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strains. As a rule, only one type of organism isharboured by patient or carrier. During an epidemicthe carrier rate rises considerably. The best way of

preventing an outbreak of the disease is to avoid over-crowding. If overcrowding is unavoidable inhalationsare effective in temporarily checking the carrier rate.The efficiency of serum treatment depends largely onthe amount of anti-endotoxin the serum contains, butthe manufacture of a satisfactory serum is still a matterof difficulty. Researches are now being carried out onthe standardisation and preparation of antimeningo-coccic serum.Dr. T. G. M. HINE (Berkhamsted) analysed 260 reports

received from all over the country. These reportsincluded clinical notes and results of treatment.Mortality before serum treatment was about 70 per cent.Mortality from 1914-18 was 60 per cent. in the civilpopulation, but dropped to 35 per cent. in militarycases. The latter were treated mainly with Gordon’smonotypical serum. The mortality was definitelyreduced in cases treated with serum containing anti-endotoxin against the corresponding type of organisms.Serum treatment must be instituted early and in

adequate doses to be effective. A pooled serum can beused until the type of meningococcus is identified.Dr. C. W. PONDER (Maidstone) agreed with Dr.

Arkwright as to the uselessness of isolating carriers.An omcial opinion should be expressed on this point.He examined the bacteriology of the naso-pharynx ofnon-contacts among the civil population. The meningo-coccus was found in 41 per cent., and of these 38 percent. gave sugar and agglutination reactions, and 26 percent. were positive to absorption tests. These resultsare higher than those obtained by other workers amongcontacts. He thought carriers of the meningococcuswere comparable to the people who,carry pneumococciin their throats and whom no one would dream of

isolating.Dr. A. GARDNER ROBB (Belfast) agreed with Dr.

Arkwright that polyvalent sera are of more generaluse than monovalent sera. Unless he had Dr. Gordonat his elbow to type the organism he would always usethe polyvalent. The results with polyvalent sera wereas good as those with monovalent sera when figureswere carefully compared and the disadvantages andinexperience of early workers remembered. Fallaciesmight arise in statistics if age-periods are not taken intoaccount. The results in infants were far worse than inpeople of military age. The death-rate at Belfast,taking all cases, was 27 per cent., and in military cases12 per cent. Results, taking age-periods into considera-tion, were about the same in the civil as in the militarypopulation.Dr. J. A. GLOVER (London) showed charts illustrating

the effects of overcrowding on the carrier rate and on theoutbreak of the disease. After about three weeks ofovercrowding the carrier rate rose above 20 per cent.,and cases of cerebro-spinal meningitis began to occur.Cultural meningococci are present in the naso-pharynxin normal times, but the proportion of serological typesincreases enormously in epidemics. As soon as over-crowding was avoided the carrier and incidence ratesfell.Dr. J. C. G. LEDINGHAM (London) spoke of his

experience in the East. Detention and isolation ofcontacts was impracticable, but avoidance of over-

crowding and general hygienic measures were effectivein checking the disease. The relation of pathogenicbacteria to their homologues needed study. He did notthink the use of monovalent serum was practicable.Dr. W. E. CARNEGIE DICKSON (London) discussed the

morbid anatomy of cerebro-spinal meningitis and thepaths by which the organism reached the meninges. Heproduced specimens to show that infection of theventricles may be earlier and more severe than that ofthe meninges.Major W. J. TULLOCH (St. Andrews) answered some of

the criticisms made on the work of the central labora-tories. He thought too much attention had been called Ito exceptions in agglutination ; 98 per cent. of meningo- 7cocci can be agglutinated by four typical monovalent csera. Concerning absorption of agglutinins, with the c

employment of standard technique no difficulty is foundin typing the cocci. Standard technique is of the utmostimportance both in culture and agglutination experi-ments, and no work is of value unless the techniquefollowed is described.Dr. A. C. E. GRAY (London) confined his remarks to

the value of antimeningococcal serum. In his experi-ence the mortality depended on the efficiency of theserum used. Efficient treatment during the first threedays really settled the issue, and this must be donewith polyvalent serum. He had had no success withmonovalent serum when polyvalent serum had failed.The occurrence of serum sickness varied greatly withthe serum used. It was not due to differences in dose.Administration of serum should not cease with thedisappearance of meningococci in the cerebro-spinalfluid, but should be continued for at least four days.Dr. J. G. FORBES (London) described a case of

meningitis caused by the Diplococcus crass1ts, and gavean account of the characteristics of the organism.

