It is a very common disorder of children and young persons, and in some cases no cause can be found; but in many instances it is due to masturbation, to a narrow foreskin and small aperture at the exit of the urinary passage, to worms in the bowels or disease of the lower end of the bowels, such as fissure or eczema, to digestive disorders, to retaining the urine overlong, to fright, to dream impressions (dreaming of the act of urination), and to great weakness brought on by fevers or other diseases. In old men it is often due to an enlargement of a gland at the neck of the bladder which prevents the bladder from closing properly. A concentrated and irritating urine, from excessive acidity or alkalinity, may induce incontinence.

Children may recover from it as they approach adult life, but they should not be punished, as it is a disease and not a fault. Exception should be made in case children wet their clothing during play, through failure to take the time and trouble to pass water naturally. It is more common among children at night, leading to wetting of the bed, but may occur in the day, and often improves in the spring and summer, only to return with the cold weather. Children who sleep very soundly are more apt to be subject to this disorder.

Treatment. In the case of a disorder depending upon one of so many conditions it will be realized that it would be folly for the layman to attempt to treat it. Children who are weak need building up in every possible way, as by an outdoor life, cold sponging daily, etc. If there is in boys a long foreskin, or tight foreskin, hindering the escape of urine and natural secretions of this part, circumcision may be performed to advantage by the surgeon, even in the infant a few months old. Sometimes a simpler operation, consisting of stretching or overdistending the foreskin, can be done.

A somewhat corresponding condition in girls occasionally causes bed wetting and other troubles. It can be discovered by a physician. Children who wet their beds, or clothes, should not drink liquid after five in the afternoon, and should be taken up frequently during the night to pass water. The bed covering must be light, and they should be prevented from lying on the back while asleep by wearing a towel knotted in the small part of the back. Elevation of the foot of the bed a few inches is recommended as having a corrective influence. Masturbation, if present, must be corrected.

It is a very difficult disorder to treat, and physicians must be excused for failures even after every attempt has been made to discover and remove the cause. Even when cure seems assured, the disorder may recur.

Cold sores are commonly induced by indigestion and fevers, and also are occasioned by local irritation of any sort, as from nasal discharge accompanying cold in the head (from which the name is derived), by the irritation produced by a pipestem or cigar, and by rubbing the skin.

Treatment. Picking and scratching are very harmful, and cigar or pipe smoking must be stopped. Painting the sore with collodion, by means of a camel’s hair brush, is poor treatment in the early stages. Better use spirits of camphor, and afterwards, if there is much itching or burning, sopping the eruption with calamine lotion will relieve the discomfort.

It is not very uncommon for patients with mild forms of diphtheria to walk about and attend to their usual duties and, if children, to go to school, and in that inviting field to spread the disease. These cases may present a white spot on one tonsil, or in other cases have what looks to be an ordinary sore throat with a simple redness of the mucous membrane. Sore throats in persons who have been in any way exposed to diphtheria, and especially sore throats in children under such circumstances, should always be subjected to microscopical examination in the way we have alluded to before, for the safety of both the patient and the public.

There is still another point perhaps not generally known and that is the fact that the germs of diphtheria may remain in the throat of a patient for weeks, and even months, after all signs in the throat have disappeared and the patient seems well. In such cases, however, the disease can still be communicated in its most severe form to others. Therefore, in all cases of diphtheria, examination of the secretion in the throat must show the absence of diphtheria germs before the patient can rightfully mix with other people.

Gargling and swabbing the throat with the (poisonous) solution of bichloride of mercury, 1 part to 10,000 parts of water (none of which must be swallowed), should be employed every three or four hours each day till the germs are no longer found in the mucus of the tonsils.

Symptoms. Acquired syphilis may be divided into three stages: the primary, secondary, and tertiary. The first stage is characterized by the appearance of a pimple or sore on the surface of the sexual organ not usually earlier than two, nor later than five to seven, weeks after sexual intercourse. The appearance of this first sore is subject to such variations that it is not always possible for even the most skillful physician to determine positively the presence of syphilis in any individual until the symptoms characteristic of the second stage develop. Following the pimple on the surface of the penis comes a raw sore with hard deposit beneath, as of a coin under the skin. It may be so slight as to pass unnoticed or become a large ulcer, and may last from a few weeks to several months. There are several other kinds of sores which have no connection with syphilis and yet may resemble the syphilitic sore so closely that it becomes impossible to distinguish between them except by the later symptoms to be described. Along with this sore, lumps usually occur in one or both groins, due to enlarged glands.

