In my previous post, I looked at a survey of 112 infant pyloric stenosis (“PS”) cases by which a regional British hospital shaped its preferences and policies for the treatment of this disease in the 1940s. I’m very interested in the development of medical science, not least so because the 1940s were when I had my first surgery. It saved my life but frankly, it also messed me up somewhat.
Many medical journal articles were written on both sides of the Atlantic during the 1940s about the best ways of treating PS babies. In my previous blog I mentioned also that these reports and letters make it clear that there was quite some variety in the treatments chosen and even some disagreement, although always expressed as professional gentlemen should.
A New York surgeon, Dr Edward J Donovan, wrote with considerable enthusiasm in a 1946 issue of Annals of Surgery about his success in operating on 507 PS babies since 1932, with a commendable (in those times) 1.7% mortality rate.
He dismissed medical treatment (with atropine and its relation eumydrin) as a waste of valuable time, making great demands on hospital staff and resources and the parents, and all this for (he claimed) uncertain results. PS babies are often dangerously dehydrated by the time a hospital will admit them, so as soon as they had been stabilised Dr Donovan would operate. He also dismissed x-ray confirmation of the diagnosis as unnecessary and delaying the recovery, and local anesthesia as making life harder for both the surgeon and the patient, and slowing healing. He favoured ether anesthetic and a vertical right rectus incision, and brought only the pylorus out through the opening. He found that the liver and various muscle layers covering the stomach area worked on and stitching the various tissue layers separately resulted in only one wound rupture in his patients. He used small clips to close the skin layer, leaving more but much smaller scars than stitches.
Other complications were also rare: one baby caught pneumonia and had surgery with local anesthetic, the gastric passage was accidentally opened in two babies, and one baby developed adhesions and needed more surgery after 6 weeks. Normally breast-fed babies could be discharged after 10 days and bottle-fed infants after two weeks.
There was a response from a Boston colleague who agreed fully with Dr Donovan’s methods although he had changed to using a “high gridiron” (under the right ribs) incision. He reported he’d had no deaths from 225 cases during the past 3½ years. A Chicago surgeon responded that he worked with local anesthesia.
Another US surgeon, Dr Charles A Vance of Lexington Kentucky, wrote an extensive article in the same journal two years earlier (March 1944). After reviewing the history of infant PS surgery in the world and in the USA, he recorded his knowledge and treatment of the malady. Like Dr Donovan he believed that surgery was the better treatment, seeing the high surgery death rates of earlier decades had been overcome in North America. His technique was also similar to that of Dr Donovan, except that he stitched the skin. In 24 years since 1920 he operated on 27 PS babies with one death (from unknown causes) and no other complications.
A North Carolina doctor responded to this article. Over 16 years he had done 60 pyloromyotomies, using local anesthesia and without any fatality; he had ruptured the duodenum in a few cases. He also used the right rectus incision and closed the skin with silk or cotton sutures.
Meanwhile in Britain…
Comparing these two US articles with others from both sides of the Atlantic, it becomes clear that by the 1940s surgery had become the PS treatment of choice for most if not all surgeons, but also that there remained a sizable body of other medical workers who advocated the non-invasive approach as a responsible and less traumatic (if more onerous) first option in many cases.
It is also clear that routine was (and remains) one of the important factors for a successful outcome: like the rest of us, surgeons need to adopt a regular procedure and continuously aim to improve on it. Like most of us they are generally reluctant to consider, let alone try working in new ways just because others recommend or claim success for it. So diagnosis, options for treatment, anesthesia, the incision, wound repair and post-operative care are hard to change, whatever the benefits might be.
In the British Isles, it took much longer than in North America for the infection bogey to be slain, particularly in the public hospitals. Dr David Levi, a prominent London surgeon, wrote often in British medical publications on PS and its surgery. In a July 1941 British Medical Journal article he made what I consider are some very interesting points.
He first reports that all 100 of his tiny patients who were breast-fed and operated on were PS survivors, because this combination gave them a large measure of protection from cross infection with gastroenteritis, which was the largest single hazard for both medical and surgical PS patients while they were in hospital. In contrast, of the 46 artificially fed babies he worked on, 5 died, all from gastroenteritis.
