.317 Commonly ..236 200 Nose: Deflection of Septum...129 .200 Medical Legislation, Report of Medicines, New, etc. Medicine and Surgery. How Old 83 cago Dew, Walter A., Belleville...317 .137 Medical Charity 42 48 Medical Organization in the An- 84 .153 .185 P ..370 Mental Abnormalities Resulting (E). .119 .137 83 Metatarsalgia, The Relief of. 200 Gradle 71 Pfeiffenberger, Mather. Paper. 76 9 Phlebostasis; a New Treatment 123 .158 217 Tuberculosis Act, The Illinois ...... U (See .201 .214 12 Public Relations Committee..122 Y 72 Young Doctors. Poem.... .282 ..382 FEB 1-1015 ILLINOIS MEDICAL JOURNAL THE OFFICIAL ORGAN OF THE ILLINOIS STATE MEDICAL SOCIETY ENTERED AT THE CHICAGO POSTOFFICE AS SECOND-CLASS MATTER VOL. XXIV CHICAGO, ILL., JULY, 1913 Original Articles No. I STENOSIS OF THE PYLORUS IN INFANCY * CHARLES L. SCUDDER, M.D. Surgeon to the Massachusetts General Hospital, Associate in Surgery, Harvard Medical School BOSTON Mr. President, Ladies and Gentlemen, Members of the Illinois State Medical Society:-I thank you for this invitation to address the annual meeting of the Illinois State Medical Society. With the approval of your committee I have chosen for the subject of my address, "Stenosis of the Pylorus in Infancy." The very great interest that we have all taken in gastric and duodenal surgery in the past few years makes me bold to ask your consideration to-day of this rather special disease of infancy. I shall divide my address into four parts: First, a systematic statement of the facts of the disease; second, reasons why the treatment should be surgical; third, a consideration of two problems which have arisen in connection with the study of these cases; fourth, a report of my own experience with these cases; and in conclusion, a demonstration by lantern slides of the easily demonstrable facts concerning pyloric stenosis in babies. 1. First then, a systematic statement of the facts of the disease: The pathology. A pyloric tumor is always present. It is about the size of the terminal phalanx of a finger or thumb, oval in shape, smooth of surface, firm or hard, like cartilage. There are never adhesions about it. The lumen of the pylorus is narrowed. The longitudinal folds of mucous membrane are enormously hypertrophied, adding to the narrowness of the lumen. This tumor is caused by an overgrowth and an hypertrophy of the circular Address delivered at the Annual Meeting of the Illinois State Medical Society, Peoria, Illinois, May 22, 1913. muscle fibers of the pylorus. The tumor is a muscle tumor; it represents an overgrowth of muscle tissue. The tumor is as evident at autopsy as on the living. It exists in the living, whether gastric peristalsis is present or not. It is no more evident to direct touch when gastric peristalsis is present than when there is no gastric peristalsis. It is a passive tumor. Muscle contraction is not necessary to its existence. That the pyloric tumor encroaches on the lumen of the pyloric canal is proven not only by the clinical signs in these cases, but by direct examination of the stomach at autopsy and at the operating table. The tumor itself is sufficient cause for the obstruction to the pyloric canal. The obstruction is an anatomic one, and is not necessarily dependent on physiologic causes. The significance of this fact will appear later. All other pathologic changes are secondary to the obstruction caused by the tumor, viz., the thickened or stretched gastric wall, the dilated esophagus, the empty intestine, the emaciated and wizened body of the baby. The Etiology.-What is the cause of this tumor found at the pylorus in these new-born babies? This has been the subject of much speculation. The most likely hypothesis is, I think, the one that considers it a congenital anomaly. The tumor represents a congenital overgrowth of muscle tissue. In support of this view are the following considerations: a. The earliest indications of the presence of a pylorus is in the third month of fetal life. There is, therefore, ample time for the growth of muscle tissue to take place. b. There is one case recorded in literature by Dent of a pyloric tumor in a seven-months old. fetus. The tumor shows the same structure that is found in the stenosis cases examined after birth. c. The symptoms in these cases appear so near to birth that it is impossible to conceive of the overgrowth of muscle as having taken place between birth and the onset of symptoms. My youngest case was only 14 days old.1 The tumor in this case was fully developed and as definite as those seen in cases 3 months old. d. The tumor is associated occasionally with other congenital defects, such as imperforate anus and clubfoot. e. Aberrant Brunner's glands that normally