Dr. S. R. ScoTT (London) did not consider that thereis any magic number of types of meningococcus. Underconditions of overcrowding there is rapid passage ofthe organism from one individual to another, and it

acquires special virulence.Dr. ARKWRIGHT replied to various criticisms, and

regretted that time did not permit him to enter morefully into the many points of interest that had arisenduring the discussion.Dr. GORDON, in replying, said that in any effort to

limit the spread of the meningococcus varying suscepti-bilities must be taken into account. Recruits weremore susceptible than old soldiers. Prophylacticinoculation had not proved satisfactory. Monovalentsera were only undertaken as a preliminary to producingan efficient polyvalent serum.

COMBINED MEETING OF THE SECTIONS OFGYNÆCOLOGY AND ELECTRO-THERAPEUTICS.

THURSDAY, JULY 1ST.AT a combined meeting of these sections, which took

place on July 1st, Dr. A. E. BARCLAY (Manchester) tookthe chair. Owing to the illness of Dr. ROBERT KNOX(London) he called upon Dr. SHILLINGTON SCALES(Cambridge) to read Dr. Knox’s paper.

Treatment of Uterine Fibroids.At the commencement of his paper Dr. Knox stated

that it was essential for all cases of uterine fibroidsto be examined by a gynaecologist before treatmentby X ray was undertaken. He illustrated the benefit ofsuch collaboration by quoting a case in which theopinion of a gynaecologist was refused, with the resultthat treatment failed to give relief. Later the patientwas persuaded to have a second opinion, and it wasfound tnat she was suffering from a mucous polypus.Pathological reports on the blood were also of greatvalue. -

At the special request of the members present fulldetails of Dr. Knox’s technique were then read. -In hisopinion the following were the contraindications totreatment by X rays or radium : (1) Calcareous degenera-tion ; (2) other forms of degeneration if at all advanced;(3) coexisting malignant disease unless considered in-operable ; (4) infection of the uterus; (5) pelvic inflam-mation ; (6) inflammation of organs in the vicinity-e.g., cystitis, appendicitis, &c.; (7) submucous pedun-culated fibroids. There W9re several disadvantages tothis line of treatment, such as the long time taken toeffect a result, treatment being given at intervals ofseveral months. Moreover, treatment is not invariablysuccessful; the tumour is often reduced in size, but doesnot disappear. The dangers which exist, such as

burns, &c., are easily avoided if the treatment iscarried out by an expert. There are, however, greatadvantages. The treatment is quite painless, there isno interference with the patient’s routine of life, nooperative shock, and rapid return to health when thehaemorrhage has been arrested. Finally, the authorliscussed the most suitable types of case for this form)f treatment.

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Dr. H. WILLIAMSON (London) pointed out the advan-tages of this combined meeting. Before entering upon thediscussion of X ray treatment he thought it was wise torealise the very satisfactory results obtained by opera-tion. Hysterectomy at the present time was one of themost satisfactory operations in the whole of surgery.The operation does not deprive the patient of herovaries, a very important consideration. In his opinionX ray treatment was contra-indicated in the follow-ing ten groups of cases: (1) Where the patient isunder 40 years of age; (2) where the tumours can beremoved by enucleation, either from abdomen or fromvagina; (3) where the fibroid shows evidence of

degenerative changes; (4) where the tumour is verylarge; (5) where there is evidence of inflammatorylesions in the ovaries and tubes ; (6) where there is anysuspicion of malignancy; (7) where there are severe

pressure symptoms in bladder, rectum, <&c. ; (8) wherean ovarian cyst is also present; (9) where the fibroid iscomplicated by pregnancy; (10) where the patient isgravely anaemic, and the R.B.C. less than 2’5 millions.Finally he stated that the most suitable cases for thisform of treatment were those over 40 years of agewith a small or moderate-sized tumour, with no evidenceof degeneration or malignancy, and where anaemia wasnot a marked symptom.Dr. LOUISA MARTINDALE (Brighton) read a report on

118 cases of Fibromyomata treated by her since 1914.Of these, 37 cases were treated by X ray therapy alone,in 5 more hysterectomy was subsequently performed. IHer choice of treatment was influenced by the size ofthe tumour. A very large tumour (i.e., a tumour

greater than the size of a six months pregnantuterus) was a distinct contra-indication. Likewisewere pedunculated or submucous fibroids. The averagenumber of treatments was seven, but amenorrhoea wasobtained after an average of four applications. In4 cases, a further series of applications was necessaryafter several months. Finally, the speaker gave avery lucid and concise account of the technique sheemployed.Dr. CUTHBERT LOCKYER (London) re-stated the views

he had published some years ago: (1) Althoughacting mainly by destroying the ovaries, X rayshave also a destructive influence on the cells of the

myoma as evidenced by the shrinkage under treatment,which, when achieved, is too rapid to be explained byinhibited ovarian activity alone. (2) Radium and meso-thorium alone are not so suitable as X rays for cases ofmyoma as no shrinkage of the growth can be expected.(3) X rays combined with radium and mesothorium

