81THE AMERICAN COLLEGE OF SURGEONS.

test the operation can as certainly be regardedas within the range of medical service. (3) Thatknowledge of the technique can be acquired fromtext-books and requires no particular training eitherin the actual administration of the treatment or

in the judgment requisite to decide on the advisabilityof its use. (4) That the treatment, while admittedlymodern, has become so well known that any ordinarypractitioner should in a proper case be preparedto adopt it. (5) That the risks of any adverse effectsare negligible in the light of statistical knowledge.On behalf of the insurance and panel committees ’it was contended : (1) That a considerable degreeof skill is required at least equal to that necessaryfor the injection of salvarsan or its substitutes,particularly also where ulceration is present. (2) Thatat the present time there has not existed sufficientexperience of the treatment and its results to justifyits inclusion in the range of medical service. (3) Thatthere are many contra-indications against the treat-ment-e.g., it is dangerous in the case of a pregnantwoman or in certain cases where heart disease orhigh blood pressure is present or in the case of patientswho have some idiosyncrasy to quinine or salicylate.(4) That the standard of skill in the Manchesterlocality is such that the treatment may fairly beregarded as special and not of such a characterthat it should be carried out by the ordinary insurancedoctor. (5) That statistical knowledge as to after-effects is not sufficiently established.The referees found for the Minister. While admitting

that injection treatment of varicose veins ismodern, they note that it is now practised withsuccess in a very large number of cases. The techniqueis not difficult and any panel doctor should beable to decide whether the patient is a fit subjectfor the treatment. There may be no substantialdifference in the actual technique of the two injections,but the referees thought the possible risks attendantupon salvarsan treatment to be such as to renderit not fairly comparable with injection for varicoseveins. Two of the referees, however, felt that when thetreatment was actually applied in Manchester inMay, 1928, it might then have been regarded as inan experimental stage, although this was no longertrue at the time of the inquiry.

THE AMERICAN COLLEGE OF SURGEONS.

THE nineteenth annual Clinical Congress of theAmerican College of Surgeons will be held in Chicagoon Oct. 14th and the four following days under thepresidency of Dr. Franklin Martin. All depart-ments of surgery-general surgery, gynaecology andobstetrics, and the main special branches of surgicalpractice-are represented in the programme, anddemonstrations will be given in the laboratoriesattached to the hospitals and schools of the fourgreat universities of the city, the NorthwesternUniversity, the University of Chicago, the Universityof Illinois, and the Loyola University. On the firstday of the session the President-elect, Dr. MerritteIreland, Surg.-Gen. U.S.M.C., will be inducted intooffice and deliver the annual, address, after whichMr. D. P. D. Wilkie will deliver the Murphy Oration.An important feature of the meeting will be the

Hospital Conference, in connexion with which greatefforts have been made to present short papersand practical demonstrations dealing with manyquestions of hospital efficiency, and it is hopedthat round-table discussions on the various prob-lems will be of service not only to the scientificstaffs of the institutions, but to hospital trustees,boards of management, and directorates. TheConference will open as soon as the College is insession, its proceedings taking place in the grandballroom of the Stevens Hotel, where the generalheadquarters of the Congress will be established.attendance at the Congress will be limited to anumber that can be comfortably accommodated intheir groups at the various clinics, so that it will be

necessary for visitors to register in advance theirintention to be present. The executive body inChicago has for chairman Dr. L. Kretschmer, andsecretary Dr. Loyal Davis.

COMPOUND COMPOSITE ODONTOMES.

THE study of odontomes is one of the most fascinat-ing branches of dental pathology. Mr. A. T. Pitts hasrecently described to the Royal Society of Medicine 1three of those rare types known as compoundcomposite odontomes which, under Sir John Bland-Sutton’s classification, were called compoundfollicular odontomes. The first case occurred in aboy aged 15, and the odontome was found in theregion of the right upper canine and the adjoiningpremolars. It appeared as a hard irregular swellingabout the size of a filbert nut. Clinical examination,even with the aid of a radiogram, did not enableMr. Pitts to determine whether it was a complex or acompound composite odontome. At the operation,however, 18 separate denticles were discovered. Nodefinite capsule could be found surrounding the wholetumour; but some of the denticles appear to have hadan investing membrane, whilst others were embeddedin fibrous tissue. One of the calcified masses containedenamel, dentine, and cement. The dentine was wellformed ; but the enamel, as so often happens whenit is found under pathological conditions, was granular.

