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within the last four years. I do not think the methodso suitable to children under 14 years of age, since tothem a general anaesthetic is usually less alarmingthan the appearance of electrical apparatus. Theprocess here called diathermy is strictly a com-binatioii of true diathermy and fulguration.Broadly speaking, the stage of true diathermycoincides with the production of sufficient heatwithin the tonsil to kill the tissue and boil containedliquids. Fulguration is the condition of electrically" arcing " off the surface of the tonsil in order toseal efficiently and permanently both arteries and ’,lymphatics. There are no contra-indications tothis method which would not apply to the simplestof surgical operations. The general health of thepatient should be noted and oral sepsis eliminatedas far as possible. As already mentioned, eachtonsil is surrounded by a maximum surface ofmucous membrane, and this fact ensures the successof cocaine spray anaesthesia. No general anaesthetichas ever been required and, of course, the use ofether would be precluded by the presence of hightension electricity. I have found it quite unnecessaryto inject cocaine, and it has always been sufficient tospray the throat with not more than 2 grains ofcocaine hydrochloride freshly dissolved in twodrachms of water.The tonsillar electrode is usually a small metal ball

mounted on a curved insulated handle of ebonite. Avariety of holders have been constructed to cope with anyangle of application.’ As the result of experiment, noadvantage was found in using more than one indifferentelectrode, and finally a sheet of thin lead, 8 in. by 6 in.,has been selected as standard ; it is covered by four thick-nesses of plain lint saturated in 20 per cent. salt solution.This electrode is securely strapped to one wrist and bearsa large M.S.A. diatheimy terminal. The frequency ofoscillation of the diatheimy machine is not at all critical,and the several well-known makes of apparatus whichI have tested all gave excellent results with a diathermycurrent of two amperes. This current can constantly beobtained once the necessary setting for the particularmachine has been determined and, when used with theresistance of an average patient, rapidly causes a rise oftemperature in the tonsil to approximately 100° C. Assoon as anaesthesia is complete the indifferent electrodeis fixed to the forearm, the patient comfortably seatedin a supporting chair, and the tongue depressed by meansof a glass spatula. The active electrode is then placed infirm contact with the tonsil and the current switched on.The tonsil soon shows, radiating from the centre of theactive ball electrode, a zone of coagulated tissue, whichrapidly desiccates. Complete destruction of the tonsil iseffected slightly beyond this area of coagulation. Thewhole process lasts but a few seconds, after which theactive electrode is deliberately arced a few times from thesurface of the tonsil in order to seal any vessels. It may bea little difficult at first to determine the depth to whichcoagulation has taken place, especially if the operator isunfamiliar with more general surgical diathermy. Muchuseful information was acquired by the writer from sectionsof raw beef treated with varying electrodes and intensities.It is occasionally advisable to complete the tonsillectomyin two, or very rarely, three, stages, but this only appliesto very large tonsils, or, alternatively, to extremely nervouspatients.

Post-operative Procedure.The patient is invariably seen at the end of a

month, and again after three months. Should a

fragment of lymphoid tissue have escaped, it is, ofcourse, removed at this stage. There is no need tohospitalise the patient and the discomfort is relativelyslight. The operation is practically painless. Duringthe 36 hours or so following the treatment theperitonsillar tissue becomes cedematous, which Ibelieve to be the rule in all operations involvingmucous membrane. A suitable hypnotic such as

Allonal will ensure the first night’s sleep. I findapproximately 20 per cent. of cases show a rise intemperature, which rapidly subsides in a few hours,and for this reason I have lately ordered all patientsto remain in bed for 48 hours after operation. Anantiseptic mouth-wash is ordered to be used aftereach meal, but gargling is absolutely forbidden,lest undue strain be placed on the throat. Thecoagulation slough commences to separate in a few ’,

days and the process continues for about ten daysor a fortnight. During the latter part of this periodthe slough may prove slightly malodorous, but thisdoes not seem to be realised by the patient, and ofcourse disappears with the departure of the slough.Secondary infection of the slough or underlyingtissue has not occurred in any instance. The generalreaction always remains slight and the localdisturbance reasonable. No secondary haemorrhagehas occurred throughout this work. A soft glassyscar, with practically no contraction of tissue,invariably results, and is assumed to be evidenceof a downgrowth of epithelium.

