1438 ] UNITED SERVICES MEDICAL SOCIETY.—MANCHESTER MEDICAL SOCIETY. [

child did well. The following indications were formulatedfor Cæsarean section in eclampsia : (1) Fits occurring in aprimigravida ; (2) onset of fits with no signs of’ the start oflabour; (3) a rapid succession of fits where consciousness isnot regained and coma is deepening ; (4) failure of advanceof cervical dilatation after several hours of an expectantattitude with the prospect of many hours’ delay before thesecond stage is reached ; (5) absence of any definite signs ofimprovement after eliminative treatment has been carried outfor several hours. The presence of all these indications consti-tutes a case of such gravity as to render the operationjustifiable.

Mr. J. M. WYATT drew attention to Le Fort’s Operationfor Prolapse, which he thought of great value in cases ofprocidentia in old people where any form of pessary fails tokeep the womb in position, and where laparotomy forfixation is contra-indicated.

Dr. H. KUSSELL ANDREWS introduced: (1) A case of Simul-taneous Uterine and Extra-uterine Pregnancy, in which" internal wandering " of the ovum seems to have occurred ;and (2) a small Ovarian Teratoma, containing, among otherstructures, brain and well-formed intestine.

Dr. C. HUBERT ROBERTS described a case of UrgentCæsarean Section in Contracted Pelvis, with prolapse of thecord. The mother and child recovered.

UNITED SERVICES MEDICAL SOCIETY.

Crux of the Medical Problem in War.A MEETING of this society was held at the Royal Army

Medical College on Nov. 13th, Fleet-Surgeon P. W. BASSETT- i

SMITH, C.B., R.N., being in the chair. A paper was read by Colonel BRUCE M. SKINNER,

M.V.O., A.M.S., on the Crux of the Medical Problem inWar. After pointing out that the accumulation of men incamps or bivouacs has invariably been followed by disease,usually in proportions amounting to an epidemic, and thateven under conditions of modern army sanitation this muststill be anticipated as a problem likely to accentuate thedifficulties of dealing with periodic accessions of largenumbers of wounded, Colonel Skinner showed that the

mobility of an army is influenced by the following factors :the amount of transport requisite, the amount of food

procurable, the amount of sickness amongst the troops, andthe necessity of protecting both supplies and also medicalunits occupied by the helpless. Any means calculated toreduce these factors making for immobility will obviouslyincrease the mobility of a force. For this reason it is neces-

sary for the army doctor to study war in order that he mayreadily grasp the designs of the field commander and beable to exercise a trained imagination in foreseeing andproviding for any military situations that may arise.Failure to exercise this trained imagination has led, andwill always lead, to failure in medical arrangements,even where material is ample. For instance, in Indianwarfare a medical unit cannot be left unguarded ; andif such a unit in the front line, instead of evacuatingits sick and wounded, becomes an extemporised hospital,the force is crippled by the necessity of furnishingtroops for its protection and perhaps so far hampered as tobe unable to give effect to the wishes of its commander

Consequently we realise the fundamental principle thatfield medical units must never become clogged with sick andwounded-a condition that can only be avoided by freeevacuation towards the base. Again, the fewer sick andwounded retained at the front, the more supplies are availablefor the healthy, and the nearer the base the hospital is

situated, the shorter the distance over which supplies of equip- ment, personnel, appliances, and food for hospital use have tobe transported, and the greater the technical efficiency ofsuch units. The true hospitals, then, must be on the linesof communication, and the advanced medical units shouldconsist mainly of ambulance transport. Colonel Skinnerinstanced Lord Roberts’s march from Kabul to Kandahar asillustrating the case of a force obliged to carry all its sickand wounded with it, since no line of communication couldbe used for evacuation. To illustrate the successfulevacuation .of the sick and wounded of a column bymeans of its lines of communication, the speaker citedan instance from the South African War, where a forceof 5000 men under General Sir A. Hunter moved