The second stage appears in six to seven weeks after the initial sore, and is characterized by the occurrence of a copper colored rash over the body, but not often on the face, which resembles measles considerably. Sometimes a pimply or scaly eruption is seen following this or in place of the red rash. At about, or preceding, this period other symptoms may develop, as fever, headache, nausea, loss of appetite, and sleeplessness, but these may not be prominent. Moist patches may appear on the skin, in the armpits, between the toes, and about the rectum; or warty outgrowths in the latter region. There is sore throat, with frequently grayish patches on the inside of the cheeks, lips, and tongue. The hair falls out in patches or, less often, is all lost. Inflammation of the eye is sometimes a symptom. These symptoms do not always occur at the same time, and some may be absent or less noticeable than others.

The third stage comes on after months or years, or in those subjected to treatment may not occur at all. This stage is characterized by sores and ulcerations on the skin and deeper tissues, and the occurrence of disease of different organs of the body, including the muscles, bones, nervous system, and blood vessels; every internal organ is susceptible to syphilitic change.

A great many affections of the internal organs the heart, lungs, liver, kidneys, brain, and cord which were formerly attributed to other causes, are now recognized as the product of syphilis. The central nervous system is peculiarly susceptible to the action of the syphilitic poison, and when affected may show the fact through paralysis, crippling, disabling, and disfiguring disorders.

Years after cure has apparently resulted, patients are more liable to certain nervous disorders, as locomotor ataxia, which attacks practically only syphilitics; and general paresis, of which seventy five per cent of the cases occur in those who have had syphilis.

Inherited Syphilis. Children born with syphilis of syphilitic parents show the disease at birth or usually within one or two months. They present a gaunt, wasted appearance, suffer continually from snuffles or nasal catarrh, have sores and cracks about the lips, loss of hair, and troublesome skin eruptions. The syphilitic child has been described as a “little old man with a cold in his head.” The internal organs are almost invariably diseased, and sixty to eighty per cent of the cases fortunately die. Those who live to grow up are puny and poorly developed, so that at twenty they look not older than twelve, and are always delicate.

It is to be noted that syphilis is not necessarily a venereal disease, that is, acquired through sexual relations. It may be communicated by kissing, by accidental contact with a sore on a patient’s body, by the use of pipes, cups, spoons, or other eating or drinking utensils, or contact with any object upon which the virus of the disease has been deposited.

Any part of the surface of the body or mucous membrane is susceptible of being inoculated with the virus of syphilis, followed by a sore similar to what has been described as occurring upon the genital parts and later the development of constitutional symptoms. The contagiousness of the disease is supposed to last during the first three years of its existence, but there are many authentic cases of contagion occurring after four or five years of syphilis.

Diagnosis. The positive determination of the existence of syphilis at the earliest moment is of the utmost importance in order to set at rest doubt and that treatment may be begun. It is necessary to wait, however, until the appearance of the eruption, sore throat, enlargement of glands, falling out of hair, etc., before it is safe to be positive.

Treatment. The treatment should be begun as soon as the diagnosis is made, and must be continuously and conscientiously pursued for three years or longer. If treatment is instituted before the secondary symptoms, it may prevent their appearance so that the patient may remain in doubt whether he had the disease or not, for it is impossible for the most skilled specialist absolutely to distinguish the disease before the eruption, no matter how probable its existence may seem. This happens because there are several kinds of sores which attack the sexual organs and which may closely simulate syphilis. The treatment is chiefly carried out with various forms of mercury and iodides, but so much knowledge and experience are required in adapting these to the individual needs and peculiarities of the patient that it is impossible to describe their use. Patients should not marry until four or five years have elapsed since the appearance of syphilis in their persons, and at least twelve months after all manifestations of the disease have ceased. If these conditions have been complied with, there is little danger of communicating the disease to their wives or transmitting it to their offspring. They must moreover, have been under the treatment during all this period. Abstinence from alcohol, tobacco, dissipation, and especial care of the teeth are necessary during treatment.

