A STUDY ON THE TREATMENT OF NON-MALIGNANT STRICTURE OF THE PYLORUS
A Ogston
1895
The Lancet
739 bed. He was restless all night, but not violent, or quite anconacions of his surroundings. Daring the next day (Feb. 4th) he did not alter materially, except that he noticed a friend and seemed to recognise her. On the 5th, at 3 A. M., there was twitching of the left arm and face, with stertorous breathing. At 11 A.M. the face was drawn to the left. The right eye did not close (right facial paralysis). Retraction of the head set in, and the knee-jerks were found to be increased. The
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... ure rose from 100.2° in the morning to 104.4° at midnight, and he died early on the 6th. Necropsy by Dr. H. M. BOWMAN.-Under the cerebral arachnoid, all over the convexity, there was a considerable amount of turbid fluid. The same was observed at the base, extending over the pons and lower surface of the medulla and about two inches up the right Sylvian fissure, which was rather glued up.'As for the spinal cord, the dura mater was healthy, but on opening it there was found to be a considerable amount of pus beneath the arachnoid and an excess of turbid dnid ; this condition extended down as far as the cauda equina. At both apices of the lungs there were dense fibrous adhesions, there being calcareous deposits in either apex, with fibroid thickening and puckering. The heart was large and flabby and weighed 14t oz.; the right ventricle was much dilated. The spleen was small and healthy. The kidneys were large, weighing 8 oz, each ; the capsule separated badly, tearing the cortex, but the section of the kidney looked healthy. No pus was found in any joint. Remarks.-The symptoms in these ten cases may be summarised as follows. Pain in the head was complained of by all those patients who were not too ill or too young to complain ; pain in the back twice, in the limbs once, and in the abdomen once. There was fever of variable degree in all cases save one (Case 6), which did not come under observation at the outset. There was no special type of fever. One case (Case 4) terminated with hyperpyrexia ; a rigor is mentioned twice only. Vomiting occurred in five cases, and usually at the commencement of the illmess. Retraction of the head developed, either a few days after the onset or at a later stage, in three instances, and a stiff neck (probably a minor degree of the same thing) once; rigidity of the limbs was observed only once or twice. Twitchings of the limbs, face, or tongue occurred about four times; actual convulsions only twice. The state of the kneejerks, examined in five cases, was : absent twice, exaggerated once, and normal twice. Strabismus was frequent, occurring four timessometimes early, sometimes late ; ptosis occurred once, and doubtful nystagmus once. The fundus oculi was examined five times, and twice only was there a (doubtful) optic neuritis. There was no conjunctivitis, iritis, or panophthalmitis (as in Dr. Gee's case quoted above), and no otitis, deafness, or vertigo. As to paralyses, conjugate deviation of the head or eyes (whether this was paralytic or spasmodic) was observed four times, hemiplegia once, hemianasstbesia once, and doubtful facial paralysis once. Mental symptoms were 'frequent. There was restlessness or irritability in four cases, noisiness or delirium in three ; there were l1allucinations of vision in two cases, and drowsiness occurred sometimes. Early coma occurred twice. The pulse was asually frequent, being irregular in three instances. The respiration before death was apt to become irregular or to assume the Cheyne-Stokes type. Abnormal states of the tongue (red, dry, furred, &c.) are noted four times, diarrhcea is noted once, and constipation once. No mention is made of a taeae cérébrale. In one prolonged case (Case 2) there was marked emaciation. Albuminuria occurred four (or, counting a transient appearance, five) times ; but in three of these cases the state of the kidneys was questionable. Glycosuria did not occur ; but that it may do so is shown by a case of (cerebral) meningitis admitted under the care of Sir Dyce Duckworth in 1891. A man was brought in comatose, his urine being loaded with sugar ; diabetic coma was therefore suspected, but post mortem he was found to have purulent meningitis.4 As to eruptions, a petechial rash was seen once (Case 2), a "fleeting erythema" once, and herpes facialis twice. The ages of the patients varied from six months to fifty-two years. Thus the commonest features of the disease were : fever of sudden onset and without obvious cause, headache, vomiting. restlessness, and even delirium, and soon afterwards strabismus and retraction of the head, and, finally, death, which was often preceded by irregularity of respiration 4 For two cases of glycosuria in meningeal hæmorrhage vide F. E. A. Colny, St. Bartholomew's Hospital Reports, xxviii. (1892), p. 153. or by coma, within a week. But some cases lasted longere.g., one for twelve days and two (Cases 2 and 6) between three and four weeks. In both of these latter hydrocephalus was found post mortem ; possibly in Case 2 the recurrence of vomiting was the clinical indication of this. Further, as above mentioned, three, or perhaps four, cases (not included in these ten) recovered. In Case 8 the sudden onset, early coma, and rapidly fatal course (thirty hours), without the development of diagnostic symptoms, reminds one of the " type foudroyante," described by writers on epidemic meningitis. A clinical relation to other diseases only appears twice. In Case 2 the patient had whooping-cough, and had been exposed to measles; and in Case 4 the meningeal symptoms developed during an attack of acute faucial and laryngeal mischief, both diseases being possibly the result of some one unrecognised infection. Only one or two remarks need be made about the post-mortem examination results. Pneumonia was never found ; pleurisy (in one case with pulmonary infarcts) twice only ; the spleen was enlarged only in two instances, and in these the enlargement may have depended on other causes than the fever (Cases 4 and 5). As to the meningitis itself, the purulent character and the distribution of the cerebral exudation sufficed to distinguish it from tuberculous meningitis ; the spinal exudation, though sometimes enveloping the whole cord, usually affected the posterior surface chiefly, and the dorsal and lumbar regions rather than the cervical. 