. In another denticle, from which a section was obtained,

. no cement was found. The largest piece consisted offour or five denticles fused together in an irregular

; mass. In all of the larger denticles radiograms showed, evidence of the presence of a pulp canal. The second, case was that of a boy aged 3 years and 8 months,who presented a hard rounded swelling in the region

, of the right upper deciduous incisors which hadfailed to erupt. A mass of nine denticles could be. seen in the radiogram ; and, in this case, a correct: diagnosis was made before the operation. The missing: deciduous central and lateral incisors were in closerelation to the denticles which were enclosed withinL a capsule and the latter was continuous with thetooth sac of the first deciduous incisor. The permanent

incisors were lying above the swelling. The largestdenticle consisted of a tritubercular crown with asingle stunted root. The other denticles resembledconical teeth. The third case occurred in a boy aged14, and this presented six supernumerary teeth

in the left upper first premolar region. The boyÞ gave a history of having himself removed four supernumerary teeth from the same region, previous. to his visit to a dental surgeon for treatment.l It is a moot point whether this last case shouldl be classed with odontomes at all. Many pathologists. would not have placed it here. But the line of demar-

cation between abnormally formed teeth and odontomes is by no means clearly defined. LongL ago, Albrecht taught that tumours are malformations,. and that it is not always possible to distinguishj new growth from development. Prof. G. W. Nicholson also regards tumours as aborted organs. Mr. Pitts. himself puts forward several suggestions. First,he raises the question of the possibility of odontomes, erupting like ordinary teeth. There seems to be no reason why they should not do so, provided thei conditions correspond with those which are essential; for the eruption of a tooth. Undoubtedly, many. odontomes do pass through this process ; but othersremain embedded within the jaw, or only become. exfoliated as a result of suppuration and necrosis

of the overlying bone. When the epithelial remnants, of the tooth band (which Mr. Warwick James has

described as the determining factor in directingthe tooth to its final position in the jaw) remain! in their correct relationship, the odontome mayL erupt like a tooth. But the aberration which leads

to the formation of a tooth tumour often involvesthese epithelial structures ; and then, if the odontome

Proceedings of the R.S.M., 1929, xxii., 659.

82 CHARTS OF FRACTIONAL TEST-MEALS.

becomes exposed to the surface it may be a processof exfoliation rather than one of eruption. Mr. Pittsalso refers to the manner in which one type ofodontome may blend with another type. Manypathologists who have investigated these tumoursrecognise this fact and it is this which makes theclassification of some cases very difficult. In hisfirst case four or five denticles were fused together inone mass, but so long as the minute structures ofdenticles are not inextricably mixed up with oneanother there is no reason for considering this massto be a complex composite odontome. Some yearsago Bland-Sutton described the case of a womanwho " spat out " a mass, consisting of dental tissuesfused together, which appeared to be a collectionof independent denticles united by cement and mightwell be included under the group called compoundcomposite odontomes, rather than under the complexcomposite odontomes. On the other hand, some ofthe individual denticles contained within a compoundcomposite odontome may be of the complex compositevariety. With regard to the third point which Mr.Pitts raises on these cases, it seems evident that anodontome may arise from the original tooth band ;or may be due to an aberration of the deciduousor the permanent tooth germ, or to that of a super-numerary tooth. Very few compound compositeodontomes have been fully recorded, and all whoare interested in the study of odontomes must feelgrateful to Mr. Pitts for the very careful mannerin which he has described these cases.

XIIITH INTERNATIONAL OPHTHALMOLOGICALCONGRESS.

IT will be timely to remind any who propose toattend this Congress, which will be held at Amsterdamfrom Sept. 5th to Sept. 13th, that if they will sendtheir subscriptions now it will greatly facilitate thework of the National Committee. We learn that 700members have already been enrolled and that 232communications, covering all branches of ophthal-mology, have been promised. It is certain, therefore,that those who find themselves unable to be at themeetings will find it extremely useful to possess theTransactions, which promise to form a compendiumof recent work in ophthalmology. So those whocannot go to Amsterdam will reap a real advantageby becoming’ members of the Congress, when theywill be supplied with a copy of the Transactions assoon as they appear. The subscriptions (25 Dutchflorins = £2 2s. English money) should be sent toDr. H. M. Roelofsz, Director of the Incassobank,Heerengracht 531, Amsterdam.

