'robler concludes from the high fat percentage of the food remnants in a given case that "the retnoval of the fat from the stomach has been repeatedly and seriously interfered with." The findings which might permit of a judgment as to the secretory process of the stomach, vary considerably.
10. Hyperacidity of the mixed stomach contents has been clefinitely established in a few typical cases, and in these eases there was also either hyperchlorhydria (Freund, Ibrahim, Feer) or achylia gastrica (Engel). In another case the increased total acidity was to a large extent referable to an increase in fatty acids.
But the acidity of the gastric contents and its percentage of hydro chloric acid are no doubt also normally present in the early stages, although, judging by the experience gained in most other disturbances of nutrition in infancy, this would be surprising. The pepsin and rennet ferments in the gastric contents have never been found below normal.
clearly pronounced pathological picture, as just described, is explained by corresponding findings in operations and autopsy. The pyloric part of the stomach consists of a rigid, resistant, cartilaginous mass of a bulging or nearly cylindrical shape, measuring 2 to 3 cm. in length and 11 to 2 cm. in thickness. The mass appears like a separately interpolated insertion between the stomach arid duodenum, the boundaries of which are rnarked at both ends: exteriorly by a furrow and interiorly by a slig,ht terrace-like elevation. Toward the duodenum it has a projection, which may also "resemble the portio vaginalis uteri." The lumen of the canal between the pylorus and the contiguous portion of Willis' antrum may be either obliterated or quite impenetrable for the finest sound or even for liquid introduced under pressure. The mucous membrane in the middle portion of this canal has longitudinal folds, while at both ends it forms irregular and almost valvular ridges. Section through the pyloric part demonstrates the fact that the "tumor" as well as the stenosis is principally caused by the considerably thick ened annular and longitudinal muscular layer of the stomach wall. Less regular findings are eonnective-tissue proliferations between the muscular tracts, moderate increase in the thickness of mucosa and sub mucosa, and rigidity and inspissation of the muscular layers or other parts of the stomach walls. Measurements of the capacity of the stom
ach, carried out after reliable methods, have only exceptionally exceeded the physiological width, contrary to appearances. Catarrhal or inflam matory changes of the mucosa are usually absent. Occasionally there are erosions, petechim, ulcers or gastritis. The serosa was always un changed, while the occurrence of a contracted mesentery- has been repeatedly observed.
In interpreting these findings, the following facts should not be lost sight of:— 1. The normal pylorus of the human fetus (aswell as the pylorus of certain nianlinals), according to both old and recent anatomical investi gations, has a very marked approach to the pathological formation; 2. This approach is considerably enhanced in infancy by the con traction of the pyloric musculature.
The author showed in 1897, on the occasion of an autopsy on an infant with a healthy stomach, that the pyloric part is not infrequently* in a state of continuous contraction. The pyloric and antral sections of these "systolic" (Pfaundler) or "antrum-contracted" (Wernstedt) infantile stomachs demonstrate a far-reaching analogy with the infantile pyloric stenosis, not only at the first glance but also in regard to all the anatomical details visible to the naked eye and even in the microscopic structure and arrangement of the muscular fascia (compare Figs. 31 and 32). If, then, operation or autopsy on infants who have frequently vomited should disclose a pylorus accidentally stiffened in systole, the condition may be easily mistaken for stenosis of the type just described. As a matter of fact, errors of this kind are recorded in the literature (cases of Henschel, Gran, and others).
Under those circumstances the question was justified whether the pylorus deviates from the normal merely by reason of a special tendency to persistence in systole after death (as during life to stenotic spasms), and this made apparent the need of criteria by which the antrum contracted stomach and Hirschsprung's infantile stomach could be distinguished. The following are such criteria:— 1. The deformity of the pylorus from displacement of its parts (contraction) in the first mentioned form is distinguished by a positive addition to its consistency by hypertrophy from the second form.