Dr Levi then reports that –
- He prefers local anesthesia and a warm operating theatre because ether anesthetic and the associated chilling are distressing and induce shock.
- He uses an upper midline incision and through two skin punctures he would inject the region and several levels of the wound with local anesthetic.
- Nothing was allowed to leave the abdomen except the offending pylorus.
- “Gentleness is more important than speed. And if the child is under local anaesthesia, and the theatre is warm, speed is of little moment.” And:
- Local anesthesia allows the infant to resume feeding with less or no after-effects and thus more quickly.
On the other side of the medicine-versus-surgery-for-PS debate, the British Medical Journal included a report in May 1946 validating the place of medical treatment. The author, Dr N M Jacoby, a senior English physician, acknowledged that surgery had largely replaced medical treatment, but asserted that eumydrin could avoid unnecessary surgery, provided that clear criteria were followed. The article repeated these (see the previous post also) and reported on 50 babies given each treatment – and both series being without deaths.
But in the English-speaking world at least, the surgical treatment increasingly ruled supreme!
The debate about anesthesia also continued with vigour, and in my next post I will review the small flood of material that appeared around 1950 on this issue.
The pieces come together …
I am one of those who had PS surgery as a newborn during the 1940s. My parents would (or possibly could) never talk about it with me, and all my life I have wanted to overcome the deafening silence I just could not banish, and been anxious to find the answer to several questions. It is exciting and reassuring for me that at last the puzzle pieces are coming together.
- Knowing as I do that my operation occurred at 10 days, the available material has taught me that I was a standard early onset case of PS. It seems such cases were best sent for surgery as soon as their condition had been stabilised.
- The scars from what would have been intravenous feeding inserts under my arms tell me that I needed treatment for dehydration before surgery, also normal. At just 10 days this would have marked me as a severe case, unlikely to respond to medical therapy quickly enough to survive and to escape almost inevitable surgery in an even worse condition.
- The upper midline incision I had is rarely used now for PS babies but it and the right vertical incision were the standard ones in most countries until this time when especially US surgeons started to prefer transverse incisions, still common today for PS babies.
- It seems from Dr Levi’s articles and the two small white spots to the left of my incision scar that I was given local anesthesia rather than ether: this also seems to have been common practice in the 1940s.
- Images of several vertical scars like mine are available on the web – some like mine with a cratered spot along the incision line scar. I’ve often wondered about the cause of this, and as I had suspected, it seems a drainage tube was sometimes left in the wound.
- In the 1940’s subcutaneous (under-the-skin) wound closure (if in fact done) is never mentioned: its cosmetic benefits in the baby’s future were not considered. Layered stitches are usually used to close underlying tissue. Until fairly recent times, the skin was closed in one of two ways with little or no regard for cosmetic outcomes. Separate silk or cotton stitches often tore through or irritated delicate young skin, or more numerous but far less damaging little clips were used, like today’s surgical staples. This at last explains why the scars from my and others’ stitches have grown with us to be as large and unsightly as they are.
These images show scars from the classic surgical incisions originally used to relieve infant pyloric stenosis, and seem to have been the most common during the 1940s and 1950s. This pair is from upper midline incisions. The wound on the left was closed with sutures (stitches), the right one with clips or staples.
Pyloric stenosis surgery using a “para-midline” (or vertical but in these cases, right-of-centre) incision became the most popular technique for many years of the mid 20th century. It was claimed to give several advantages over the original standard, the midline, although the statistics don’t seem to bear this out and one suspects the choice was more a matter of “I’ve been taught to do it this way.”
Again, the scar on the left shows this wound was stitched, and the right wound seems to have been stapled.
I am grateful to the people who have shared their photos publicly to help others with damaged bodies feel we are not alone.
During the past decade a “medical secret” has come to light that may be significant to many thousands of PS survivors. It is probably not by oversight that in five years of reading old medical journal articles, I have never found a trace of this “secret” in the contemporary medical literature.
In the USA at least during about 1950 – 1986, infant surgery was often done without any pain control, let alone anesthesia “because babies don’t feel or remember pain”.
This has had terrible effects, the extent of which is quite unknown, and may be behind at the very least some of the inborn anger, depression, stress related maladies, and obsessions of the people concerned. Several of the links to the right of my blogs deal with this in some detail, and this blogsite has and will continue to write about it.