If the brain is well constituted and naturally developed, the sexual desire undergoes a complex development in consciousness. It becomes refined through the interlacing plexuses of the ideational organization and from this basis are evolved all the delicate, exalted and beautiful feelings of love that constitute the store of the poet and play so great a part in human happiness and human sorrow. What is true of this particular desire is true of all our desires. Only by unremitting efforts at education can we hope to make moral prophylaxis efficient, and correct the errors so disastrous to society, as well as to individuals.

THE TONSIL QUESTION.

BY WILLIAM H. PHILLIPS, M.D., Cleveland, Ohio.

The tonsil question divides itself naturally into two parts: First, the advance in knowledge of the pathological significance of the tonsils; and second, the treatment of these conditions. Logically, it would seem that the sequence of the divisions in the tonsil question should be as above given, viz.: first the study of its pathology and next the treatment, but as a matter of fact the thing has been reversed and the reasoning has been of the a posteriori type. Thus first a method of treatment was promulgated and then by endeavoring to prove or disprove the rights of such treatment to recognition, much was learned regarding tonsillar pathology. In order to be orthodox and not disturb the existing order of things, for of all crimes that is the greatest,we shall adhere to this cart before the horse condition of affairs in this little resumé of the tonsil question, and consider the method of treatment first, and then the pathological significance.

Tydings, of Chicago, is credited with having performed, ten years ago, the first tonsil enucleation done in this country, and, as we are still practically the only country on earth doing such enucleation, he is probably to be credited with the first scientific tonsillectomy ever done. It appears that but few men followed Tydings' lead, for between 1900 and 1904 there is little in tonsil literature to indicate that much general interest was taken in the subject. In 1904 and '05, however, there began to appear in laryngological journals a series of excellent papers on the minute anatomy of the tonsil, and studies of the tonsillar capsule, so called, and also some few reports on the "radical tonsil operation." In 1907 the journals were filled, and have been ever since, with various technics for "tonsillectomy," and disputes, pro and con, as to the advisability of sacrificing all the tonsillar tissues, and the ultimate effect of such work upon the body economy. The literature of 1909 shows practically an unanimity upon the part of recognized laryngologists as to the treatment of diseased tonsils, viz., surgical, and with but one standard of surgery, viz., complete tonsillectomy. In 1911 the tonsil question is already on the wane.

A standard has been established beyond cavil and now it is merely a question of the individual keeping up to the standard.

Why has tonsillectomy taken the place of the older tonsillotomy? First, because it is the only method by which that form of tonsil most frequently associated with the severer types of infection, the submerged tonsil (of which more later) can be adequately removed; second, because recent careful study of tonsils and tonsillar diseases shows that the foci of infection in diseased tonsils, lie, not in the mouths of the crypts, but at their bases next to the capsule. It is from this point that toxins or germs. find their way through the lymphatics to the deep cervical glands and into the circulation and thence to various parts of the system. Tonsillotomy, however radical, because it does not reach the capsule, accomplishes nothing in a diseased tonsil except possibly to seal the cut openings of the crypts by inflammatory debris and leave an infected stump. This stump is capable of producing more serious trouble than the undisturbed organ created originally when the mouths of the crypts were wide open.

To those of you who feel that you have seen much good following tonsillotomy and that it is a proper operation in the light of present knowledge, the following may elucidate matters. Two types of operative tonsils are recognized by laryngologists today, first, the protruding tonsil, be it hard or soft, and second, the submerged tonsil. The protruding tonsil is the one so frequently guillotined. In the majority of cases the only disturbance it produces is the obstruction it offers to respiration and this is far more frequently due to the associated adenoid than to the tonsil. It is rarely the seat of serious infection, except the acute diseases, scarlet fever, diphtheria, etc., and as a rule is but a part of a general hypertrophy of the pharyngeal lymphoid ring. Many of these cases seem to improve after tonsillotomy if a thorough adenectomy was done at the same time, for as said before, the tonsil condition is more a functional hypertrophy, the result of the mouth breathing forced by the adenoid growth, than a diseased condition and the improvement is largely due to the adenectomy. If the adenoid was not removed, or was imperfectly removed, these tonsils will often fill out again very rapidly, so much so that in the course of a few months it will look as though nothing had been done. Notwithstanding the fact that improvement, at least in appearance, often follows the guillotine in these cases, these protruding tonsils if operated at all are better treated by tonsillectomy, first, because recurrence of the hypertrophy is thereby avoided and, second, because no stump is left, either already infected or to be infected later.

