Dr George F Still was an eminent physician and surgeon who in the 1920s worked at what has been Great Britain’s premier hospital for sick children for much longer than I can remember: the Great Ormond Street Hospital for Sick Children in London. He reported on 24 years of experience with the condition that is the reason for the highest number of surgical operations on babies: infant hypertrophic pyloric stenosis (PS).
He addressed the British Medical Association in November 1922 and his report was included in the 13th April 1923 issue of the British Medical Journal, all but the most recent years of which I am happy are available on the web. His experience gives us a fascinating picture of some the “challenges” (read: hazards) associated with infant surgery in the first decades of the 20th century, as well as the impact of a new surgical technique on the survival of babies with pyloric stenosis.
Dr Still’s opening remarks express regret that he’s reporting on a subject that had received much attention during the past decade, presumably since the German surgeon Conrad Ramstedt discovered and in 1912 published his novel method of remedying PS by a technique which was less radical, faster, and more often immediately successful than any of the then current treatments. Ramstedt made surgery the preferred option rather than the last resort for many pediatricians after a diagnosis of PS.
In 24 years Dr Still had recorded 248 cases of PS, and his statistics are probably still largely valid today: the 248 babies included only 37 girls, almost half the total cases being first-born babies, and 4 families accounted for 8 of the cases. He comments that many doctors denied having ever encountered a case of PS but believes this is because in the past many cases were unrecognised or labelled as “marasmus” (a catch-all label for “failure the thrive”) or “chronic gastric catarrh”. Dr Still does not commit himself on whether PS can be “congenital” but notes its onset is usually during the first to fifth week after birth, though sometimes later.
He describes the onset and symptoms of the disease in terms that are very familiar to any description of PS today: the combination of vomiting, constipation and wasting. He notes that the vomiting can start very insidiously, deceptively intermittently or quite suddenly and with immediate loss of weight and condition. He had also found that a change of diet could delay the development of the vomiting, which could easily confuse early diagnosis.
Eyes and fingers were ultra-essential and skilled diagnostic tools until the late 20th century. For Dr Still, visible peristalsis of the stomach and being able to feel “the pyloric olive” (the swollen muscles) confirmed a PS diagnosis on the basis of the threesome mentioned above: Dr Still clearly did not need ultrasound scans and barium meals – and was of course unable to benefit from their evidence! He comments that only twice in 248 cases could he not find “the olive”, although this sometimes required more than one consultation or up to 15 minutes of probing. He regarded “the olive” as essential to his diagnosis and would not commit to ”an extremely grave operation” without finding it.
Dr Still only kept a record of the results of 232 of his 248 cases during the 24 years to 1922. 76 of these babies died: 7 of these were too close to death for surgery and these children died within a week. Of the 225 who were able to be treated, 156 recovered and 69 died; his comments on these cases are poignantly noteworthy.
First, he comments that the high death-rate among PS babies reflects that during half of his 24 years of work, surgery was the last desperate resort rather than the preferred option. He also comments on the high death-rate among cases operated on in a public hospital rather than the smaller and “private” “nursing hospitals” “or in the patient’s own home” (sic!). Dr Still’s statistics are horrifying to us in this regard: of the 98 cases treated in a public hospital, 55 died and 43 survived; of the 127 treated “privately” 113 survived and 14 died. No wonder the good doctor seems to have steered his patients towards private modes of treatment. From my wider reading it has become clear that cross-infection, post-operative shock, the frequent unavailability of “wet nurses” in public hospitals, and separation from mother were major causes of infant death after PS surgery until mid-century.
Dr Still then reviews the results of his surgical treatment of PS, and he comments that whereas surviving surgery used to be regarded as a medical triumph, by the 1920’s it had become commonplace if not (yet) highly likely. He adds an observation that parents and surgeons today don’t seem to know about or consider: “indeed, there is a tendency to lose sight of the fact that complete recovery can take place without operation at all.” He adds that 6 of his 156 recoveries escaped surgery by therapies that required prolonged but rewarding care.
He mentions a treatment that was apparently one of the most successful for PS before Ramstedt’s operation was introduced from 1912: lavage, or the repeated washing out of the stomach. When the risk of surgery in his earlier career meant his scalpel was the last resort, Dr Still found that of 78 cases he treated by lavage 43 recovered and 35 died. His report cautions that lavage (once or more daily) must continue for up to 16 weeks before the PS has subsided, that it requires skilled nursing and very patient parents, that it usually means the end of breastfeeding, and that many babies cannot survive this lengthy and arduous process. However, he suggests lavage as a first line of treating mild cases of PS with whom wasting is not serious. Today lavage may still be used as part of PS treatment, but we should consider medical treatment with atropine sulphate for such babies, as is done much more routinely in some countries than where English is spoken!
Before Ramstedt and 1912 there were several very severe and last resort surgical techniques in use to remedy PS, but the simplicity, rapidity and survival statistics of Ramstedt’s operation quickly consigned the other surgical remedies to history. However, in 1922 Dr Still was still cautious about Ramstedt’s pyloromyotomy, chiefly for reasons that are no longer considered significant or fatal hazards: most of his fatalities occurred within days of the surgery, resulting from bleeding from the pyloric incision into the abdominal cavity, infection or surgical shock.
In his report Dr Still praises a colleague’s skill in using the dilatation of the pylorus to save all but one of 46 cases. Dilatation is a severe and invasive technique that was successful before Ramstedt in the hands of just a very few surgeons; today it is no longer used to remedy infant PS.
In conclusion, Dr Still remarks cheerily that whatever treatment is given to PS infants, whether it be simple feeding, gastric lavage, or operation, it seems to leave no after-effect in the children involved.
Some of the areas Dr Still did not include in his interesting review were the use of anesthesia for his surgical work on babies, his patients’ post-surgical care, and the long-term effects of their treatment. Other articles by his contemporaries often discuss especially the first two of these, already then “hot topics”. As for the last of these silences, had he been able and interested to follow his PS patients for 24 or more years into the future, I wonder what Dr Still would have included in his update report?