Much changed in the 1930s for babies suffering with infant pyloric stenosis (PS). The medical journals of the decade show signs of continued progress but also growing disagreement as to the diagnosis, treatment options, anesthesia and incisions that were part of the treatment of PS.
We can be grateful that several professional medical bodies (though far from all) have been generous and benevolent in making their older medical journals readily and freely available to the interested public. Reading the reports and discussion of the 1930s has brought home to me how much medical science and practice have seen constant and rapid development during the past century. We all benefit greatly from these advances; in fact, I owe my life to it. But this review of the 1930s has also left me in the dark in some ways …
The mortality rate fell further
During the 1930s the mortality rate for PS at Toronto’s Hospital for Sick Children dropped from 14% to 1-2%. A US surgeon also reported on the death rate falling to 1-2% during the 1930s. A British specialist, Dr David Levi, reported that by addressing the identified risk factors there was just one death among his 50 cases for 1934-35; however, many hospitals in the UK continued to see very high death rates (see my previous post).
The number of times I have read online of family members who died of infant PS during these years gives me some indication that the number of sick infants who died from the condition or resulting complications may have been considerably higher than the statistics of doctors and hospitals suggest. The are also medical journal articles written around 1950 that mention the high deathrate from general anesthetics being given to babies by people without the specific knowledge and experience needed for this delicate task.
More surgical treatment
The 1930s literature shows a growing advocacy of surgery as the preferred way of remedying PS – in the English speaking world. Conrad Ramstedt, the man who gave the world the surgical answer that is still and exclusively used “… advised 8-10 days of medical treatment before resort to surgery provided the baby is not too weak to withstand surgery.” This approach became a subject of polite but one senses passionate debate in the 1930s. Germany and Denmark were among the countries that continued to follow Ramstedt with high rates of successful medical treatment.
So on the one side were the advocates of medical treatment for all but those few cases that failed to respond to it. On the other side were the surgeons, one senses even then a powerful profession.
We read that “In 1930 Ramstedt had collected information about 1,842 cases from sixty different clinics. Of these, 1,345 had received medical treatment with a mortality of 16 per cent, and 497 were treated surgically with a mortality of 22.5 per cent. The statistics of the mortality for those treated medically as well as surgically are, on the average, more encouraging in those hospitals which confine themselves to one of the two methods. This may indicate that hospital discipline and consistent treatment are of importance. On the whole, the mortality rate seems to be lower in the case of medical treatment.”
What happened, I imagine, was that the surgery advocates built success in tackling most of the causes of their 22% death rate. The medical treatment also developed: lavage (regular cleansing of the stomach and coaxing it to accept food) gave way around 1922 to the use of atropine, a muscle relaxant that needed careful use to avoid poisoning. By the 1930s, a safer compound, eumydrin (atropinemethylnitrate) had replaced it. However, its use still saw a 1935 mortality rate of 3.3% and was reported to require a hospital stay of an average 102 days! Although medical treatment as recorded was almost always effective in the long term, it was exacting, demanding of hospital resources, and stressful for parents. The infant being able to live without the traumatic effects of 1930’s style surgery and an avoidable scar clearlywas not regarded as outweighing these considerations.
Those who favoured an operation stated quite rightly that it would result in the symptoms disappearing quickly and the duration of the disease being shortened. The post-surgery treatment usually took only two to four weeks, long by today’s standards but much less than the 1930s medical avenue.
But there was agreement in one area: the aim of both medical and surgical therapy was to allow the PS baby to take nourishment for survival, and this demanded good hospital care.
A move to local anesthesia
This development was not as strong but was clearly widespread, especially in the USA. The reason for so many surgeons switching from chloroform or ether to local anesthesia will be outlined in the next post, as it gathered pace in the 1940s.
Was the use of general anesthetic dangerous? Our hearts and lungs function differently during our first year or so, and this means anesthetists administering general narcosis to infants must be specialists. Chloroform was abandoned early as too readily and suddenly fatal. But in the journals of the first few 20th century decades we find many general assurances that ether and/or ethyl chloride could be safely given to babies, that PS babies only need to be lightly anesthetised, and that a general anesthetic has several benefits. It relaxes the baby, which apart from benefitting the baby makes the surgeon’s work easier: the baby doesn’t stress and move and local anesthetic affects the tissue during and after the surgery. General anesthesia also makes closing the incision easier. One wonders, what can be better than these benefits? Every 1930s report I could find was silent on that (as well as the deathrate from general anesthetics) despite what seems so obvious: one doctor put it very simply in a 1940 report: “Local anesthesia has not proved satisfactory, as it is very difficult to restrain a struggling infant.”
Yet in the 1930’s articles I already found several reports stating that an opium and/or alcoholic sedative followed by the incision site being saturated injected with local anesthetic were adequate and the writer’s preferred way. One wonders: what was motivating the surgeon who wrote in response to the above words: “For some ten years, we have operated entirely under local anesthesia. After the preliminary administration of [the sedative] luminal or nembutal, we give the child, shortly before operation, a sugar teat to suck. You may be surprised to hear that in the Quaker City the so-called sugar teat is made up of ten drops of paregoric and ten drops of whiskey or brandy to one ounce of a 5 per cent glucose solution. You will, likewise, be surprised how the babies take to this mixture, and also, more or less, amused by how promptly they become happily intoxicated.”
Changing incision preferences
A fair degree of mystery and silence also surround a move away from the common use of the vertical midline and paramedian (right of midline or “right rectus”) incisions to transverse (cross) incisions either diagonally under the right ribs or simply across the right of the upper abdomen. In the 30s there was a flurry of articles about the pros and cons of various upper abdominal incisions: considerations included the ease of access and extension they allow, how the muscle structure and blood and nerve supplies are affected by each location, and how easy and effective their closure is. These articles’ presentations and the discussion they evoked are fascinating – but nowhere could I find why the vertical incisions were replaced (esp. in the USA) by the various horizontal ones. As with the medical treatment of PS, Great Britain and Europe continued to see the vertical incisions with far more favour. This will also be discussed in more detail in a later post.
Today the cosmetic factor is often mentioned: how can we do this purportedly minor surgery with the least damage? This in recent decades has translated into the growing use of the umbilical and laparoscopic pyloromyotomies. Until recent decades the infant surgery’s impact on the patient was never mentioned.
As one who carries a very obvious scar from the 1940s style surgery I have been interested to compare how obvious and un-disfiguring others’ PS badges are. My conclusion is that all the old “slice and sew” ways of accessing a troublesome stomach can be done quite tidily or otherwise, depending on the surgeon’s care and skill and the way the wound heals.
This unexplained move from vertical to transverse incisions has reinforced my feeling that while medicine is certainly scientifically based and normally conducted that way, it can also include a strong element of fashion or “I’ll do as I was taught”.
Left in the dark
Two of my unanswered questions have already been mentioned. There is one more.
Written as these articles were, some 10 – 20 years after the end of the terrible suffering inflicted by World War 1, was there really no thought given to the possibility that surgery without general anesthesia might have long-term effects?
We are grateful that although the medical profession can still be very closed to patients’ questions, we have seen great progress in medical science, both technically and in that many of our doctors are more aware of the humanness and needs of their patients.