A Case of Loreta's Operation for Stricture of 
the Pylorus. 
BY ♦ 
T. W. HUNTINGTON, B. A., M. D., 
Sacramento, Cal. 
SACRAMENTO. CALIFORNIA : 
Reprinted from the Occidental Medical Times, September, rS8y. Reprinted from the Occidental Medical Times, September, 1889. 
A CASE OF LORETA'S OPERATION FOR STRICTURE OF 
THE PYLORUS. 
By T. W. Huntington, B. A., M. D., Surgeon Southern Pacific Co's 
Hospital, Sacramento, Cal. 
Read before the Sacramento Society for Medical Improvement. 
Until recently no attention has been paid to the after-effects of 
chronic gastric or duodenal ulcer upon the anatomical structure of 
the pylorus. That stenosis of the pyloric orifice is occasionally 
an important sequel of such disease is now undisputed, while the 
operation devised by Loreta for the relief of this condition seems 
to be a rational and comparatively safe procedure. It is certain 
that the operation will prove a boon in a rather numerous class of 
obscure, tedious and urgent cases, which present a history of pro- 
longed gastric derangement, and in which medication and dietetics 
have proven unavailing. The following case will be of interest as 
a contribution to the literature of this subject : 
T. W , set. 23, native of Ireland, by occupation a laborer, 
entered the Southern Pacific Co's Hospital Jan. 16, 1889. The 
following history of the case was obtained : Four years ago, while 
in Ireland, patient had a prolonged attack of gastric trouble, ac- 
companied by epigastric pain, vomiting, and loss of appetite. A 
similar attack occurred one year later, and he had never fully 
recovered. In July, 1888, vomiting recurred, accompanied by 
constant belching of gas from the stomach, great pain in the epi- 
gastrium, absolute disgust for food, loss of weight, and general 
debility. About this time he applied for treatment at the Hospital 
as an office patient, and continued in this capacity until Jan. 16, 
1889, without relief. The diagnosis made was chronic gastric 
ulcer. Upon admission to Hospital, he was placed upon a strict 
diet, consisting of peptonized milk and raw minced meat. There 
was almost immediate improvement in the patient's condition. 
On March 23, 1889. however, the gastric symptoms were so 
distressing, that it was determined to irrigate the stomach daily 
through a stomach tube. For this purpose a solution of bicar- 
bonate of soda, two drachms to the pint, was used at first, and 
later on a solution of boracic acid, one drachm to the pint. Al- 
though improvement followed upon this treatment, yet, at the end 
of two weeks, he still complained of accumulation of gas in the 
stomach, and of deep epigastric pains, from which he had never 
been relieved. Rigid diet was adhered to, and at times the patient 2 
was nourished by rectal alimentation alone. While occasionally 
there was relief from vomiting, this symptom never failed to recur. 
On June ist, it was discovered that the stomach was greatly di- 
lated, and failure of his general condition was unmistakable. On 
the 7th of June he went to San Francisco, on an indefinite leave 
of absence, but his former symptoms were so aggravated that he 
returned in one week. From this time vomiting was almost con- 
stant, whether the stomach contained ingesta or not; he frequently 
vomited coffee ground material. Having determined that the pa- 
tient's trouble was now due to cicatricial contraction of the pylorus, 
and his consent having been obtained, I decided to operate by 
Loreta's method. For several days previous to the operation, 
the patient was prepared by daily irrigation of the stomach and 
rectal alimentation. 
On the 1 Sth of June, assisted by Doctors Cluness, Gardner, 
and Simmons, with a number of other physicians, the patient was 
etherized and I opened the abdominal cavity by an incision four 
inches in length, extending from the sternum to the umbilicus. 
