Death is sometimes due to true starvation; more frequently, how ever, it is caused by secondary affections which attack the unresisting organism, such as phlegmons and other suppurative processes, aphtha-, nutritive disturbances with intestinal symptoms, or pneumonia. Nu merous infants died during or soon after operation.
The duration of the illness in fatal cases is principally- dependent upon the degree of the stenosis, and therefore widely varies between three ancl twenty weeks. About one-half of the cases died under con servative treatment in the second month, and the other half in the third month, the number of deaths occurring either in the first or in the fourth or fifth month being very small.
Diagnosis.—The following symptoms are chiefly of value: the char acteristic vomiting, especially if it occurs in otherwise perfectly healthy breast-fed infants, without any indication of digestive disorders; re tarded defecation, particularly if the lower abdomen is sunk in and the intestine appears to be empty; the visible gastric peristalsis, which can be observed by placing the patient in a good .sidedight and, after he has finished feeding, irritating tlte skin, attention being paid to a possible confusion with colon peristalsis; the presence of a pyloric growth which should, if necessary, be searehed for under light chloroform aniesthesia. Previously existing vomiting and ischoehymia would justify- the suspicion of pyloric stenosis, even though there be no hypochlorhydria.
For purposes of differential diagnosis the following points should be considered:— 1. Simple pylorospasm, the distinctive signs of which are men tioned on p. 217.
2. True congenital stenotic deformities in the area of the stomach and duodenum, for a description of which see p. 21S.
3. Dyspeptic conditions from over-feeding and other causes. These, however, usually cause simultaneous characteristic intestinal symptoms, such as changes in the stool, which yield to dietetic treatment. They may also be combined with "pylorospasm," which might possibly give rise to characteristic stenotie symptoms; but as they are rather indistinct and not clearly defined, it would not be permissible to diagnosticate them from hypertrophie stenosis.
4. Habitual vomiting which, according to Finkelstein, is usually caused by cOngenital hyperaisthesia of the gastric mucosa against milk containing a high percentage of fat.
In these cases there is no ischochymia. Vomiting occurs soon after feeding and the general condition is not materially impaired; hyper kinesis and pyloric tumor are absent, and fat-poor diet promptly im proves or relieves the condition. What Finkelstein calls " uncontrollable vomiting" is in my opinion due to pylorospastn, at least so far as ischo chymia and spastic phenomena are associated with it.
5. Vomiting of constipated, hypotonic infants with a flabby enlarged stomach.
ff. The rare cases of "specifically toxic" effect of certain human milk (Variot), in which a change of milk leads to rapid improvement.
Peritonitis and meningitis are hardly likely to seriously- simulate the character of pyloric stenosis.
Prognosis.—Pylorie stenosis of the Hirschsprung type should always he regarded as a grave affection. As soon as the diagnosis is positive, it will be opportune to state that the illness will last several weeks and that there is no remedy to relieve the highly disquieting signs of serious vomiting. On the other hand, confidence may conscientiously be inspired by rational treatment, and relatives be referred to the fact that in really desperate eases with extreme cachectic manifestations a change for the better has rapidly and apparently spontaneously been experienced. Heubner states, on the ground of considerable personal experience, that in spite of the alarming impression of the condition, a favorable prognosis may be given under expectant treatment, but he seems to have worked under specially favorable conditions. Cases occurring in the first week of life ran on the average a less favorable course than those occurring later.
rp to the present but little experience has been collected in regard to the later fate of cured cases. In some, there was increased suscepti bility of the stomach and nervous disturbance such as nocturnal enuresis, epileptic paroxysms, delayed mental development and increased general irritability (Heubner) for many years afterwards. Tiernheitn-Karrer found distinct motor insufficiency (retention of the chyme) and hyper acidity as late as the second or third year, which, however, caused neither pain nor impairment of the general condition.