Interest in infant pyloric stenosis (“PS”) is certainly not falling away: just the number of medical journal articles on its causes, incidence, treatment and after-effects readily available on websites is a clear indication of that. For most of my 60-plus years I have searched the public libraries – and been sad to find that even the catalogs and shelves of the largest have only the most general and usually outdated information on PS. The web has certainly opened up the world in many ways!
However, my web-based research on this subject found a 50% increase in medical journal articles and reports published back in the 1980s compared with the number I logged from the previous decade. How sad that for so long all this information was effectively restricted to doctor’s offices and university libraries, and that even now some of the material that is surely of historical interest only is still available to the general public only at great cost (sample: US$35 per article). But I am very thankful that several leading journals now make all but their most recent issues freely available via the internet.
Although my work has mapped some of the progress that took place in some of the subject areas related to PS, it is also glaringly obvious that our understanding of the causes and therefore the reduction or even prevention of this disease is making little progress and is probably in the “too hard” basket.
What did the 33 reports and extended Comments and Letters related to PS during the 1980s show?
1 Is the incidence of PS rising or declining?
There were Reports from several countries about whether the incidence of PS was rising or declining during the years up to 1990. It seems on balance that the incidence can fluctuate quite considerably: in Central Scotland PS was reported as having increased from 2.1 per 1,000 live births in 1970-77 to 5.2 per 1,000 in 1978 and 8.8 per 1,000 in 1979, this last being the highest figure ever recorded in the world. Analysis of these figures could not find any pattern or factor that might have caused this. Statistical work inEngland andCanada found similar though not quite as extreme fluctuations. Suggestions that increased numbers were due to better diagnosis did not stand up to closer analysis.
2 How do we come to get PS?
Another subject that gets frequent attention is the genetics of PS, but none of several Reports on family links really added anything substantially new. It was again found that the strong link between women with a PS history and their children’s having it had a genetic cause and was not related to the baby’s environment in the womb.
3 Is PS for the very young only?
Two Reports reminded everybody that PS can very sometimes develop in infants well after the usual “window” between birth and 3-4 months. Cases were cited as starting at 5.5 and 22 months and another at 2 ½ years. Two of these cases were proved at these babies’ Ramstedt operation.
4 Should any surgeon and hospital treat PS?
A big issue in the UK during the 1980s was: is PS better treated by a pediatric surgeon and a pediatric anesthetist in a large city children’s hospital, or can it be adequately dealt with at the local hospital by a general surgeon? Five articles (including one from Scandinavia presented statistics and arguments.
The team at the Royal United Hospital in Bath found that its use of local anesthesia in the majority of cases resulted in less post-operative vomiting, and several other benefits. But it also found a greater incidence of complications and the Report recommended that pyloromyotomies be done by paediatric specialists.
Another British Report was damning: of 101 PS operations during the later 1970s at the Gloucestershire Royal Hospital, including 1/3 with local anesthesia, 20% resulted in complications (many with wound and other Staphylococcus aureus infections) and two deaths. No demonstrable benefit in using general anesthetic was found. It seemed that at least some British hospitals had made little progress in what was in the past the Number One danger for infant (and other) surgery: skin and gastro infections.
A third British Report stated: Hypertrophic pyloric stenosis is generally easy to diagnose and is treated by the most standardised operation in surgery. This may, however, lead to its being performed by relatively inexperienced operators. Recent figures from two district general hospitals show that breaches of the duodenal mucosa and dehiscence [rupture] of the incision are eight to 10 times more common among occasional operators than among experienced surgeons.
A 1988 Report from London’s Great Ormond Street Hospital for Children was able to show in some detail that complication rates there had in effect fallen into line with those often reported in the USA. It needs to be remembered that in 1945 many UK hospitals reported death rates from PS up to 25%, when those in the US were between 2% and zero.
