We all take so much for granted. Until recently I always assumed my life had always been straight-forward: conception, birth, infancy, growing up and adult life and work are all part of natural process, right?
In recent weeks I have been reading some of the many medical journal reports of the past century about infant pyloric stenosis (IPS), a condition that I now realise could have cut my life very, very short, especially if I had been born just 20 or 30 years earlier.
It was during the 1910s and ‘20s that the treatment and outcome of this strange but quite common malady changed hugely.
In the 1910, the treatment of PS was mostly medical and dietary: a drug (atropine sulphate) could reduce the swollen muscle over time, and as I posted last time, daily washing out of the stomach and also feeding the sick baby with thickened milk sometimes helped. The most desperate parents were offered one of several very extreme surgical techniques, but in the mid 1910’s none of the babies operated on for PS at England premier children’s hospital (Great Ormond Street) survived, and the death-rate for babies treated non-surgically was 80%.
Then in 1912 the German Dr Conrad Ramstedt announced his accidentally discovered surgical technique (“pyloromyotomy”) which was enthusiastically utilised worldwide, although in the UK it was adopted only in 1918. Initially the death-rate in London fell but was still terribly high (41% in 1919), but during the following decade it fell to a mid-20s percentage – and remained stuck there. In 1945 (when I was born) the deaths after pyloromyotomy in the UK remained at 25%; in the US it was considerably lower.
This largely explains the many reports in medical journals of the 1920s describing IPS and the various ways of treating it with happier results. For this review I have drawn on four reports, two from the British Medical Journal and two from Annals of Surgery by U.S. surgeons. We can be grateful that such material is now readily available on the web; please contact me if you need help finding it.
Diagnosis has changed little except that (as noted in my previous post) none of the four reporters saw a need for x-rays unless diagnosis was unclear. In the 1920s some paediatricians succeeded in finding the “pyloric olive” every time; others not, but it was agreed that only very rarely was it impossible to diagnose IPS correctly. How different from today, when many surgeons seem to use x-ray and/or ultrasound routinely (and one may wonder why) to confirm what must almost always be abundantly obvious.
Treatment in the 1920s varied much more than in English-speaking countries today. An English surgeon reports finding that in many cases medical treatment should be tried first, and that it is successful in about 80% of cases. The reports all mention successful medical treatment. Only babies whose condition had deteriorated greatly and those whose medical care had not arrested their decline would be prepared for surgery.
On the other hand, an American surgeon wrote: “Medical treatment has undoubtedly been successful in a certain number of cases, but it is not improbable that some of the cures were really cases of pyloric spasm, and not hypertrophic stenosis. It is doubtful if cases of well-marked hvpertrophic stenosis are often cured except by operation.” This doctor was a strong advocate of the surgical option.
Today the medical treatment of IPS is widely used, but it seems hardly at all in the English-speaking world, where cost and convenience considerations seem to rule and the effects of surgery on the baby’s later life are not mentioned.
Preparation was identified early as one of the keys to the IPS infant’s recovery. Several of the reports mention a steep learning curve: without experience surgeons regarded the new Ramstedt technique as a sure lifesaver, but the majority of their patients died from “collapse” which must be understood as not being able to withstand surgery or the shock and trauma it added to their already critical condition. It was soon discovered that “emergency surgery” is fatal to IPS babies, and that a day or two must be given to rehydrate the baby and restore its blood biochemistry. A New York surgeon reported that of his 104 cases 7 subsequently died, 6 of these being among his first 19 cases.
Anesthesia is mentioned in all four reports, and remarkably the story is the same every time and on both sides of the Atlantic. General anesthesia using ether and/or a compound was the rule. In one case local anesthetic was used at the parents’ insistence and in a very few cases the baby’s respiratory weakness made it advisable. It was found universally that babies could withstand ether provided it was used carefully and applied lightly. General anesthetic resulted in relaxation that made surgery faster and easier – as laypeople could well imagine! With local anesthesia babies strained, causing its viscera to pop out of the wound (complicating the operation and increasing the likelihood of post-operative shock and of adhesions later) and making the wound’s repair more difficult. The injected local anesthetic also slowed wound healing.
It was in the next decade (the 1930s) that we see a marked move away from rendering babies unconscious during surgery and a widespread but suspicious silence about pain relief. That is another subject – and quite a subject.
Surgery for IPS was quick. The reports mention 10-15 minutes as the time needed. The challenges and dangers in the 1920s were very much those still mentioned today: the perforation of the mucosa (lining of the alimentary passage) or duodenum (large intestine), an “incomplete myotomy” (the pyloric muscle is not sufficiently split which allows it to regrow and the blockage remains or returns), bleeding, and inadequate repair which results in the wound herniating or reopening.
The surgeons who wrote these four reviews used only two incisions, both vertical: the midline approach which Dr Ramstedt used but which carries some hazards, and the paramedian, a centimetre or so to the right of centre and also known as the “upper right rectus” incision. The transverse (across) opening which became almost standard in the USA and is still widely used today, evidently belongs to later years, as of course do the umbilical and laparascopic approaches to the pylorus.
Post surgery care, as has been mentioned in my previous post, was a subject with widely differing reports and outcomes in past years. As reported by Dr Still (see previous post) the British private hospitals had good results in the 1920s: babies were cared for in separate rooms, sometimes each baby with a trained sister for the first day or two, and some private hospitals employed a specially experienced sister to care for at-risk babies. In the British public hospitals, however, all these standards left much to be desired.
Although the two US reports reflected here mention a fall in the IPS mortality rate that is similar to that in Britain, neither surgeon mentions the statistics for public and private hospitals.
On a personal note, I was touched by the discovery that the surgical scar I carry is from the very same incision mentioned by Dr Ramstedt in 1912, although it is rarely if ever used today. I carry a link with my lifesaver’s work!
Also, one of the reports, written by Dr Arthur C Strachauer, practising in Minnesota, clearly reflected him as a notably sensitive, careful, and caring surgeon in his general tone and in the many detailed practical tips he gave for diagnosing, operating on, and caring for PS infants. I can find much comfort in thinking that my needs just may have been handled by someone like him!