ON the recommendation of the Minister of Health,the King has been pleased to appoint Dr. BedfordPierce to be a temporary Commissioner of the Boardof Control.

____

Lord Dawson has been re-elected President of theRoyal Society of Medicine for another year Thehon treasurers for the year 1929-30 are Dr. A. M. H.Gray and Mr. W. Girling Ball; the hon. secretariesMr. E. K. Martin and Dr. George Riddoch; thehon. librarians Dr. William Bulloch, F.R.S., andMr. H. W. Carson ; and the hon. editors Dr. HughThursfield and Mr. J. Swift Joly.

Sir Albert Levy has set aside 250,000 to form afund for the support of hospitals and other charitableobjects. The whole of this sum, plus interest, will bedistributed " in 25 yearly instalments," the totalamounting to about 400,000, of which £100,000 hasalready been allocated for hospital purposes. Adivision of one twenty-fifth part of the capital andincome will be made on May lst and Nov. 1st of eachyear, and communications may be addressed to thesecretary of the Albert Levy Benevolent Fund at5, St. James’s-place, London, S.W.I. Sir Albert istreasurer of the Royal Free Hospital, to which he haslately made two gifts of £50,000 each.

The Clinical Interpretation ofAids to Diagnosis.

A Series of Special Articles contributed by Invitation.

’ XXXVII.

CHARTS OF FRACTIONAL TEST-MEALS.

PART II.*-ABNORMAL CURVES.

Charts Showing High Acidity.IN Fig. 3 and Fig. 4 are given examples of typical

charts showing high acidity. It will be seen that inboth of them there are at least two readings of free HCIabove 50. When this is encountered it is always trueto say that the case is probably from a pathologicalsubject, although, as was noted last week, such achart is occasionally encountered in a healthy person.Fig. 3 shows a rapidly rising curve of acidity withrapid emptying of the stomach, which is more fre-quently encountered in cases of duodenal or juxta-pyloric peptic ulcer than in any other condition. Itis, therefore, correct for the pathologist to reportthat the chart is suggestive of such a condition. Itmust be emphasised that neither this nor any othertype of chart can ever be conclusive evidence of thepresence of an ulcer.

Fig. 4 differs from the preceding one in that thecurve of acid (both free and total) rises slowly withoutperhaps reaching such a high concentration as in thelast condition. It is typical of what is sometimescalled the " climbing curve "-i.e., there is no dropin the acid in the later stages, probably becausespasm or obstruction of the pylorus is preventing thefree regurgitation of alkali through the duodenum.Such a chart is characteristic of many cases of gastricand juxtapyloric ulcer, and suggests that withoutsuch a degree of irritability of the stomach as ispresent in cases producing Fig. 3 there is some

impediment to the pyloric outlet.In Fig. 5 is shown a chart of the " Plateau " type

which is characteristic of pyloric obstruction. Such achart would be prolonged for three hours or longer,depending on the patience of the subject and observer,and if the stomach is completely emptied at 2hours, the amount of contents recovered at thatmoment will probably considerably exceed 100 c.cm.Such a chart is diagnostic of pyloric obstruction, andit will further be noted that in such cases the concen-tration of HCI is seldom so high as in the cases

discussed previously, and that there is a greaterdisparity between the curves of free and total acidityowing to the presence of organic acids resulting fromfermentation.

Low Acid Charts.

Fig. 6 is a typical example of complete achlorhydriaof the " benign " type. There is complete absenceof HCI and total acidity is also low. Emptying isusually rapid and may be very rapid. It would bebeyond the scope of the present article to discuss atlength all the possible interpretations or causes ofsuch a chart, but the following points must beemphasised :-

1. It occurs in about 5 per cent. of normal healthy men.2. It is present in probably every case of pernicious

anaemia..3. It is occasionally, but somewhat uncommonly, present

in cases of cancer of the stomach.

Apart from such cases of complete achlorhydria,cases are sometimes met with in which there is atrace of free HCI at one or two readings only. Greathesitation must be observed before considering anysuch chart as indicative of a pathological condition.It is a very common finding in perfectly healthypeople who are nervous or who have been upset by

* Part I., on the Interpretation of Charts of Fractional Test-meals, appeared last week.