I believe that this application of diathermy totonsillectomy possesses at least all the advantagesof other methods, and yet none of their disadvantages.

Medical Societies.

HARVEIAN SOCIETY.

AT a meeting of this Society on April 10th, withDr. P. MONTAGUE SMITH, the President, in the chair,Sir THOMAS HORDER opened a discussion on

HIGH BLOOD PRESSURE.

His interest in the subject, he said, was chieflyclinical; he differentiated between three types ofcase. In the first group he placed those patientswith evidence of definite organic disease due to arterio-sclerosis or atheroma-i.e., those in whom there wasdiffuse arterial degeneration. This was the largestgroup of the three. Patients with this type of highblood pressure showed associated changes in theheart and kidneys, and later developed the renalcondition severally termed granular kidney, inter-stitial nephritis, and gouty nephritis. Symptomswere protean and included heart failure, angina,renal insufficiency, retinal changes, haemorrhages,thrombosis, and uraemia. Prognosis and treatmentwere less hopeful with this type of case than withthe others, and it was important to assess the stateof the myocardium. The second group was alsothe next largest. It comprised those cases in whichthe onset of symptoms and the development of highblood pressure were associated in the mind of thedoctor, but in which there was no certain evidenceof organic change in the heart, kidneys, or blood-vessels. These cases he classed as hyperpietics, butthe line dividing them from the arteriosclerotic typewas indefinite. Finally, there was a small group inwhich the renal element was dominant; there mightbe a mixed nephritis or frank parenchymatousnephritis. The patients were usually women in thelate thirties with a blood pressure registering 240 to 300systolic and 120 to 150 diastolic. They had albumin-uria, retinal changes, and no oedema; they usuallydied in uraemia.

Hyperpiesia.The cases in the second group might be subdivided

into five minor classes. First, the plethoric type ofman of sedentary habits, with a tendency to overeat.Hypertension in these cases might be in some degreecompensatory to cope with increased metabolism.Secondly, there were cases where hypertension wasdue to some exogenous poison, the commonest ofwhich was alcohol. Thirdly, there were menopausalcases. Women in the late forties often entered on astage of hypertension which might last some monthsor years and then, gradually or occasionally suddenly,subside. At one time he had thought a systolicpressure of 175 the limit beyond which these casesshould be considered pathological, but he had seenwomen with a systolic pressure of over 200 emergefrom this phase, and he was no longer prepared toset a definite limit. The diastolic pressure did notrise part passu with the systolic in this group, and the

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greater the lag the better the prognosis, since thediastolic pressure represented the permanent strainon the heart and vessels. Men often seemed to gothrough a similar phase of hypertension, but later inlife than women. Boys at puberty often experienceda similar rise in pressure, especially those boys inwhom the heart had given cause for concern. Somecardiologists said that they could detect thickeningof the brachial arteries in these cases but he did notknow how they did it. He considered that the risein tension might be a compensation for heart strain,since he was not one of those who held that the heartcould not be strained by exercise. Fourthly, therewas a group of nervous hyperpietics. In many ofthese the patient’s knowledge of his high bloodpressure helped to keep it high. Good effects could begot in these cases by encouraging equanimity.Finally, were there possibly cases which might becalled essential hyperpiesia ? Such patients had ablood pressure of 200 systolic, 100 diastolic, all theirlives, without evidence of toxic or other causes.