Results. The majority of syphilitics recover wholly under treatment and neither have a return of the disease nor communicate it to their wives or children. It is, however, possible for a man, who has apparently wholly recovered for five or six years or more, to impart the disease. Without proper treatment or without treatment for the proper time, recurrence of the disease is frequent with the occurrence of the destructive and often serious symptoms characteristic of the third stage of the disease. While syphilis is not so fatal to life as tuberculosis, it is capable of causing more suffering and unhappiness, and is directly transmitted from father to child, which is not the case with consumption. Syphilis is also wholly preventable, which is not true of tuberculosis at present. It is not probable that syphilis is ever transmitted to the third generation directly, but deformities, general debility, small and poor teeth, thin, scanty growth of hair, nervous disorders, and a general miserable physique are seen in children whose parents were the victims of inherited syphilis. In married life syphilis may be communicated to the wife directly from the primary sore on the penis of the husband during sexual intercourse, but contamination of the wife more often happens from the later manifestations of the disease in the husband, as from secretion from open sores on the body or from the mouth, when the moist patches exist there.

It is possible for a child to inherit syphilis from the father when the germs of syphilis are transmitted through the semen of the father at the time of conception and yet the mother escape the disease. On the other hand, it is not uncommon for the child to become thus infected and infect its mother while in her womb; or the mother may receive syphilis from the husband after conception, and the child become infected in the womb.

The chief social danger of syphilis comes from its introduction into marriage and its morbid radiations through family and social life. Probably one in every five cases of syphilis in women is communicated by the husband in the marriage relation. There are so many sources and modes of its contagion that it is spread from one person to another in the ordinary relations of family and social life from husband to wife and child, from child to nurse, and to other members of the family, so that small epidemics of syphilis may be traced to its introduction into a family. Syphilis is the only disease which is transmitted in full virulence to the offspring, and its effect is simply murderous. As seen above, from sixty to eighty per cent of all children die before or soon after birth. One third of those born alive die within the next six months, and those that finally survive are blighted in their development, both physical and mental, and affected with various organic defects and deformities which unfit them for the battle of life. Syphilis has come to be recognized as one of the most powerful factors in the depopulation and degeneration of the race.

Treatment. The treatment of chronic rheumatism is generally not very successful unless the patient can live in a warm, dry climate the year round. Painting the joint with tincture of iodine and keeping it bandaged in flannel affords some relief. The application of a cold, wet cloth covered with oil silk and bandage, by night, also proves useful. Hot baths at night, Turkish baths, or special treatment conducted under the supervision of a competent medical man at one of the hot, natural, mineral springs, as those in Virginia, often prove of great value. Rubbing and movement of the joints is of much service in all cases; any liniment may be used. Drugs are of minor importance, but cod liver oil and tonics may be required. These should be prescribed by a physician.

LUMBAGO. This attacks the muscles in the small part of the back. It comes on often with great suddenness, as on stooping or lifting. It may be so severe that the body cannot be moved, and the patient may fall in the street or be unable to rise or turn in bed. In less severe cases the pain “catches” the patient when attempting to straighten up after stooping. Pain in the back is often attributed by the laity to Bright’s disease, but is rarely seen in the latter disorder, and is much more often due to rheumatism.

STIFF NECK. This is a very common variety of muscular rheumatism, and is seen more especially in young persons. It may appear very suddenly, as on awakening. It attacks the muscles of one side and back of the neck. The head is held stiffly to one side, and to turn the head the body must be turned also, as moving the neck causes severe pain. Sometimes the pain on moving the neck suddenly, or getting it into certain positions, is agonizing, but when it is held in other positions a fair amount of comfort may be secured.

RHEUMATISM OF THE CHEST. In this form there is more or less constant pain, much increased by coughing, sneezing, taking long breaths, or by movements. It attacks usually one side, more often the left. It may resemble neuralgia or pleurisy. In neuralgia the pain is more limited and comes in sharper attacks, and there are painful spots. The absence of fever in rheumatism of the chest will tend to separate it from pleurisy, in which there is, moreover, often cough. Examination of the chest by a physician, to determine the breath sounds, is the only method to secure certainty in this matter.

Muscular rheumatism also affects the muscles about the shoulder and shoulder blade and upper part of the back; sometimes also the muscles of the belly and limbs.

Treatment. Rest, heat, and rubbing are the most satisfactory remedies. In stiff neck, rub well with some liniment, as chloroform liniment, and lie in bed on a hot water bag. Phenacetin or salophen in doses of ten grains, not repeated more frequently than once in four hours for an adult, may afford relief; only two or three doses should be taken in all. In lumbago the patient should remain in bed and have the back ironed with a hot flatiron, the skin being protected by a piece of flannel. This should be repeated several times a day. Or a large, hot, flaxseed poultice may be applied to the back, and repeated as often as it becomes cool. At other times the patient may lie on a hot water bag. Plasters will give comfort in milder cases, or when the patient is able to leave the bed. A good cathartic, as two compound cathartic pills, sometimes acts very favorably at the beginning of the attack. Salicylate of sodium is a useful remedy in many cases, the patient taking ten grains three times daily, in tablets after eating, for a number of days. In rheumatism of the chest, securing immobility by strapping the chest, as recommended for broken rib, gives more comfort than any other form of treatment. Many other measures may be employed by the physician, and are applicable in persistent cases, as electricity and tonics. The hot bath, or Turkish bath, will sometimes cut short an attack of muscular rheumatism if employed at the onset of the trouble.