In the light of the weight of advice against PS being treated by specialists in general hospitals a Surrey surgeon reported on the more favourable experience with 46 PS babies at his hospital between 1984 and 1989. All were given general anesthetic and right upper transverse incisions. There were no deaths and 78% made uneventful recoveries. In one respect their data was far more favourable than that from the US: only 6.2% of the British babies were submitted to radiology (x-ray) whilst in some US surveys the figure was 80%. The British surgeon concluded with pride: The results of this study show that such patients can be successfully treated in district general hospitals, and three areas merit special attention: meticulous surgical technique, the use of prophylactic antibiotics, and early graduated feeding.
5 What was notable about the 1980s treatment of PS?
Four of the articles were reviews of the diagnosis, treatment and results of infant surgery for PS. These also emphasise that The operation of pyloromyotomy as described by Ramstedt in 1912 is simple and effective, but attention to detail is necessary if minimal morbidity and zero mortality are to be achieved.
A German article observes that radiological investigation doubled there between the 1960s and ‘70s, from 9% to 19%. The second of these decades also saw a reduction in post-operative vomiting and an average earlier discharge from hospital, with no deaths and reduced morbidity (complications).
A Report from Perth in Australia, based on hospital records and census data for 1971-84, found no link between PS and breast feeding or birth order. Low birth weight, short gestation pregnancies, and a paternal family history of the disease were significant features: 11% of the cases had a family link, 55% of which being with the father’s side and 25% the mother’s family. Several aboriginal cases were noted – for the first time ever.
An article from Denmark reminds us that in Europe medical treatment of PS is still common although less and less so. Between 1950 and 1984, 679 patients were treated at a regional hospital, 114 of them medically. The study noted that Complications occurred in 17% of medically treated patients and in 8% of surgically treated patients. Six deaths occurred among the medically treated and four among the surgically treated patients. During the study period, a shift toward centralization and surgical treatment took place.
Unanesthetized circumcision. Note the classic face of pain with prominent brow bulge, facial grimace, and gaping mouth. Reprinted with permission from The Saturday Evening Post Society, copyright 1982 BFL&MS, Inc.
6 Infant surgery without pain?
The “big issue” for many during this decade was the Article by Dr K J S Anand disclosing that much infant surgery at that time (and presumably for many years) had been done without any form of anesthesia because of the widespread belief that “babies don’t feel or remember pain”. My reading leads me to note that Reports from leading pediatric surgeons and large city children’s hospitals on both sides of the Atlantic often mention the use of general or local anesthesia; I conjecture that the idea that “babies don’t suffer” developed because in any but the large city pediatric hospitals it is often not easy to find enough specialists in infant anesthesia, a skill quite distinct from the safe anesthetising of older childen and adults.
I have included links and several posts on this blogsite on this subject and will continue to do so from time to time.
I find it outrageous that despite the research reports and advocacy on infant pain and trauma that is now available, the web has reported (1) a continuing reluctance in some quarters to anesthetise infants for surgery, and (2) that male circumcision with and without pain relief continues to be practised, even outside the religious faiths that regard it as compulsory.
There are several subjects not mentioned above that also attracted considerable attention during the 1980s, notably the long-term after effects of infant surgery for pyloric stenosis. Watch this space during the next week!
Links and references to the material in this blog are available on request and will be added as time allows.
I’m feeling grateful to have been born in the metropolitan area of New York City and had ps surgery in 1952 with a pediatric surgeon. My mother told me that this doctor had to be “brought in.” The surgery was done at Beth Israel Hospital in Newark, New Jersey (very close to New York City). Furthermore, my mother told me that he was a German Jew and was only here because of the Holocaust! Otherwise, apparently, it wasn’t easy to find a doctor with this specialty of operating on ps babies. That’s what my mother led me to believe. I always felt lucky in this way. I literally shook when I read in your post, Fred, that, in one study, ps babies operated on by general surgeons in less urban areas had high infection rates and incision ruptures. Oh my. And some babies died. Well, I am so fortunate to be here. I’m glad you are here, too and advocating for those of us with ps histories, many of us searching for answers to so many questions. Thank you.