The second form of operative tonsil is the submerged type and this unfortunately, or perhaps fortunately, cannot be successfully guillotined. It is the so-called small tonsil, innocent looking enough to the unpracticed eye, often producing a distinct enlargement to the finger when applied externally at the angle of the jaw,

and not infrequently associated with enlargement of the so-called tonsillar gland of Wood, or the whole deep jugular chain. It is not often accompanied by much adenoid enlargement. It is the so-called small tonsil and yet, when enucleated its size is often surprising. To understand fully the why and wherefore of the submerged tonsil, one must be familiar with the anatomy of the tonsil and its surrounding structure; a thing we need not go into deeply at this time. Suffice it to say, that its faucial surface is covered in by two tightly applied folds of mucous membrane, the supra tonsillar fold above and the plica triangularis anterior and below. These folds close the mouths of the crypts of a large portion of this tonsil, preventing their drainage and ventilation and closing in such products of infection as may find entrance. Enlargement of the tonsil is upward into the soft palate, forward and backward, dissecting its way beneath the pillars, downward beneath the plica and outward into the constrictor of the pharynx. Recent study has demonstrated that it is this tonsil above all others which is the diseased tonsil and most often demands removal. As the infection usually lies deep at the base of the crypts in contact with the capsule, the tonsil must be removed either down to the capsule or with the capsule. A tonsillotomy here is practically certain to leave an infected stump bound to defeat the object of the operation and be the source of much future trouble. Complete removal down to the capsule is a difficult and unsatisfactory thing, because of the intimate relation between tonsil and capsule. It is much casier to shell it out capsule and all.

Pathologically considered, recent study of the tonsils has demonstrated especially one thing, that, as stated before, it is the submerged tonsil, to which little attention has been paid in the past, to which we are indebted for much. By pressure and interference with free muscular actions, it is responsible for some cases of tubal deafness and tinnitus. Practically all cases of primary tonsillar or glandular tuberculosis and recurrent quinsies are associated with this form of tonsil. It is the hotbed of the follicular or toxic tonsillitis which is such a frequent accompaniment of our grip epidemics, and many a case of acute articular rheumatism, toxic or septic endocarditis and nephritis is directly traceable to toxic or bacterial absorption from this point during an epidemic of strepto- or pneumo-coccic grip infection. Davis, during the epidemic strepto-coccic infection of 1909-10 made bacteriological examinations of forty-five submerged tonsils removed in the capsule from grip patients, and every one showed strepto infection at the base of the crypts. Wood and Grober have shown a direct connection between the tonsil and the apex of the lung, the choice site of pulmonary infection, demonstrating anatomically the possibility of direct infection of the lung from the tonsil, and the probability that many cases of pulmonary tuberculosis owe their origin to this tonsil. Many obstinate eye infections, recurrring iridocyclitis, episcleritis, phlyctenular keratitis, etc,. which respond

to the tuberculin test are cured permanently only after enucleation of these tonsils. Kramer reports follicular tonsilitis as often attendant upon tuberculin treatment and explains it as the flaring up of a hidden tuberculous deposit in the tonsils. Wright and Hurd report a series of twenty-five submerged diseased tonsils enucleated in the capsule, more than half of which showed tubercular deposits around the capsule.

In the past two or three years, as a result of a better understanding, our attitude toward tubercular or infective lymph-adenitis of the neck has undergone much change, so that today the progressive surgeon is less and less inclined to advise radical removal of simply the passive carriers of infection, thereby inviting recurrence after recurrence, but goes to the source of infection and urges complete eradication of the submerged tonsil first; thereby he often has the pleasure of seeing his patient recover completely and without a neck full of scars, for it is a well known fact that the lymph glands can take care of an enormous amount of infection, if only the supply be shut off.