They complained of headache, giddiness, and lassitude.If these cases were understood they might help toexplain raised arterial tension in general. Were they,perhaps, the expression of an endocrine disturbance,and, if so, of the adrenal or the pituitary, or both ? PThe will-o’-the-wisp of focal sepsis had received

much attention in cases of hyperpiesia. A diffusesepsis might also be considered. affecting the wholeof the upper respiratory passages or a large sectionof gut. The evidence was elusive. Our predecessorswho called these patients gouty were as near the truthperhaps as ourselves in our eternal search for sepsis.Exacerbations of symptoms occurred from time to

time, accompanied by waves of hypertension. Inten-sive treatment should be undertaken during theseattacks. The prognosis was serious until organicdisease was excluded ; even then a patient with hightension could not be regarded as a good life. Hedisliked any case in which physical examination failedto reveal anything abnormal, and if there was afamily history of arterial disease he liked it even less.A man was not only as old as his arteries, but hisarteries were the resultant of the arteries of hisforbears.

Treatment.

Early diagnosis of high tension should lead toprophylactic treatment. It was impossible to changea temperament, but strains and stresses could bediminished. Reassurance in these cases was a formof treatment, and, if accepted, often caused a fall intension. It should be explained that high bloodpressure was not a disease but a symptom, andprobably a valuable adjustment. Rest and dietmust have their place ; it was less important to limitthe diet in any particular than to reduce the wholeamount taken. Much fluid should be avoided, sincewater was secreted by the kidneys, not merelydiffused, and therefore threw more work on them.Portal depletives such as mercury and salines werevaluable, and constipation should be corrected. Warmbaths and high frequency had their place, and vene-puncture was valuable during exacerbations ; hepreferred to remove 50 to 100 c.cm. of blood dailyfor a few successive days rather than to take a largerquantity on a single occasion. Drug treatmentincluded iodine, iodides, and occasionally nitrites.Digitalis was often helpful ; in these cases the heartoften needed tonics when it was erroneouslyimagined that depressants were required. Anabolinwere still on trial but had given no impressive resultsso far. Thyroid and bromide were useful for meno-pausal and nervous cases. For each individual thestate of the heart, the kidneys, the vessels, thenervous system, and the tissues must be assessed.Success depended on the care given to the individualcase.

Discussion.Dr. GEOFFREY EvANS agreed with Sir Thomas

Horder that it must be decided in every case whetherthe condition was functional or organic, but he

doubted whether a distinct line could be drawnbetween the two. In the menopausal cases he hadfound that the blood pressure rose, and then eitherreturned gradually to normal, or remained high andincreased, or else fell below normal and remainedthere. The first of these courses he regarded as

indicative of functional disease, the second of organic.The aetiology was the same ; possibly some patho-genic agent caused a simultaneous change in functionand in structure, but one change might outbalancethe other. The prognosis was better when structuralchanges were not apparent. The cause of the con-dition should always be sought. He described thecase of a medical student who at the age of 19 wastold by one doctor that he had a high blood pressure,and by four that he had not; he lived a tranquiltemperate life to avoid arterio-sclerosis, and at theage of 48 had a systolic pressure of 240 and a diastolicof 120. He had been developing this hypertensiongradually, without any cause being discovered.Progress of the disease was in waves-stationaryphases followed by exacerbations. Sir Clifford Allbutthad given the name of hyperpiesia to those caseswith persistent high tension and without urasmia inwhom death usually occurred from cerebral haemor-rhage. These were the cases which did not respondto rest and diet. At about 35 they began to developretinal haemorrhages ; a few years later renalsymptoms appeared, and at 45 they gave the typicalpicture of chronic interstitial nephritis. They diedof uraemia, cardiac failure, or haemorrhage. Asstructural and renal changes developed the prognosisbecame worse, but even in the absence of such changesdeath might occur from cerebral haemorrhage.

