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for the gastric juice to fail to promptly re-establish the patient's appetite, which sometimes becomes enormous, and to correct at once the painful slowness of the digestion; it has happened repeatedly under such circumstances, that thanks to this powerful arousing of the appetite, I have succeeded in obtaining the actual and permanent cure of the disease.

Unfortunately the effect is not so constant when fever is present, the tuberculous poison then seems to inhibit the gastric glands, rendering them less accessible, or even insensible, to their natural stimulus; and it is then preferable to wait for a quiescent period, with freedom from fever, when the remedy will recover its virtues and permit a return to overfeeding. Even in the terminal stages of the disease, I have observed an unfortunately transitory resumption of the gastric functions, due to the employment of the gastric juice, or at any rate an arrest of the vomiting and a noteworthy subsidence of the pains, even in patients who are past all hope of re

covery.

The gastric juice represents accordingly a valuable adjuvant in the dietetic treatment of the tuberculous patients, if not a curative agent. It must be stated however, that while it is highly efficient as an antidiarrhoeal agent in general it does not serve at all for the control of the diarrhoea which indicates the invasion of the intestine by the tubercle bacillus.

Such is my personal experience. I would not dwell upon it, had it not been supported by a considerable number of physiologists. Gouel, physician to the hospital for Tuberculous, in Villepinte, G. Petit, Legry, physician of the Tenon Hospital, Surmont, Thumbert, Nienhaus, von Muralt (Davos), Meyer (Leysin), Lips (Wehrewald), and

very recently by J. Darwin Nagel (New York), all of whom have reported their results to me. At the time (1904) when I was made the object of severe criticism in Germany, on account of the composition of my gastric juice, I requested Professor Litten (Berlin) and he consented, to experiment with this juice upon his tuberculous patients, and he had the kindness to notify me by letter that the results obtained from it were most remarkable.

Infantile Gastro-Enteritis:-The above outlined indication for the gastric juice, although very satisfactory, is less so in my opinion than its indication in infantile gastro-enteritis. As a matter of fact, we do not possess any really efficient medicinal agents against the latter, whereas, definite triumphs are accomplished by means of the gastric juice. The gastric juice here acts after an elective, in some manner a specific fashion, first by assisting the survival of premature infants and those weakened through an insufficiency of digestive secretion; next, by permitting the return to nourishment, in the course and at the termination of acute gastro-enteritis and finally, by counteracting chronic gastroenteritic conditions.

Two conditions only are required for its action; the gastro-enteritis must not be due to intestinal tuberculosis; and the digestive glands must not be entirely destroyed by the infection.

The action of the gastric juice in prematurely born and weak infants was investigated by Professor Guerin and Dr. D'Gaussel, of Montpellier. Although no larger doses were prescribed than 12, 15 or 20 drops at each nursing, the effect was a remarkable one. The child who had no appetite and remained indifferent to all stimulation takes the breast more greedily,

, 1910

Series, Vol. V.

ceases to vomit, and its assimilation is shown by its weight, which begins to increase after a fall or a prolonged stoppage. The favorable action of opotherapy, in infantile gastro-enteritis, has formed the subject of numerous contributions; the theses of Drs. Edhem and Malakiano (Montpellier) and of Dr. Nicolas (Paris) carried out in the services and under the direction of Prof. Mery, of the Hôspital des Enfants-Malades.

This favorable action of the gastric juice, in the gastro-intestinal affections of childhood, had been reported to me, since the beginning of my investigations, by Professor Sabrezes of Bordeaux, to whom as the translator of Pawlow, I had offered some of the first phials of my product. It was confirmed later on by Messrs. Barbier, Guixiou, Terrien, all pediatricians, and by countless colleagues, I might say by the unanimous verdict of those who have tried it, among them Professor Martinez Vargas of Barcelona, who has published an article dealing with this question. All are agreed that the pig's gastric juice acts in doses of half to one teaspoonful, administered before each partaking of food, in acute gastro-enteritis. In children who suffer from persistent diarrhoeas, and are constantly losing in weight it re-creates the gastric secretion, instead of supplementing it.

These remarks are equally applicable to chronic gastro-enteritis, as long as the athrepsia (malnutrition) is not absolute and the digestive glands remain capable of reacting to a stimulus. I have succeeded, as well as many others with me, in bringing back to life little cadavers which refused to absorb a mouthful of

fluid, but these cadavers still had gastric glands and intestinal glands.