belong only in the duodenum have been found in the tumor at the pylorus. It seems to me therefore that the evidence at hand favors a prenatal or congenital overgrowth of muscle tissue as the best explanation for the tumor present in these cases of infantile pyloric stenosis. Why talk of or consider the etiology? Because it is important to determine the significance of spasm of the pylorus which is said to occur in certain of these cases. If it is likely that a congenital overgrowth of muscle is the cause of the tumor, then spasm, which has never yet been known to have caused an hyperplasia, is removed still further from the field of symptomatology in these cases. I think it will appear as the facts concerning this disease are unfolded that spasm has little, if anything, to do with these cases of tumor obstruction. The Symptoms.-The symptoms are those of obstruction. The patient is usually a healthy appearing, breast-fed boy. There is at first, often overlooked, loss of appetite. The baby does not care to nurse. Vomiting appears soon after birth or within the first two or three weeks. This vomiting is characterized by its persistence and its projectile character. It is the vomiting of obstruction. The quality of the food seems to make no difference with the vomiting, the vomiting depending rather on the quantity taken. The amount of the vomitus depends largely on the amount of the feeding. The material vomited is the food taken. The vomitus never contains bile, an excess of HCl, blood, mucus or lactic acid. Because of the little material passing through the pylorus into the duodenum the baby is constipated. The dejections are consequently small in amount; there being very little milk residue, the stool, consisting almost entirely of bile, pancreatic juice and cast-off epithelium, is meconiumlike. There is a progressive loss of weight. The child has not been receiving sufficient nourishment to keep the weight up to the normal gain. Instead of the normal gain there is an actual loss. There may be erratic gains in weight which subsequently are lost. If the baby's abdomen is uncovered while the baby is feeding, or while the 1. Boston Med. & Surg. Jour., Dec. 14, 1905. baby is taking water from the bottle, there will be noticed rather vigorous peristaltic waves passing across the upper half of the abdomen from left to right. This visible peristalsis is very marked in many cases. The stomach is contracting violently in the attempt to overcome the obstruction. If the abdomen is palpated from the side and from before backward, in about from 60 to 80 per cent. of the cases it will be possible to feel the tumor between the thumb and finger. This will be noticed more readily just after the peristaltic wave passes the pyloric portion of the stomach. The tumor may be obscured by an enlarged liver, by enlarged lymphatic glands, or even by the lower pole of the right kidney. The stomach itself will be dilated, particularly if the baby has lived some time after the obstructive symptoms have been present. The obstructive vomiting, the palpable tumor, the visible peristalsis, the meconium-like stool, the epigastric fullness, the continual loss of weight, these are the symptoms of pyloric obstruction in infancy. Despite experiments with feeding and the use of drugs of various sorts, the baby gradually wastes away and dies of starvation; dies of a pyloric obstruction. This is the typical picture of an unrelieved pyloric stenosis in infancy, and it is the usual termination. The death certificate in cases of this kind in the past, and also to-day, is often signed by the attending physician: Inanition, acute gastritis, infantile atrophy, gastro-intestinal catarrh, marasmus, dyspepsia or pyloric spasm. Diagnosis. The diagnosis in typical cases is comparatively easy. However, there are many cases of babies difficult to feed who may be suspected of having a pyloric tumor. Pediatricians have employed the term "spasm of the pylorus” in order to explain the obstructive symptoms seen in little babies who suffer from persistent vomiting, and in whom there is a demonstrable tumor. This idea of a spasm of the pylorus is a purely hypothetical notion introduced by clinicians to account for symptoms which they are otherwise unable to explain. There is little doubt that there is a group of cases difficult to feed which are fairly easily explained by the idea of pyloric spasm without the tumor. These supposedly pure spasm cases occur in bottle-fed, excitable, irritable, neurotic babies. The onset of symptoms is several weeks after birth. The stools contain fecal material. A pyloric tumor, if felt, is felt only when the gastric contraction occurs. The vomiting lacks the characteristics of the |