PATHOLOGY: We feel we have shown, by histological sections
of the normal pylorus and of the pylorus affected
by congenital hypertrophy, that the pyloric sphincter
itself is not directly affected by the hypertrophy.
The prepyloric portion of the pyloric canal
undergoes marked hypertrophy of its circular muscle,
and we believe an outgrowth of this circular muscle,
forcing its way into the duodenum, compresses the
pyloric sphincter, which is only slightly enlarged
and is seen to be at the apex of the fornix of the
portio vaginalis. The points which occur to us are
such questions as, whether the pyloric sphincter and
the prepyloric portion of the pylorus have a separate
Is this under the control of the sympathetic
parasympathetic nervous system? We know in Hirschsprung's Disease division of the sympathetic fibres
leads to remarkable recoveries.
More recent work on cardiospasm shows very
encouraging results by removing the sympathetic fibres
round the left gastric artery and its oesophageal
In no other condition, however, is there such
marked hypertrophy of muscle at the sight of obstruction, and it seems doubtful even if the course of the
sympathetic fibres to the pylorus was definitely
established, that attempts would be made to divide
these nerves in the hope of a satisfactory result.
The treatment, by division of this hypertrophied
muscle, is so satisfactory in this condition, that
little in the way of methods of treatment is being
sought after, but more in the nature of methods of
prevention. The causation, however, still remains
CLINICAL: This thesis is based on fourteen cases operated
on over a period of nine years. Two of the cases
were delivered into this world by the author and
these were the only cases operated on at an early
date. The average age of these infants when submitted to surgical treatment was 6 weeks and the average
weight was 7 lbs. 8 ozs. In all cases a Fredet-Rammstedt operation was performed.
The majority of these infants were discharged
from hospital within seven to nine days.
Two of these babies died, one from broncho
pneumonia 14 days after the operation, and the other
immediately after operation owing to the parents
refusing operation when the child was four weeks old,
and returning two months later with the marasmic,
dying infant, pleading for something to be done.
The prognosis in this case was extremely bad as the
child was practically moribund and at that time our
knowledge of pre-operative treatment was very much
less than it is now.
The work of Maizels & McArthur, who stress the
value of pre -operative treatment and the recognition
of alkalosis so common in neglected pyloric stenosis
cases has, we feel, done much to make the course of
these little patients much easier after operation and
has resulted in a greatly lowered mortality.
Another important factor is the advantages of
the private room in hospital and the private nurse.
Most of these cases were operated on in the
Transvaal Memorial Hospital for Children.
All were in private rooms and many had their own
private experienced children's nurses.
Congenital pyloric stenosis has always been
looked upon., and we believe rightly, as a medical
The operation is only an incident, albeit an
important one, in the malady.
The gradual onset, the change from occasional
regurgitation to the characteristic vomiting, the
presence of gastric peristalsis and the routine
palpation of the abdomen for a tumour must be the
duty of the physician.
Similarly, after the operation, the details of
feeding are of great importance to secure a successful_ result and entirely beyond the province of the
The surgeon may study his operation figures and
decide that his failures occur in wasted infants who
have been weaned from one patent food to another.
That his successes occur in the breast fed children
of nearly normal weight and in his private cases
which are nearly always diagnosed and operated on at
an early age. It is reasonable for him to ask that
his aid should be invoked before the patient is
We agree most heartily with Wallace & Wevill
who show, in a report of 145 pyloric stenosis cases
operated on in the Royal Hospital for Children,
Edinburgh, that if the mortality rate which in this
series was in the region of 20% is to be reduced to
a reasonable figure,it is essential that the diagnosis should be made at a much earlier date.
There appears in nearly all cases to be a
period of three to four weeks after the commencement
of symptoms, during which time these cases are treatrl
as digestive disorders and the feeding is changed
every few days in the vain hope that the vomiting
will cease. Eventually, when the child is more or
less in extremis, it is sent to hospital in a state
of health which makes any form of treatment a dangerous procedure.
Pyloric $tenosis should be considered as a possibility in every case of forceful vomiting in
infancy and it should be recognised that the longer
the delay in sending the cap i ld for treatment the
less are its chances of survival.
It should be cons idered an abdominal emergency
of infants and one feels confident, if the condition . were diagnosed within one week after the commencement
of symptoms and sent for operation without delay, the
mortality rate would be greatly reduced,
How can this be attained? We feel it is only
from the family doctor, more keenly alive to this
somewhat rare disease and more aware of the possibili
ties of surgery, that further improvement must come.