—While more or less benefit and relief may be obtained from frequent washing of the abdominal sac thus produced the real cure will only come, as shown by Mikulicz, from opening of the stomach and dilatation of its constricted upper orifice.
PYLORIC STENOSIS.
Reduction in caliber of the pyloric opening, amounting in extreme cases to absolute closure, may be met with at various ages and following various conditions.
A congenital stenosis has been observed, although very infrequently.[54]
[54] Fiske (Annals of Surgery, July, 1906) states that there are at present on record 121 cases of hypertrophic stenosis of the pylorus in infants. The three theories advanced to account for the condition as occurring before birth presuppose either a true malformation with muscular hypertrophy, a secondary hypertrophy due to prenatal pyloric spasm, or a spastic condition of the pyloric region without definite gross anatomical lesion. None of these theories satisfies the condition in any but a small proportion of cases, although either of them doubtless is or may be correct in certain instances; 71 of these cases have now been operated upon, of which 33 died, gastro-enterostomy giving 57 per cent. of recoveries and pyloroplasty 54 percent.
Pyloric constriction following cicatricial contraction of healed ulcers is perhaps the most common non-malignant form. This rarely proceeds to absolute closure, but is frequently sufficient to lead to dilatation.
Conversely any condition of the stomach which drags it out of shape and leads to kink or abrupt angulation near the pylorus may lead to early postural and later to actual structural contraction.
The pressure or alteration of shape produced by neoplasms, either within the substance of the stomach or more frequently without, will cause more or less irregular contraction of the pyloric end amounting to pyloric stricture.
By old adhesions similar conditions are produced, while a definite form of spastic contraction, corresponding much to cardiospasm just described, will cause more or less pyloric obstruction.
Finally malignant tumors involving the pyloric region invariably spread to the pyloric ring, and not only infiltrate it but cause it to become inflexible and diminished in size, to a degree finally amounting to almost complete or to absolute obstruction.