Dr. J. F. HALLS DALLY said that hypertensionwas a symptom of many causes ; it was thereforedifficult to formulate a scientific treatment. Over-feeding led to the retention of waste products whichwere not easily secreted by the kidney. Accordingto the French school the liver was an importantdetoxicating agent; he considered that in this con-dition the liver dysfunction was part of the generalcondition. Exercise was more important to restoreits action than cholagogues or salines. Control ofthe condition should be aimed at rather than treat-ment. The patient should regulate his life and hisdiet ; meat appeared to have no effect on the damagedkidney, and provided the diet was adapted to theminimum metabolic level it need not be otherwisealtered. As to intestinal togaimia, the only toxinwhich had so far been investigated had a depressor,not a pressor, action ; oral sepsis was more important.He did not agree that a man was as old as his arteries ;many patients with seriously diseased arteries livedfor years. The renal condition had much more effecton the prognosis. Attempts at reduction of pressureby drugs were usually dangerous ; in most casesthe high pressure was essential for kidney secretion.The diastolic pressure was more important than thesystolic because it was more constant and lessaffected by emotion. A diastolic pressure of morethan 120 was usually indicative of disease of thekidneys. Apoplexy usually occurred, not in thosecases with the highest pressures, but with thosebetween 160 and 190 systolic. He only used vene-section as an emergency measure, and starved thepatient for three days afterwards. He had had nogood results with anabolin, and all the results to beobtained from potassium iodide could be obtainedequally well with French tincture of iodide. Theiodine, not the potassium, was important.

Dr. A. H. DOUTHWAITE said that reassurance wasnot sufficient treatment for a patient during anexacerbation, and the symptoms must be relievedby reduction of pressure during the attack. He hadfound iodides, nitrites, bromides, and anabolin to bevalueless. Thyroid and dieting had been useful inmenopausal cases. In other cases he had found thatvenesection every two or three months worked welland relieved symptoms. At Guy’s Hospital intra-muscular injections of acetylcholine in doses of0-1 g. were being given ; a course of this treatment

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effected a reduction of pressure with relief of sym-ptoms lasting for a period up to six weeks. Hethought that intestinal toxaemia was associated withhigh blood pressure in those cases with foetor orisand sallow complexions, since these symptomsalways increased during exacerbations. Experimentson intestinal toxins had been carried out by injectionof a dose of the toxin into an animal; the fact thatno rise in blood pressure resulted gave no indicationof what would result from chronic intoxication.These substances might act by causing an hyper-trophy of the suprarenal medulla, with increase ofcirculating adrenalin. A similar mechanism was atwork during the menopause, when the ovarian hor-mone failed to exert its counteraction on the supra-renals, and accounted for menopausal hypertension.

Dr. ADOLPHE ABRAHAMS said that the school ofLewis did not hold that the healthy heart could bestrained by exercise, but the toxic heart might.Might not some of the boys at puberty seen by SirThomas Horder be cases of veiled renal disease ?The subject would be less involved if the height ofthe blood pressure was always correlated with thesymptoms. He took it that Sir Thomas Horderagreed that practitioners must insist that hyper-tension should not be considered to be arterio-sclerosisin every case.

Dr. GILBERT ORME said he had seen many casesof transient hypertension during the late fortiesamong male mill hands in the North of England.In all the cases which survived normal tension wasregained after about two years.

Dr. R. CovE-SMlTH said that probably everybodyhad his own normal standard of blood pressure, andno definite line should be drawn in deciding whereabnormal pressures began. He found it difficult tobring increased tension into line with cardiac strainas a compensatory mechanism. Digitalis was a

useful stimulant to the myocardium in cases of hyper-tension, and he knew of no evidence that it increasedthe blood pressure in the normal man.

Reply.Sir THOMAS HORDER said that he could not prove

that his young boys were not cases of potentialnephritis, but he had never heard of any nephriticdevelopments later. Changes in the vessels werenot necessarily an indication of their condition ; theymight be healed, in which case the man was asyoung as the repair of his arteries. He treated hispatients during exacerbations, not with reassurancemerely, but with rest in bed, a vegetable, fruit, andmilk diet, a fast day once a week, intensive iodine,and venesection. As to heart strain, if Dr. Abrahamswould watch the finish of the boat-race he would seethe text-book picture of heart strain among therowers: pallor, dyspnoea, and the typical facies. Ifthe coronary circulation was under the same controlas the general circulation, then hypertension mightvery well be compensatory for heart strain byincreasing the blood-supply to the myocardium.

BRISTOL MEDICO-CHIRURGICALSOCIETY.