No important hemorrhage was encountered in opening the omen- 
tum, and the anterior wall of a greatly dilated stomach was easily 
exposed. The pyloric orifice could not be definitely located, al- 
though the conditions seemed to be such as to warrant completion 
of the operation. A vertical incision, one-half inch in length, was 
made through the anterior wall at a point midway between the 
two curvatures and three inches from the pylorus. No important 
vessels were severed. Through this opening a search for the py- 
loric orifice was instituted, and the opening detected with some 
difficulty; it was located on the upper curvature, the duodenum 
being turned backward and covered by a pouch or cul-de-sac, 
formed by the dilated end of the stomach. The point of the little 
finger engaged in the pylorus with much difficulty. A small uter- 
ine dilator was then introduced and the opening slightly enlarged; 
further dilatation was effected by means of Bigelow's powerful sinus 
dilator. The incision in the gastric wall was then enlarged to ad- 
mit the index fingers of both hands, by means of which the oper- 
ation was completed. The dilatation was carried to a degree suf- 
ficient to admit three fingers readily. The stomach wound was 
closed by continuous silk suture of- the muscular and mucous 
coats, and by Lembert's interrupted silk suture of the peritoneal 
coat. The abdominal wound was carefully cleansed with sublimate 
solution and closed with silver sutures. Time of operation 1% 
hours. 
The patient suffered but slightly from shock and vomited once, 
two hours after. The vomitus consisted of blood and biliary 
matter. His temperature for the following week ranged between 
normal and ioo° F. For the first ten days no food was given by 
the mouth, patient's strength being maintained by nutrient enem- 
ata, consisting of liquid peptonoids, whiskey and peptonized milk. 3 
Small pieces of ice were permitted from the first, and were ren- 
dered imperative by annoying thirst. 
During the night of June 26th, patient vomited twice, owing to 
indiscretion in the use of ice. The following morning it was dis- 
covered that one of the sutures at the middle of the abdominal 
incision was broken, and that the wound had opened. Through 
this orifice a fan-shaped portion of omentum protruded. This 
was at once carefully cleansed and replaced, the wound being re- 
closed by a strong suture. After the second week the patient was 
nourished wholly by the stomach, solid food being gradually sub- 
stituted for liquids. There was no further interruption to recovery. 
July 20th, two months after operation, patient has an excellent 
appetite; eats liberally of solid food, without vomiting or distress. 
He has gained rapidly in weight and strength, and hopes to re- 
sume work at an early day. 
Positiveness in the diagnosis of cicatricial, or non-malignant 
stenosis of the pylorus is far from easy of attainment. There are, 
however, three factors, which, if present simultaneously, point 
strongly to the existence of this condition-First : a well-authen- 
ticated history of chronic gastric or duodenal ulcer. Second : 
persistent vomiting of partly digested food, or of biliary fluid. 
Third : marked dilatation of the stomach. Epigastric pain, disgust 
for food of any sort, and chronic constipation, together with 
various phenomena depending upon functional derangement, are 
of value only as confirmatory symptoms. 
According to Treves, of London, this operation has been done 
frequently on the continent of Europe, Loreta being the most 
prominent operator. Up to May, 1889, this method had been 
resorted to but once in England, and that case was treated by 
Treves himself. Drs. Kinnicut and Bull, of New York, have 
recently published a table of twenty cases by various operators. 
To this table I have added Treves' case and my own, making 
twenty-two in all. Of these, fourteen are reported cured, one 
improved, and seven dead. The causes of death in the fatal cases 
are as follows : Cancer of the stomach, hemorrhage into the 
stomach after operation, renal disease, exhaustion (on the eight- 
eenth day), tetanus, and collapse. In one case the cause of death 
is not given. 
Loreta states that in uncomplicated cases he has met with 
almost universal success. It is to be regretted that his statistics 
are inaccessible, he having lost the notes of many of his cases. 
In the preparation of this class of cases for operation, much can 
be done to insure a fortunate result; and in this connection I wish 4 
to give due credit to the efforts of my assistant, Dr. George B. 
Somers. To him was entrusted almost the entire responsibility oi 
treatment, both by irrigation and dietary measures, and to his 
efficient management I believe our success was largely attribu- 
table. The patient's condition at time of operation was excellent, 
his strength having been conserved by skillful feeding. 
426^ J sheet.