5 Hence, to exclude a spinal meningitis it is not enough to look around the foramen magnum, or even at the cervical region of the cord, but the whole length of it must be examined. SURGEON IN ORDINARY TO HER MAJESTY THE QUEEN IN SCOTLAND; SURGEON TO THE ABERDEEN ROYAL INFIRMARY. I COULD have wished before publishing the method of treating pyloric stricture without operation, with which this communication deals, that further experience of its efficacy had been obtained beyond that which it is in my power to offer. But in my experience non-malignant stricture is rare, and to wait for fresh cases on which to try it might entail almost indefinite delay. I have accordingly decided to make it known as it now stands, that it may, if they think well of it, be tested by others. It is now twelve years or thereby since Loreta drew attention to this stricture of the pylorus by his proposal to treat it by opening the stomach in front, introducing the forefinger into the wound and insinuating it into the stricture so as to expand it from within. The operation was a good deal practised, and with success. But most at least of the cases were only temporarily benefited, as recontraction slowly and surely occurred. And some of the cases were found to be due to the cicatricial contraction of former inflammations and adhesions around and external to the pylorus itself, and hence to be unsuitable for finger dilatation. Mikulicz's improvement upon Loreta's operation, that of incising the strictured bowel longitudinally and suturing the incision so as to form a transverse line of union and widen the bowel, has not been sufficiently tried and reported upon to enable a final verdict to be passed by the surgical profession upon its merits. It probably, however, shares to some degree the objections that are advanced against Loreta's operation. It entails an equal or greater danger to life, and is not suited for every case. In his communication to the Surgical Section of the International Congress at Berlin in 1890 Billroth mentioned that in seven cases he had, for cicatricial stenosis, to excise the pylorus, with the result of four cures and three deaths ; to perform partial wedge-shaped excision without complete division in five cases, of which two recovered and three died ; while of five cases where the pylorus was not absolutely narrowed, but only twisted by extensive external adhesions, he had in two to introduce the finger and explore by Loreta's method in three, 5 Klebs: Virchow's Archiv, vol. xxxiv. Trevelyan : Brain, vol. xv., p.104. 740 741 742 all dying, the other two recovering after the adhesions, which were less extensive, had been separated. These are rather discouraging results, and it has further to be remembered that many of those who suffer from this stricture are in debilitated and broken health, from the dilated and weakened state of the stomach, and from the attacks of hepatitis and peri-hepatitis that have accompanied or caused the disease. Any method, therefore, that offers a fair prospect of effecting a cure without the risks that an operation entails is worthy of consideration ; and such a method, now to be described, I have carefully tried, and from my experience of it am inclined to recommend in suitable cases of the disease. The method suggested itself in the following way. Having had to deal with a few cases of pyloric stricture I was led by the considerations mentioned above to consider whether some safer plan than operation might be devised for overcoming the stricture. Why should a pyloric stricture, or for that matter any nonmalignant and therefore cicatricial stricture, of the intestinal tract not be dilated and cured by similar methods to those by which we dilate and cure those of the urethra and rectum? 7 Why not pass through them something that would act in the same fashion as a bougie ? It is evident that the passage through the stricture of a hollow viscus in any part of the body of the liquid or pulpy matters it contains does not dilate the stricture from within like a bougie. We have daily evidence of this in the oesophagus, rectum, and urethra. It is probable indeed that, in some instances at least, the narrowing of the part is rendered less rapid by this agency, and that in the stationary urethral strictures sometimes met with in elderly men it may arrest the stricturing process and prevent its becoming absolute. But the influence of liquid and pultaceous matters must be limited in causing dilatation by the fact that their chief energy is exerted on the walls of the viscus above the narrowest part of the stricture, where we find the dilatation that exists above all such narrowings. The moment the mass is propelled into the jaws of the stricture it experiences a diminution of pressure, owing to there being none below, and it escapes through without exercising more than a feeble influence on the narrowest part of the stenosis. Thus it fails to exercise any such pressure there as causes the local irritation, followed by moderate inflammation, softening, and yielding, which we believe to be the mechanism by which a bougie dilates. But since bougies are out of the question in nonoperative treatment of the pylorus, it seemed probable that if solid spheres of the diameter of bougies suspended in the food were passed through the stenosis they might act like bougies and