AT a meeting of this Society held on April 9th,Mr. C. FERRiER WALTERS, the President, being in ’,the chair, Dr. A. D. FRASER read a paper on the ,

CAUSAL ORGANISM OF ACUTE RHEUMATIC FEVER

and its relationship to chronic rheumatism, cancer,and other diseases. An investigation into thepathogenesis of acute rheumatic fever had, he said,culminated in the isolation of a causal organismand the reproduction of the disease in animals. Theorganism had a very complicated life-history and had Ibeen found associated with many other diseases ofobscure origin. It was seen in an Aschoff nodule as anuclear body occurring singly or in pairs like dumb- I

bells, giant pneumococci, or a cottage loaf. It mightbe surrounded by a clear halo, as if encapsuled. Thestaining reaction to haematoxylin varied, beingsometimes dense black, sometimes light brown. Itcould not be identified by special stains. A Gram-positive coccus had been isolated from a case ofrheumatism. It grew well now on weekly subcultureand required no special media. It was non-haemolyticand formed acid with glucose, lactose, maltose,saccharose, and salicin. It acidified and clotted milkand produced small, uniformly pink colonies on bileagar. On nasgar the colonies were moderately large,rather opaque and moist, with even edges. It lookedthe same after repeated subculture as it had at first.It gave the impression of reproducing by budding.Cultures had been injected intravenously into rabbitsand had caused no obvious symptoms beyond wasting,but the animals had died in less than eight weeks.Autopsy revealed large firm vegetations on the mitraland aortic valves and small white areas in the kidneys.Microscopically there was marked interstitial fibrosisof the inner half of the myocardium and the papillarymuscles. In the outer half there were small focalareas of cells amongst disintegrated muscle-fibres;these consisted of large irregular cells with densely.staining nuclei together with the cottage-loaf cells.The vegetations on the valves consisted of masses ofcocci, mostly Gram-positive. There was, however,no inflammatory reaction in the underlying tissues.The renal abscesses proved to be more in the natureof infarcts, but no cocci were found in them. Cultureproduced a pure growth of the same coccus as had beeninjected, and this culture produced the same lesionswhen injected into another rabbit. The lungsshowed rheumatic pneumonia and two curious typesof structure lying in the small arteries or capillaries.One type was an irregular mass of nuclear materialwithout definite structure, with rounded, clearer,bulging ends. Their appearance suggested sporulatingbyphse of some kind of fungus. Some of them clearlyshowed the conjugation of two cells within a capsule,one smaller than the other. The other type was amass of acidophil cytoplasm containing small particlesof nuclear material of irregular shape and size. Aroundthese structures was marked endothelial proliferation,while the alveoli contained many cells and sometimesfibrinous exudate, together with many cottage-loafcells and cells with budding nuclei spores.

Dr. Fraser then described the post-mortem findingsin a case of chronic rheumatic fever which diedduring an acute attack. The large bowel had shownacute hyperaemia with black ridges running along themucosa in the long axis of the bowel and scatteredulcerated areas, covered by a yellowish-brown thinmembrane. Examination of smears from the ulcershad shown the usual flora with a predominant largebacillus, varying in its reaction to Gram stain. Amongmasses of mononuclear cells in the bowel wall hadbeen polymorphonuclear leucocytes and cells withthe budding nucleus. There were also large diplococci,some of which took Gram stain. Two fungi hadeventually been isolated from the ulcers.

The Oomycete and the Ascomycete.One of these fungi, an oomycete, was parasitic on

the other, an ascomycete. The latter had not yet beenobtained in pure culture. Ascomycetes rheumaticus,as he called it, grew well on all ordinary media andwas a facultative anaerobe. It formed acid in glucosebut had no effect on other sugars. In milk it caused aslight acidity and opalescence. It did not liquefygelatin. Its colonies on nasgar were large, smooth, andwaxy with irregular edges, and after some timehyphae grew down into the medium. For the firstday or two the cultures were like budding yeast cells,but longer oval cells appeared later and long septatebranching hyphae with large rounded cells at theirends. Occasionally two cells could be seen unitedby a conjugation tube. Similar cells were found in thelungs of rabbits injected with this organism; theanimals died within a week, with nodules in the heart,kidney, brain, and intestine.