Diarrhoeas-Dysentery:- The remarkable therapeutic action of the gastric juice in infantile enteritis, takes place likewise in the diarrhoeas of adults, whether resulting from gastric insufficiency or depending upon the influence of the season. It is possible that the gastric juice in these cases, by arousing the gastric secretion which has been weakened by the infection, cures the intestine by pouring into it an acid secretion which stimulates the arrested or diminished pancreatic and intestinal secretion.

At any rate this action is very evident, and it led me to study the influence which the gastric juice may exert in dysentery. I have no personal experience in this connection, but the observation of Professor Surmont, Dr. Fontoynout and Dr. Rigand of Madagascar, Dr. Challies of Vias, Professor Hobbs of Cairo; and a general summary of Dr. Le Feunteun, naval surgeon in Brest, cause me to believe that gastric opotherapy has a very favorable action in chronic dysentery. Dr. Le Feunteun writes me that he is inclined to con

sider my gastric juice as a true specific against chronic amoebic dysentery, which is not influenced at all by serum treatment.

Such are the indications of the opotherapy with the gastric juice of pigs, as obtained by me. Besides the indications, I shall briefly outline the contra-indications.

Contra-indications: The action of the

gastric juice is not always certain in the psychic or organic nervous gastropathies, nor in muco-membranous enterocolitis and it is nil in tuberculous enteritis with diarrhoea. On the other hand, it is not infre

quently favorable in allaying the pains of cancer of the stomach; Dr. Cettinger, physician of the Broussais-Hospital, spoke to me of his having made about ten favorable observations in this respect. Another instance was pointed out to me by Professor Surmont. Personally I have observed its effect on a patient suffering from an inoperable gastric tumor, intolerance and severe pains. In the case of two patients upon whom I performed gastro-enterostomy, the gastric juice exerted a very favorable effect upon the general condition, one of these patients suffering from neoplasm with adhesions to the liver and pancreas, is now living, after nearly two years, and has repeatedly had a return of his appetite and strength, thanks to the gastric juice. This influence is inconstant how

ever.

Finally, the gastric juice must be cautiously employed in cases of hyperchlorhydria. Professor Courmont has frequently administered it successfully, in spite of the customary treatment, and he found that the gastric juice seemed to act directly upon the irritable mucosa, soothing it and regulating the secretion, in the same way as digitalis controls the arythmia while strengthening at the same time the cardiac systole. In certain cases of hyperchlorhydria, on the contrary, it will cause the return or an exacerbation of the pyrosis.

In case of ulcer of the stomach, the gastric juice seems to be positively dangerous.

Το summarize: Clinical experience fully confirms what one is justified in assuming from the physiology, the gastric juice is the true remedy for gastric insufficiency and its results.

I rue Magellan, Paris, France.

DERMOIDS.

BY

JOHN H. LONG, M. D.,

Brooklyn, N. Y. Clinical Assistant in Surgery, Brooklyn Hospital; Instructor in Surgery Long Island College Hospital.

A necessary preliminary in the study of dermoids is a brief consideration of a few

points in embryology.

The central nervous system is formed by infolding of the ectoderm along the dorsum of the embryo; the formation of the neural canal is completed by fusion of the lateral ridges of the folds with each other, forming the roof. This gives a line of union of ectoderm to ectoderm along the dorsum of the embryo from head to coccyx. The neural canal extends around the end of the notochord (the future spinal column) and communicates with the enteric canal. The anus is formed later by the invagination of the ectoderm, at a point anterior to the tip of the notochord (which later becomes the tip of the coccyx) thus leaving a pouch behind the anus which communicates at one end with the neural canal, at the other with the rectum. This is the post-anal gut and is normally obliterated; its remains form Luschka's gland.

The somata-pleura, which form the latera walls of the body, extend inward from each side; gradually enclose the body cavity, and unite in the mid ventral line from perineum to root of neck. From the root of the neck to the point of the chin this line is broken by four lateral clefts, the branchial or gill clefts. The uppermost one of these becomes the tympano-eustachian passage. The lower

three are obliterated. Thus we have an unbroken line of surface union between

The

After the splitting of the later walls of the embryo into somatapleure and splanchnopleure, the Wolffian body, from which the ovarian follicles are developed, is differentiated from the same group of cells which form the intestinal tract with its mucous membrane. The mucous membrane of certain rodents supports tufts of hair. In one kind of bird, the dartos, there is a growth of hair in the stomach which guards the pyloric opening.

