HYPERTROPHIC PYLORIC STENOS'S, TYPE HIRSCHSPRUNG.
The general pathological picture is, as a rule, surprisingly uniform according to the descriptions reported. Robust and perfectly healthy children are suddenly seized with violent vomiting without any apparent cause in the first few days or weeks of their existence. This first symptom remains ill the foreground (" hyperemesis lactentium"). Further mani festations are evidently dependent upon the constant vomiting: decrease of the urinary and fecal excretions, lowering of the weight curve, and consequent decay of the body. The abdominal region is sunk in, the gastric region is distended and occasionally agitated by peristaltic waves. In severe cases death supervenes in six to ten days, owing to general debilitation which conservative treatment was unable to arrest. In other cases, objective manifestations may- yield to suitable treatment or spontaneously, and a cure may be effected in a relatively short time.
Occurrence.—The affection has so far been chiefly described by North German, English, American and Scandinavian authors From Romanic and Slav countries a few cases have recently (since 1905) been communicated, which, however. amount to less than 4 per cent. of the total material now known. Unless, therefore, insufficient observation or mistaken diagnosis simulates a less frequent occurrence in certain coun tries (Ibrahim), a predisposition of the Germanic races would have to be assumed.
There is no doubt that the male sex is more predisposed than the female, male infants being affected more than four times as often as the female ones. Many are first-born infants.
The affection has frequently been observed to occur in brothers and sisters. The probability that later born infants are affected is, according to statistics, more than 1 : 30. In one case, the mother of an affected infant is said to have had the affection in her first year. The statement that mothers have experienced violent gastric complaints during or preceding pregnancy has also been critically considered, owing to the frequency of its occurrence. A neuropathic tendency has likewise often been referred to.
Contrary to nearly all affections of the digestive tract, breast-fed children considerably preponderate in pyloric stenosis, the average figures showing that nearly three out of four patients had been exclu sively breast-fed.
The age of the infants at the time the first characteristic symptom of vomiting appeared, is as follows: to 4 days in 25 per cent.
4 to 14 days in 25 per cent.
2 to 3 weeks in 25 per cent.
3 to 6 weeks in 25 per cent.
Ibrahim's investigations of 266 cases demonstrate a rapidly ascend ing curve (Fig. 30) in the first month, and reduced frequency at ad vancing age. After the eighth week the affection no longer occurs in its typical form.
Symptoms.-1. V omiting, which at first occurs but occasionally, BOOR increases in frequency, often after each feeding, either immediately or after one and one-half to three hours. Vomiting does not always de pend upon food having been taken. The quantity is often surprising, as it may demonstrably surpass that of the last feeding, especially so in advanced cases. Up to 200 c.c. may be thrown up like an explosion in a wide jet. The vomited matter consists of slightly digested milk, eithcr in rennet flakes, whey-like or coagulated, mixed with little mucus and gastric juice. The vomitus has sometimes an objectionable odor from the presence of butyric acid, rarely from putrefaction; it, is said never to contain bile, but sometimes notable exceptions have been observed. Not infrequently it also contains more or less digested blood in varying quantities.* Vomiting is not a sign of nausea or collapse; the ineffectiveness of the customary remedies characterizes it as "uncontrollable." Two symptoms are directly dependent upon vomiting. They are deficient defecation and impaired nutrition.
2. Deficient Defecation.—Quantity and number of defecations are reduced to a minimum, total absence of same having been observed from three to twelve days. In severe cases the stools have the appear ance of the non-fecal hunger-stool, smeary and dark brown, or of the nature of meconium, gelatinous and olive-colored.