appear to affect more rapid h2amostasis than X raysalone. (4) The French " cross-fire " combined withintensive technique promises the best results ; only by"cross-fire " can topographical difficulties be overcome.(5) Treatment is of no avail in cases of submucous

growths. Since then he had somewhat modified his

opinion in favour of the use of radium. He did not

quite agree with the treatment of young patients bythis means, until the regulation of dosage was moreexact.Mr. F. L. PROVIS (London) said that the Rontgen

treatment of gynaecological cases should be conducted bythe gynaecologist himself. A very careful selection ofcases should be made and the diagnosis be absolutelycertain. The length of time taken to effect a cure hasbeen quoted as a disadvantage of X ray treatment. Thisstatement, critically examined, does not hold good.Compare the result with that of supra vaginal hysterec-tomy. On an average it takes 18 months to cure byX rays, and menopausal symptoms are not severe. Itis questionable whether a patient is in perfect healthafter a hysterectomy has been performed. Also vaginalhysterectomy induces an early menopause.Dr. S. G. SCOTT (London) considered that satisfactory

results are dependent upon two factors: (1) efficientdosage, (2) careful investigation of cases before treat-ment. He did not, however, think that any finaljudgment was at present possible: firstly, becausesufficient material was not forthcoming, and secondly,because it is only since the advent of the Coolidge tubethat it has been possible to give anything like consistentand effective doses.

Dr. AGNES SAVILL (London) spoke of the advisabilityof fewer and shorter exposures, to avoid the nausea sofrequently found after this form of treatment.Dr. W. MITCHELL (Bradford) agreed with previous

speakers that in papers published on this subject dosagewas very inexactly described. He considered that thequestion of dosage to be given in any individual caseshould be left to the radiologist.Dr. SHILLINGTON SCALES agreed that our present

methods of treatment were largely empirical, andthat it was impossible to lay down any acceptedstandard as suggested by Dr. Cuthbert Lockyer, owingto the fact that the methods of each skilled worker,whilst arriving at the same result, differed so consider-ably in detail both as to dosage and filtration. Noworker skilled in this form of treatment would consentto carry out unquestioningly a prescription of dosageand technique ordered by a physician or even a gynoe-cologist whose experience in this respect was not sogreat as his own. For a gynaecologist of equal practicalexperience would probably prefer to carry out the treat-ment himself, and Dr. Cuthbert Lockyer’s disclaimerof the necessary knowledge would indicate that thiswould not often be the case. He was glad Dr. Williamsonconsidered that adverse developments following uponX ray treatment were not necessarily caused by it,and he himself thought that operative treatment wasfollowed by even more frequent ill-results. Our know-

ledge of the biological effect of X rays was still farfrom exact, and our methods and apparatus so subjectto change and advance that standardisation of our

technique was at present impossible.

SECTION OF PHYSIOLOGY AND PHARMACOLOGY.

WEDNESDAY, JUNE 30TH.Meetings of this section took place on June 30th,

July lst, and July 2nd. On the first of these dates adiscussion on

Acidosis in Diseasewas opened by Professor F. GOWLAND HOPKINS, F.R.S.,the President of the section. Professor Hopkins firstemphasised the need for the removal of the ambiguitywhich is associated with the use of the term acidosis."He then went on to describe the regulation of thereaction of the tissues, pointing out that the bloodconstitutes a kind of mechanism for the coarse

adjustment of the concentration of hydrogen ions,the more exact regulation being brought about

by the kidneys and respiratory centre. Thedisturbance of reaction produced by exposureto anoxaemic conditions as described by Haldaneand his co-workers, and the appropriateness of theterm " alkalosis " to the description of the symptomswas discussed. Professor Hopkins concluded his speechby referring to the riddle presented by the production ofthe acetone bodies when carbohydrate metabolism isarrested or disturbed.

’

Professor W. M. BAYLISS, F.R.S., suggested that therewas little use for the word " acidosis " in the sense ofan actual increase of concentration of hydrogen ions, assuch an eftect was rarely produced in life. Thesymptoms of reduced alkali reserve were probably notdue to excess of hydrogen ions. The speaker quotedexperiments which showed that the plasma proteinstook no part in the regulation of the reaction of theblood.Further emphasis was placed on the desirability for

a clearer definition and application of the nomenclatureby Dr. H. H. DALE, F.R.S.Professor T. H. MILROY pointed out that the acetone

bodies were very strong acids, and in this way accountedfor the marked fall of alkali reserve in conditions ofketosis. He discussed the increased output of ammoniaand the utilisation of alkali administered by the mouthin these conditions.Dr. E. P. POULTON pointed out a source of fallacy in

Van Slyke’s method for estimating the alkali reserveof blood on account of the variation of the carbon-dioxide combining power of the plasma with the carbon-dioxide content of the blood from which it was separated.He then referred to a number of cases in which theactual reaction of the blood had been measured directly,