Mortality Statislics.—Ibrahim states that the mortality was 46.1 per cent. of all cases treated internally; 22.9 pet• cent. of the cases treated internally in Germany; 9.5 per cent. of the eases treated by- Heubner; 54.5 per cent. of all operated cases.
The value of these figures is very restricted, as was pointed out by Ibrahim. In my opinion this refers not only to the conservatively treated cases, but also to the operated ones, because the mortality of the cases which have been published and can therefore easily be established, is no reliable measure for the actual general mortality which alone is of interest; and cases, especially surgical ones, which have taken a favorable course are far more likely to see the light of publication than those which resulted fatally. The optimistic total result of such calculations thereby becomes misleading. Besides, there are many other undeterminable factors, such as the varying inclusion of different types, which will jeop ardize the value of these figures. Nor am I prepared to eonclude from these figures that the rational internal treatment produced a lower mortality than operation, or that the mortality of operated cases, as compared to those conservatively treated, has—to say the least—not improver/ during the last fiVe years.
The period when reports on this affection emanated almost exclu sively from the operating table and the outcome was regarded as almost certain death, has now been followed by one where a less sweeping prediction has rightly been recognized.
Treatment. —The first, question is whether the treatment should be conservative or operative. Opinions on this point were formerly divided. Those indeed who could not emancipate themselves from the imagina tion of a "congenital tumor" thought that every diagnostically estab lished case of Hirschsprung's pyloric stenosis, or at least every ease of palpable pylorus, shoulcl be referred to the surgeon as early as possible. To-day the majority think different. The more experienced an author, the greater will be his confidence in conservative measures, even when confronted with the gravest eases exhibiting the fully developed symptom complex. It would certainly- not be right to call operation of Hirsch sprung's stenosis bad surgery on principle, but the demand is justified that narrow indications he laid down. Above all, in fresh cases conser vative treatment under competent direction should be instituted accord ing to one of the acknowledged methods and in an intelligent, logical and carefully controlled manner. Heubner even demands that operation
be deferred until the end of the third month of life, for the reason that at about that period a favorable turn usually took place with internal treat ment. Operation may possibly be considered if after this period there is no tendency whatever toward overcoming the stage of absolute intoler anee (Ibrahim). But according to our present lights, the decision should even then be left to individual judgment, because several weeks of observation will not furnish a reliable basis for the assumption that conservative treatment would be no longer able to help. The least reliable indications for surgical interference are persisting peristalsis and palpable pylorus, because they may outlast all other signs in cases of a cure.
1. Conservative Treatment.—The occasional presence of hyperacidity of the gastric contents together with the fact that spastic factors always participate in the geuesis of functional disturbance, are the only con siderations upon which eausal treatment can be based. In all other respects a high degree of empiricism is to be relied upon.
(a) Dietetic. Treatment.—Its object is to keep the infant alive up to the time where according to experience a spontaneous turn may be ex pected. The procedure should be strictly individual and "with intelli gent knowledge of aetion" (Ibrahim). 13y frequent feedings, amounting to ten or twelve daily, the quantity of the allowable single close is deter mined which will either arrest vomiting or restrict it say to once or twice daily. If this allowable quantity is very low, perhaps 20 or 10 Gins., it will usually be impossible to reach the 70 to SO calories pet- kilo. body weight necessary for maintenance. It will then be so much more neces sary to ascertain the tolerance of the stomach which, in accordance with experience, will increase, and to carefully increase the quantity in order to maintain the body-weight and finally to raise it. The milk should be preferably iced* and administered "passively" by means of a spoon or feeding cup, or, if needed, by the nasal feeding tube, and not by active suckling. A portion given a short time after vomiting has the most favorable chances to be retained.