate of potash 1 part, water 5,000 parts; or sulphate of zinc 1 grain, water 1 ounce, into the urinary canal may be used. They should be employed as follows: The patient first passes his water, the urinary canal is then washed out with several syringes full of warm water. One of the above solutions is then injected slowly into the canal and held there five minutes by the watch. The

best syringe for this purpose is one made of glass, having a plunger wrapped with cotton thread. If a testicle swells, apply cloths wrung out of cold water, or an ice bag. Rub the affected part with the following mixture: Oil of wintergreen (10 drops) and olive oil (1 teaspoonful). The treatment of bubo is described on page 142. If chordee is troublesome, apply cloths wrung out of cold water.

STRICTURE OF THE URETHRA.

True or organic stricture of the urethra is a narrowing of the tube. It is commonly the result of long-continued or neglected gonorrhea. Stricture of the urethra may be produced by direct injuries, as kicks or falls on the perineum, or by the use of too strong injections, or by the careless passage of instruments.

Occasionally stricture results from simple urethritis, not gonorrheal, and symptoms not unlike those of stricture are sometimes caused by a stone in the bladder obstructing the passage, and by an enlarged prostate gland.

Gonorrheal stricture of the urethra is usually of slow development. It may be several months or years after the attack of gonorrhea before the patient becomes conscious of any change in the size or shape of the stream. First there may be only a twisting or flattening of the stream. In severe cases it gradually becomes smaller and smaller, until it is no larger than a knitting needle and passed with great difficulty, or it comes away drop by drop, and finally results in complete retention. One of the earliest symptoms of stricture is a gleety discharge from the urethra.

Occasionally retention of the urine is the first symptom of the

disease.

Sudden retention may be due to spasm of the urethra (spasmodic stricture).

Spasmodic stricture may occur independently of any specific disease of the urethra, but it is more frequently a complication of organic stricture. Exposure to cold and wet (catching cold), or a debauch, are the usual exciting causes.

When retention occurs the bladder gradually becomes distended and a fullness or distinct tumor may be felt in the lower part of the abdomen, which in severe cases may extend as high as the navel. Sometimes there is an involuntary flow, or an overflow of urine from a distended bladder-a patient says he can not hold his water, and in such case it may be difficult to convince him that he is suffering from retention until a catheter is passed and a quantity of urine is withdrawn.

Treatment.-A neglected stricture of the urethra is a serious disease, the treatment of which is difficult in many cases, even in the hands of the most experienced surgeon.

If a case is allowed to run on until there is an actual stoppage or retention of urine, the consequences are extremely serious, and death may result unless this condition is relieved.

Place the patient on his back with his knees slightly drawn up, and try to pass a catheter. The instrument should first be thoroughly cleansed by placing it in boiling water. It should then be oiled with olive oil, and carefully passed into the urinary passage and an effort made with the greatest gentleness to pass it into the bladder. Try the largest size catheter first; if this fails, try the smaller ones. If a catheter can not be passed at the first trial, place the patient in a hot bath, give him 20 drops of laudanum or one-quarter grain morphic sulphate, and an hour or two later try the catheter again. If it is not practicable to place the patient in a full bath of hot water, then cover his belly and other parts of his body with flannels wrung out of hot water and change them every 15 minutes. The object of the hot bath and the laudanum is to produce relaxation. Sometimes a patient will pass his water in the bath.

COUGHS AND COLDS.

When a person has a cough that lasts more than two or three weeks, even though the symptoms are mild, the case is serious enough to require an examination by a physician, and one should be consulted on the first opportunity.

A case of bronchitis or bad cold usually begins with a cough, sometimes starting with an irritation in the throat, which gradually travels down into the lungs. Though the cough at first is dry, there will be some expectoration later on, especially marked in the morning on first arising. It may at first be white and tenacious, later on becoming yellowish. With this there will be some soreness over the upper and front part of the chest, and if the cough is violent there will be considerable soreness of the muscles between the ribs.

Treatment. For the soreness over the chest a good rubbing with soap liniment may help to relieve the symptom. A tablet of Brown Mixture or one teaspoonful of Mistura pectoralis (expectorans) N. F. given every three hours is serviceable. The bowels should be kept open by a tablespoonful of Epsom salt, when necessary.

Patients with coughs and colds should not be kept in a hot, dry room without ventilation. Plenty of fresh air should be allowed to come into the room, with the precaution, however, that the patient be not exposed to a draft and that he be properly clothed so as not to become chilled when the weather is cold.

A cold in the head may often be aborted if the patient, when he feels the cold coming on, will take a hot bath or a hot mustard foot