north from Thabanchu to operate north of Wynberg inSeptember, 1900. Here Thabanchu, connected with Bloem-fontein by ambulance posts at Sanna’s Post and Boschman’sKop, was used as an evacuating station for the sick duringthe concentration and for part of the march to Wynberg,this latter point being used for the same purpose as soon asthe force reached its vicinity. Wynberg, being on a railway,was able to dispose of the sick and wounded of the columnby means of an ambulance train, and thus to keep its

hospital accommodation free from congestion and adequatefor the needs of the force. A field hospital was left by thecolumn at a point in the neighbourhood of Wynberg, where itformed a connecting link between the fighting troops andtheir advanced base. The whole episode furnished a goodexample of adequate cooperation between the inspector-general of communications, represented by his deputydirector of medical services on the one hand, and the officercommanding the fighting troops, as represented by hisassistant director of medical services on the other.

Turning to history of less recent date, Colonel Skinnerbriefly described the battle of Blenheim with special refer-ence to the medical situation, and showed how, in theabsence of a specialised medical administration, the workof disposing of the enormous aggregation of wounded, bothin his own army and abandoned by the enemy, completelyoccupied Marlborough himself for four days after the victory.Applying the situation and the locality to a force organisedon modern lines, Colonel Skinner indicated the main pointsthat would arise for solution and the means by which theproblems would be solved. Placing the action in England andassuming that a mixed force of regular and territorial troopshad just fought a successful action against an invader, thevery important r6le of voluntary aid societies in supplementingthe medical units and relieving the force of its wounded waspointed out, and Colonel Skinner made the important sugges-tion that Red Cross detachments should be instructed in themethod of registering the names, &c., of the sick andwounded entrusted to their care, so that reliable recordswould be available as in medical units. He showed that, ina friendly country, there would probably be wide lateraldispersion of the wounded, the Red Cross detachment ofeach small community, working in collaboration with the

deputy director of medical services of the lines of communi-cation, providing for the needs of as many invalids as itcould accommodate and thus relieving pressure not only onthe fighting troops but also on the lines of communication.Further examples were quoted from the South African war,the Bohemian campaign of 1866, and the Russo-Japanesewar, and conclusions were drawn which may be summed upas follows : 1. A force without sufficient medical trans-

port loses mobility and requires additional A.S.C. trans-

port. 2. A force with adequate medical transportgains in mobility and needs less A. S. C. transport.3. The necessary evacuating transport must take theform of a medical unit-such as the ’’ Ambulance Column "

now proposed for the Indian army-because in the stress ofwar we cannot rely on any other branch of the army to

supply our needs, nor upon any improvised transport. The

sphere of operations for this unit is between the fieldambulances and the line of communications, working underthe deputy-director of medical services of the latter. 4. Theorganisation of such a system of evacuation forms the cruxof the medical problem in war.A highly interesting discussion ensued in which the

following took part: Surgeon-General W. BABTIE, V. C., C.B.,C.M.G., Colonel W. G. A. BEDFORD, C.M.G., A.M.S.,Lieutenant-Colonel C. H. BuRTCHAELL, R.A.M.C., MajorE. B. WAGGETT, R.A.M.C.(T.), and Dr. F. M. SANDWITH.

MANCHESTER MEDICAL SOCIETY.

Gastric Ulcer.A MEETING of this society was held on Nov. 6th, Dr. C. C.