A review of tonsil literature is interesting and instructive, interesting in that it shows that until tonsillectomy was established, most laryngologists detested tonsil surgery, first, because it was crude and unscientific; second, because results were unsatisfactory and reflection was thereby cast upon their work. Personally until three years ago I had practically given up tonsil surgery and the little that I did still remains to haunt me and I am redoing it as fast as possible. Such a study is instructive in that the pathway of many obscure infections is being brought to light. The problem of tuberculosis begins to assume a different aspect as it becomes more and more a possibility that the tonsil is the real pathway of infection in perhaps a large percentage of the cases and the origin of many obscure infectious processes is being brought to light. We do not yet know the why and the wherefore of the tonsil and, of course, until we do we can never fully appreciate its pathological significance, nor can we say that its surgery is upon an absolutely scientific basis, but certain it is, if results count, we took a long step in the right direction when we accepted complete tonsillectomy as a recognized procedure.

TREATMENT OF PNEUMONIA.

We hear much from our friends of the dominant school concerning the scientific methods of treating this disease and the wonderful results that follow the same. At times, however, when the actual results thus obtained are compared with those of former years, enthusiasm is less prominent, and much food for thought results. An article that recently appeared in the Interstate Medical Journal upon the present status of pneumonia written by Beck of Baltimore rather well illustrates this. Among other things he says:

"The great instruments to be employed in the treatment of inflammation of the lungs are blood-letting, tartarized antimony and mercury; of these blood-letting is the chief." This statement is quoted from Watson's "Practice," 1845. In the light of modern therapy this seems quite obsolete, yet it is doubtful whether the results to-day are better than they were in the days when every patient suffering from pneumonia had to be bled.

NERVOUSNESS AS A HABIT.*

BY FRANK C. RICHARDSON, M.D., Boston, Mass.

Professor of Nervous Diseases, Boston University.

The present day enthusiasm in the conservation of health and the prevention of disease is shared by every branch of medical science.

The effort at discovery and elimination of the psychic causes of nervous and mental diseases by workers in those fields is no less important than that of the laboratory worker in his search for virulent microorganisms and immunizing sera.

Whether or not nervous and mental diseases are on the increase, it must be admitted that the American people of today are deservedly looked upon as a nervous race.

The pernicious influences with which our business and social life abounds are well recognized and considerable has been accomplished in the way of correction.

In recent years there has been an unmistakable tendency toward shorter hours of work, more out of door life, more rational recreation, and less indulgence in alcoholic and other ex

cesses.

Fewer business houses expect, or permit, their salesmen to include in expense accounts large sums for alcoholic persuasion. We hear of prolonged drinking bouts and forty-eight hour poker seances rarely except as reminiscences of by-gone days.

Notwithstanding these and other evidences of an awakening realization of the necessity for conservation, under the impulsion of the modern necessity for luxuries, the strife for gold and place still wages fiercely. Business methods tug hard at the restraining bonds of legitimacy, and social custom approaches perilously near the border line of license. Conscience may be stilled by the specious excuse of "universal custom," but the steadying, uplifting, ennobling influence of conscious rectitude is lost and for this there can be no compensation.

Competition makes tense every power of mind and body, and the frequent combination of intellectual superiority with mental instability furnishes to the young and ambitious an alluring but dangerous example.

While it may be true that the world's best work is done by neurotics, that "ordinary men are the only ones who enjoy normal health" (Tchekhof), that "the Philistine is a wholly successful fool" (Nordau) it cannot be denied that even in these better days hosts of human beings are being driven by the harassing tire of a hard and wearing life, or the pressure of a too complicated civilization, to nervous disaster and mental incompetency.

It is, therefore, necessary that the educational campaign against influences pernicious to nervous and mental integrity be

President's address delivered at the meeting of the Society of Neurology and Psychiatry held at Narragansett Pier, June, 1911.