have seen men and women go insane under the burden of the anxiety. In these extreme instances it may well be believed that the insanity was lingering unrecognized until the accident suggesting fear of venereal disease became the immediate and exciting cause of the disaster.

The bases of the suspicions of these people are widely different. Some individuals exhibit tangible lesions of the surface, which they choose to misinterpret, after a real or fancied exposure to venereal disease. Thus a facial acne, a keratosis pilaris of the outer faces of the thighs and arms, a telangiectasis ("spider cancer") of the surface of the chest, some innocent mollusca of the scrotum, or a few aphthous ulcers of the mouth due to indigestion, serve as unmistakable signs of syphilis. Often in their restless anxiety these victims swallow medicaments with a view to eradicating the malady with which they are convinced they are infected, and these drugs, by the production of a medicamentous rash, add to the supposed evidences of disease.

When no lesions are present on which to build these anxieties, a basis is readily discovered in the anatomical peculiarities of the body. In this way the bluish tinge at the rim of the corona glandis is taken to be a sign of "gangrene;" the fungiform papillæ of the tongue are named as "mucous patches;" the reddish hue of the meatus externus urinarius indicates “inflammation." In some cases the testicles are too closely drawn up to the body; in others they are too lax; in yet others the penis is shrinking; in women the vulva is beset with "papules" when its follicles are unusually conspicuous. If these unfortunates once become possessed of works on medicine, they are usually worse distraught. It is not at all surprising that even classical illustrations of this singular craze are furnished in the persons of physicians themselves. The subject, even though it seem to have a ludicrous side, is not without its tragic aspects. We have known men to take their lives in despondency

over such fancied disorder. The trained physician must be ready to appreciate every phase of the madness.

The treatment of the several forms of hypochondriasis described requires the utmost skill, prudence, and good judgment on the part of the physician. The chief remedy at hand is a knowledge of the truth. This alone is often sufficient. A common-sense explanation and a little encouragement often suffice to remove a persistent cloud of shame and dread. Unfortunately, as the history of the world clearly proves, men and women will not always listen to the truth. Sympathy does good at times; at others it is worse than useless, and ridicule, even scolding, may answer the end better. For the obstinate subjects who refuse all aid of this character and persist in retailing their long list of symptoms to the ear of the physician, he may even make shift to accomplish his end by wholesome threats. It may be wise in cases to point to the idiotic condition that occasionally crowns a labor of the sort upon which the hypochondriac is engaged, or even, as a last resort, to make it appear that, since the patient will listen to neither truth nor reason, his friends must be made acquainted with the facts in his case. The last is often an effective argument. It is a pitiable fact that some of these states are utterly hopeless. The patients either belong to the insane class or are of those of whom it was long since written that even brayed in a mortar their folly will not depart from them.

For the young male sexual hypochondriac important advice touches his moral surroundings; but over and above this he should be made to abandon tobacco and alcohol, to employ the flesh-brush after his cool morning bath, to avoid hot and Turkish baths, and even cold bathing at night, which is apt to be followed by undue stimulation when he is well warmed in bed. His food should be nutritious and simple. It is a common error for these young persons to attempt living on a slim diet to avoid stimulating the sexual propensity. All medi

cines of the sort commonly given to allay nervous excitability, such as bromide of potassium, are rigidly to be excluded. For these subjects they are vile remedies, and they exert an injurious effect upon the mental tone of the person who relies upon them. From a scientific point of view, they are given with a wholly false conception of the end to be attained. The bowels should be evacuated daily, and there should be open-air living and physical exercise. The dance, theatrical performances, club life, and the perusal of certain kinds of literature are equally harmful. To persons of this class medical books are to be especially prohibited.

ACUTE URETHRITIS.

THE term "urethritis " includes all forms of urethral inflammation. By far the most common of these inflammations is gonorrhoea. Cases of urethritis originating without the influence, direct or indirect, of gonorrheal infection are not common. Urethritis arises sometimes from other forms of infection, from constitutional defects, or from mechanical or chemical injury to the urethral membrane; but these forms of the disease are chiefly interesting from the standpoint of etiology, since in symptoms and treatment they correspond with some of the stages of the more common disorder. In the following pages, except where mention is made of other forms of urethritis or of the disease as it occurs in women, the subject under consideration is gonorrhoea in men.

Unfortunately, gonorrhoea has long been considered by the laity and by the majority of physicians a purely local disease, devoid of danger to health or life except when accompanied by local complications, such as epididymitis or prostatitis, or when followed, in improperly treated cases, by stricture and the resulting disorders of kidneys and of circulation. In consequence of this belief, the chief, and with many physicians the only, aim of treatment has been to remove a disagreeable discharge, other and more serious phases of this really formidable disease being entirely overlooked.

The various complications of gonorrhoea are considered in succeeding chapters. It is important, however, before describing the disease, to impress upon the minds of the physician and student the fact that gonorrhoea not only is followed frequently by serious complications, which may result in local deformities, sterility, stricture, kidney

disease, arthritis, sexual neurasthenia, and other forms of chronic invalidism, but also may be the direct cause of systemic toxæmias manifested in inflammation of various organs of the body, including the iris, retina, peritoneum, and meninges, or may produce metastatic infection and destructive inflammation of these organs, in some instances with fatal results. The gonococcus has been found and satisfactorily demonstrated in the blood, in synovitis, in tendo-vaginitis, in abscesses of various glands, in endocarditis, in pleurisy, and in other inflammations developed during the course of a gonorrhoea. In a few such cases, the gonococcus has been found in the blood.

Much evidence has accumulated to show that gonorrhoea, with or without the aid of a secondary pusinfection, is directly or indirectly responsible for some cases of neuritis, myelitis, meningitis, and other disorders of the nervous system, including locomotor ataxia and progressive muscular atrophy. That in women gonorrhoea is followed very frequently by severe and persistent pelvic disease is a fact now generally recognized by the medical profession.

In managing a case of gonorrhoea, the practitioner should not only bear in mind the possible serious consequences of the disease to the individual, but also should remember that without skilful and careful treatment the disease has a marked tendency to become chronic, and that the individual is often capable of transferring the disease through sexual intercourse long after all apparent discharge has ceased and he has considered himself cured. The number of men who thus unwittingly infect their wives cannot be determined accurately, but the list of innocent victims of the disease is certainly large. It is the duty of the physician, then, not only to treat his patient's gonorrhoea, but also to instruct him regarding its attendant dangers to others as well as to himself.

Etiology.-Though the majority of all instances of

also in Myelitis