produce the same results. Whether the natural forces operating in propelling onwards the food would suffice to carry them through, and whether unforeseen difficulties might not arise, could be ascertained only by an actual trial. The first attempts were made with spheres of sugar coated with various substances which it was supposed would resist the digestive process until they had passed the pylorus ; and several materials were made use of to form the spheres. But nothing was found suitable save gutta-percha rolled in the hand into globules, and these arranged into sizes by passing them through a gauge for urethral or oesophagea] bougies. Gutta-percha spheres are easily and simply made, and, being of almost the specific gravity of the stomach contents, have no tendency to settle in the lowest part of the stomach or to float in the uppermost strata of it, contents. The gauges chosen were those on the French scale, which gives a greater selection of sizes and a more gradua' dilatation ; but so sensitive is the pylorus that it was after. wards found convenient to mark intermediate sizes betweer two numbers, thus between, say, Nos. 20 and 21 would com< 20+ and 21-, the former being one that passed witl difficulty through No. 20 aperture, the latter passing witl ease through No. 21 aperture of the gauge plate. It was a first thought that the spheres would be most efficacious i given by the mouth at night, the patient sleeping on his lef side ; but they were found to cause sleeplessness from rest lessness of the lower extremities (" fidgets") and bad night mares, so that this was abandoned, and they were given i! the early morning, just after breakfast, and the patien allowed to go about his usual avocations. By this plan the; caused less discomfort, and the only precaution taken was tl forbid very hot food and liquids, which might have softenej the gutta-percha so much as to destroy the rigidity of th sphere. They are found in the fasces, having passed through the alimentary tract without alteration. It is not difficult, b observation of the patient's symptoms, to form an approximat idea of the size of the pylorus in cases of stricture. If the pylorus be narrowed at all this is at once shown by the discomfort or suffering that follows the eating of large morsels of tough food, such as beef and mutton. Moderate mastication does not reduce such morsels full of tough fibrous structures to such a size as to permit of their passing through the orifice without inconvenience, and the patient experiences uneasiness or prolonged cramp-like pains, ex. tending from the right epigastric region to the angle of the left scapula, an hour or two after eating, and continuing until they are relieved by a gurgle of flatus and food passing into the duodenum. Hence such patients avoid these articles. of food instinctively, and select softer substances, like fish, or more finely divided foods, like minced meat, puddings, and pulpy articles of diet. If ordinary minced meat can be taken without discomfort, the stricture is certainly greater in size than a No. 10 or No. 20 urethral bougie of the French scale. If the orifice is less in size than this, only liquid and pulpy foods, containing no solid particles larger than boiled rice, can be taken without distress. These data are of assistance in commencirg the treatment as by regarding them the approximate size of sphere to use can be pretty well ascertained. The treatment is best commenced by administering immediately after breakfast a sphere which is considerably less in size than the estimated size of the stricture, the patient swallowing it like a pill in a mouthful of some cold liquid. If it causes no feeling of uneasiness in the pyloric region a larger size should be given next morning, and so on. When the effective size has been reached it will be known by its causing within twelve hours uneasiness or soreness in the pyloric region, and perhaps cramp-like pains in the stomach, until it has traversed the stenosed portion of the bowel. These pains are very characteristic, and as the treatment has to be guided by their appearance and nature a more minute description of them may be useful. After a, sphere which just fits the pyloric stricture has been swallowed, a certain time, varying from three quarters of an hour to five or six hours, or even more, elapses without any unusual sensation, and then discomfort gradually comes on in the pyloric region, in nature something between a stitch and a cramp, and often accompanied by intermittent cramplike pains extending along the stomach towards the spleen or left scapular angle. The former sensations I presume to be caused by the sphere irritating the pylorus as it passes through the stricture, and where the stricture is a long one the discomfort can be felt passing along it as the sphere advances, and finally it disappears with a rush or two of flatus as the sphere escapes into the duodenum beyond; the latter intermittent cramp seems to be due to the efforts of the stomach to overcome the obstruction. The amount of discomfort experienced by the patient is in proportion to the tightness with which the sphere fits the stricture ; should this not be excessive, a slight soreness at most may be felt on the following day, or even for a day or two, when , food is passing the narrow part; but if it be excessive . the pain may be sharp, knife-like, or, like the pain of ulcera-. tion, may be accompanied by tenderness on pressure over the . pylorus, and may continue for a day or two, or even a week or more. In this case it is generally associated with heart. t burn and acidity, and is significant, I incline to believe, of ; small fissures or abrasions of the stricture having been caused, ! for the employment of alkalies and bismuth, to keep the . contents of the stomach alkaline, is very serviceable in
doi:10.1016/s0140-6736(01)94197-2
fatcat:kgigmzjz2rbldgiaj5ipvmpwpe