The mucous membrane, therefore, develops some dermal structures. Upon these facts and the well known powers of mutability of mucous membrane, J. Bland Sutton explains the presence of dermoid structures in ovarian dermoid cysts.

the two halves of the body, extending from the vertex to the perineum dorsally, and from perineum to sternal notch ventrally, and a vertical line broken by four lateral lines from sternal notch to chin. face develops from five processes below the cranium, one vertical extending down from the cranium, from which develops the nose and pre-maxillary bone; two lateral from which develop the superior maxillary border of the face and lower margin of the orbit. These two processes extend inward from each side and coalesce with the nasal process, thus forming lines. of union, one on each side of the median line, extending from the outer angle of the orbit to the inner angle, thence down the side of the nostril, then straight down to margin of lip. These folds meet each other in the midline in the palate. The lowest pair of processes form the mandible and fuse with each other in the midline. The cranium early consists of skin closely adherent to the dura mater, later the bones of the vault develop each from its own center, between these two structures. The foetal thyro-lingual duct extends from the foramen caecum at the base of the tongue, between the genio-hyoglossus muscles to the posterior portion of the body of the hyoid bone, thence to the pyramid of the thyroid gland. This is lined with epithelium.

The infundibulum, which is a prolongation from the brain, fuses with the pituitary body, which is a glandular development from the buccal cavity; this normally recedes into the cranial cavity followed by a diverticulum from the pharynx, the pouch of Rathke, which is obliterated. The auricle of the ear is formed by the coalescence of six tubercles.

Sutton defines dermoids as tumors furnished with skin or mucous membrane occurring in situations where these structures are not found under normal conditions. They only possess tissues which naturally belong to skin or mucous membrane.

Dermoids may be arranged in four. genera:

1. Sequestration dermoids. Tubulo dermoids.

2.

3.

Ovarian dermoids. 4. Dermoid patches.

Etiology:-As the first point in the explanation of the causes of dermoids, I will briefly describe implantation cysts which are a subdivision of sequestration dermoids. These cysts are acquired, not congenital in origin, they are of small size and occur most frequently on the palmar surface of the hands of tailors and seamstresses and in the eyeball. They follow slight punctured or penetrating wounds which carry in a small section of the dermis and plant it in the subcutaneous tissue.

The colony retains its vitality and acts as a skin graft; its sebaceous glands secrete and its epithelial cells are cast off; if hair follicles are carried in, they give rise to hairs. The secretions, being enclosed, naturally form a cyst; one or two hairs are frequently found in these cysts. They seldom acquire any considerable size. This explains how the dermal cells behave when caught in the subcutaneous tissue.

Second point: How and where are these dermal cells isolated when they are isolated and give rise to dermoids?

Slight irregularity or over-lapping in the lines of coalescence will bury a group of surface cells more or less deeply. Failure of obliteration of the embryonic canals which are lined with dermal derivatives or mucous membrane accounts for the location of the tubulo-dermoids. Inclusion and modified development of the embryonal cells of the Wolffian body, which are destined for mucous membrane, explains the occurrence in the ovary.

Pathology:- The walls of the cysts are composed of stratified epithelium, or mucous membrane, containing sweat glands, sebaceous glands and hair follicles in most cases. The contents vary from clear mucus or oil and cast-off epithelial cells to all the structures developed from the dermis, i. e., hair, nails, teeth, and flat bones. Note that heart, liver, bladder, etc., are never found in a true dermoid cyst.

The nucleus of the dermoid, excepting the implantation cyst, is present at birth. It may or may not be developed at the time. Some develop in infancy; some in advanced life; more commonly at puberty.

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process during the development of the cranial bones, and in the same manner on the nose during the development of the nasal bones, so in these two locations they are not limited to the surface coalescence. If the sequestrated nest remains superficial to the cranial bone the cyst does not enter the cranial cavity. If the nest is entirely separated and is buried under the cranial bone an intra-cranial cyst is the result. If the process of the nest is surrounded by bone instead of being cut off, it will give rise to a combined extra-and intra-cranial cyst. The most common locations of cranial dermoids are the anterior fontanelles and inion. They may attain the size of cocoanuts.

The most common location for facial dermoids is the outer angle of the orbit. I have seen three within the last year, one of which was attached to the lower margin, the other two to the upper. These all presented the main part of the cyst on the side of the face, but when dissected out were found to extend an inch or more toward the median line and deeply to the bone. These cysts rarely grow larger than a hen's egg, and contain hair, epithelial cells and sebaceous material. They can be differentiated from sebaceous cysts by the mobility of the skin over them, being deep structures, while sebaceous cysts grow from the skin.

The treatment is complete removal. It is necessary to be prepared to go deeper and wider than the superficial appearance would indicate. Two of these cases occurred about puberty, the third in a young adult. The cysts of the branchial clefts occasionally contain teeth. A dermoid situated over the sacrum at birth may be mistaken for spina bifida.

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