HEYWOOD being in the chair.Dr. F. CRAVEN MOORE, in opening a discussion on this

subject, said that with the advent of the surgeon in gastricdisorders grave doubt had been thrown on the significanceof those manifestations on which it had been customary tobase a diagnosis of ulcer of the stomach. It had beenshown that haemorrhage, even profuse hæmatemesis, the

crowning sign of gastric ulcer, might obtain with nothing

1439ROYAL ACADEMY OF MEDICINE IN IRELAND.

more than a few small erosions or merely a diffuse oozing oiblood from the mucous surface. In the so-called acute ulee!of the stomach diagnosis was to some extent a problem ojdefinition. The difficulty arose where gastric symptoms-pain, acidity, vomiting-almost certainly of reflex origin,were complicated at some time by a gastric haemorrhage.He believed the occurrence of this latter indicated a gastriclesion-erosion of the solitary follicles, which " erosion

"

may proceed to a "typical" acute ulcer. Erosions were

probably a frequent occurrence in reflex dyspepsias, butthey became manifest only by the fortuitous occurrence ofhæmorrhage, perforation, or by progressive necrosis untilthe subserous coat was involved when local sensorymanifestations indicated the presence of a gastric lesion.For the recognition of a " chronic " ulcer of the stomach-aprogressive erosion to which incomplete reparative inflam-matory changes had been superadded-the sensory manifes-tations afforded the most assured basis. Subjective pain,due, he believed, to local (protective) muscular spasm, wasearlier but curiously irregular in its time incidence afterfood, as contrasted with that of duodenal ulcer or of reflexdyspepsia ; its radiation through to the back was charac-teristic ; it was frequently, if not invariably, associated withpersistent local epigastric tenderness, some muscular rigidity,and with an area of tenderness on deep pressure to the leftof the lower dorsal spines, and less commonly with anepigastric cutaneous hyperæsthesia. In ulcer of the lessercurvature the pain might in time incidence closely simulatethat of duodenal ulcer. Vomiting was an invariable feature,but, unless of the type associated with pyloric stenosis, itwas irregular in occurrence and time of incidence after food,commonly occurring with the height of the pain, whichwas relieved thereby. An occasional and characteristicfeature of chronic gastric ulcer was alkaline pyrosis.Haemorrhage, manifest or occult, was an invariable manifesta-tion, but not continuous. Gastric secretion was in mostcases increased, the excess generally being greater the nearerthe lesion to the pylorus. The appetite was as a rule good,though marked sitophobia might lead patients to giving awrong impression. Wasting, sometimes extreme, was almostalways present, but liable to characteristic fluctuations. Itwas explicable by starvation and particularly water starva-tion. The course of a case of chronic gastric ulcer seemedto differ from duodenal ulcer in that during the intervals ofwell-being there was not the same complete absence of

symptoms.Mr. A. H. BURGESS remarked that not infrequently cases

presenting all the classical symptoms of gastric ulcer werefound on operation to be free from any stomach lesion, thedisease being in the gall-bladder, pancreas, appendix, or

other viscus. The pain in these cases was of reflex origin,referred in lesions of the alimentary canal as far downwardsas the appendix to the epigastrium, in lesions of the colon orpelvic viscera to the hypogastrium. He had not found thegastroscope of any material help in diagnosis. The radio-

graphic screen after bismuth meals in expert hands gave themost valuable assistance. The surgeon, when operating onthe cases, should preserve an open mind as to the procedureto be adopted until the lesion was disclosed ; every opera-tion should be in the first instance " exploratory," and onlywhen an actual ulcer was demonstrated should any operationbe performed upon the stomach; "symptomatic" " gastro-enterostomy merely courted disaster. The finding of onedefinite lesion should not preclude a systematic examinationof the other viscera if the patient’s condition allowed, sinceulcers of the stomach or duodenum were not infrequentlyassociated with gall-stones or chronic appendicitis.. Mr. A. E. BARCLAY insisted that the diagnosis of gastricconditions must be made by combining all the points noted inthe X ray examination with a consideration of the clinicalpicture of the case. He held strongly that gastric pain wassolely the result of spasmodic contraction. In a recent caseof cesophageal obstruction in a girl who had vomited bloodno obstruction was noted and no pain was experienced untildry bread was swallowed. This evidently irritated a smallulcer of the oesophagus and set up a spasm of such severitythat peristaltic waves were seen sweeping down and com-pressing the food. The pain of a gastric ulcer was exactlysimilar to this and depended solely on physical causes, assuggested by Hertz. Ulcers of the stomach were divided,radiographically, into three classes : 1. Ulcers of thefundus, which were exceedingly rare, gave rise to