“Blackheads” appear as slightly elevated black points, sometimes having a yellowish tint from which a little, thin, wormlike mass may be pressed. Pimples and blackheads are both due to inflammation about the glands of the skin which secrete oily material; the mouths of the glands become plugged with dust, thus retaining the oily secretion and causing blackheads. Then if these glands are invaded by germs producing pus, we have a pimple, which usually results in the formation of matter as described above. Constipation and indigestion favor the occurrence of pimples and blackheads; also a poor state of the blood, or anæmia.

Treatment. Tea, coffee, tobacco, and alcohol should be avoided, together with veal, pork, fats, and cheese. The bowels must be moved daily by some proper cathartic, as cascara tablets containing two grains each of the extract. The dose is one to two tablets at night. The blackheads should be squeezed out with a watch key, or with an instrument made for the purpose, not finger nails, and pimples containing matter must be emptied after being pricked with a needle (which has been passed through a flame to kill germs on it). If there is redness of the skin and irritation associated with pimples, it is sufficient to bathe the skin with very hot water and green soap three times daily, and apply calamine lotion at night. In other cases, when the skin is not sensitive, and zinc or mercury has not been used, the employment of sulphur soap and hot water at bedtime, allowing the suds to dry and remain on the face during the night, is to be recommended. An ointment consisting of half a dram of precipitated sulphur with half an ounce each of powdered starch and vaseline applied each night, and hot water used on the face three times daily are also efficacious. Sulphur lotion is better than sulphur ointment.

Decayed Teeth. These not uncommonly give rise to headache.

Disorders of the Nose and Throat. Such troubles, especially adenoids and enlarged tonsils in children, enlarged turbinates, and polypi (see Nose Disorders) are fruitful sources of headache. In nose headaches there is often tenderness on pressing on the inner wall of the bony socket inclosing the eyeball.

Diseases of the Maternal Organs. These in women produce headache, particularly pain in the back of the head. If local symptoms are also present, as backache (low down), leucorrhea, painful monthly periods, and irregular or excessive flowing, or trouble in urinating, then the cause of the headache is probably some disorder which can be cured at the hands of a skillful specialist in women’s diseases.

Antitoxin is the treatment above all other remedies. It has so altered the outlook in diphtheria that, formerly regarded by physicians with alarm and dismay, it is now rendered comparatively harmless. The death rate has been reduced from an average of about forty per cent, before the introduction of antitoxin, to only ten per cent since its use, and, when it is used at the onset of the disease, the results are much more favorable still. This latter fact is the reason for obtaining medical advice at the earliest opportunity in all doubtful cases of throat ailments; and, we might add, that the diagnosis of any case of sore throat is doubtful, particularly in children, whenever there is seen a whitish, yellowish white, or gray deposit on the throat. Antitoxin is an absolutely safe remedy, its ill effects being sometimes the production of a nettlerash or some mild form of joint pains. In small doses, it will prevent the occurrence of diphtheria in those exposed, or liable to exposure, to the disease. The proper dose and method of employing antitoxin it is impossible to impart in a book of this kind. Paralysis of throat, of vocal cords, or of arms or legs partial or entire is a frequent sequel of diphtheria. It is not caused by antitoxin.

The points which it is desirable for everyone to know are, that any sore throat with only a single white spot on the tonsil may be diphtheria, but that when the white spot or deposit not only covers the tonsil or tonsils (see Tonsilitis) but creeps up on to the surrounding parts, as the palate (the soft curtain which shuts off the back of the roof of mouth from the throat), the uvula (the little body hanging from the middle of the palate in the back of the mouth), and the bands on either side of the back of the mouth at its junction with the throat, then the case is probably one of diphtheria. But it is often a day or two before the white deposit forms, the throat at first being simply reddened. The fever in diphtheria is usually not high (often not over 100° to 102° F.), and the headache, backache, and pains in the limbs are not so marked as in tonsilitis.