spasmodic obstruction at the cardiac orifice. 2. Ulcers ofthe body of the stomach gave spasmodic contraction,f resembling and often indistinguishable from the hours

glass contractions. He maintained that the severity ofthe spasm (present in all active ulcers) depended on theirritability of the ulcer, not on the size. 3. Ulcers of

: the pylorus were difficult to recognise in the early stages, but.

gave rise to a very free and rapid secretion of gastric juicewhich gave off large quantities of carbon dioxide when thepatient took a dose of sodium bicarbonate. The stomach was

,

more or less normal in shape and size. Very active peristalsiswas also noted, but the rate of emptying was uncertain inthe early stages. In the latter stages obstruction resultedand the retention of food was easily noted. Two distincttypes of stomach were seen: a large atonic sac extendingeven into the pelvis and a rarer type of normal length butvery broad owing to the distension with food, peristalsisbeing usually absent.

Dr. E. M. BROCKBANK urged the importance of carefulclinical observation with CO2 gas, test meals, and X rays asaids to diagnosing between gastric catarrh, appendicular andgall-bladder dyspepsias, neuroses, ulcers, and malignantdisease. He also spoke of the value as treatment and an aidto diagnosis of large doses of bismuth given at night with nofood allowed from 6 P.M. to 8 A.M. The patients felt nodiscomfort from it and it cured neuroses and many cases ofulcer.

Dr. E. B. LEECH considered that in many cases of chronicdyspepsia an absolute diagnosis for or against gastric ulcerwas impossible. X ray examination should be resorted to inall difficult cases. Exploratory laparotomy should. be con-sidered by the physician.

ROYAL ACADEMY OF MEDICINE INIRELAND.

SECTION OF MEDICINE.

" Vitalism" in Practical Medicine.

A MEETING of this section was held on ivov. 1st, Dr. J.O’CARROLL, the President, being in the chair.

-

The PRESIDENT delivered an opening address on the abovesubject. Having given a brief review of the work of thesection during the 30 years of its existence, he addressedhimself to the view of the nature of life put forward byProfessor Schafer in his recent address to the BritishAssociation for the Advancement of Science. He heldthat the physico-chemical explanation of life was quiteunhelpful to the physician ; that, however possible it mightbe that life might arise de novo from unorganised matter, itwas nevertheless impossible to predicate that only the sameforces, physical or chemical, operated in a living as in adead thing. In life new force or forces came into existence,.for which no convenient name other than" vital" " force hadbeen devised. That force showed its existence in manyways, but chiefly in its capacity of resistance to extinction.Vital resistance begot an adaptability to circumstances, adivision of function among the parts of a compoundorganism for better maintenance and defence of the wholeindividual, and finally a power of compromise betweencontending or hostile organisms of similar or different kinds.That division of labour and power of compromise implieda certain social order which seemed an embryonic formof social ethics. The rise of an ethical or moral sensewas a stumbling block in the evolutionary theory, runningcounter as it did to the doctrine of the survival of thefittest. But in a compound organism the cells of highestfunction were commonly the most vulnerable and theleast capable of renewal; while the cells of lowestfunction usually made the longest defence, were most

capable of proliferation, and were the last to die. The

interdependence of high and low class cells gave each aninterest in the survival of the others. In a communityof similar organisms, within certain limits, the same law-applied, and when it was forgotten the community suffered,Thus arose a communal morality, the ethics of mutual pro-tection. If this view of life held good the rise of the ethicalsense was a natural development and not a violent break inthe history of life. Unless the terms" chemistry" andphysics" were to be extended quite beyond any accurate