Just after World War 2 a pediatric surgeon, Mr R. B. Zachary, moved across the Atlantic from Boston (USA) to Sheffield (England). Some years later he commented on this move in a medical discussion recorded in the December 1951 issue of the Proceedings of the Royal Society of Medicine. I found it interesting reading.
He observed that his new-found English colleagues believed that successful surgery for infant pyloric stenosis (PS) required amongst other things breast feeding, “parenteral fluid therapy” (intravenous and subcutaneous correction of body chemistry), and local anesthesia. Yet, he said, in the Children’s Hospital in Boston where the statistics compare favourably with those of any other centre, these factors did not matter: the breast-fed baby was a rarity and general anesthesia was the rule, and it was given by nurse anesthetists in training. There were also significant differences on the use of intravenous and subcutaneous body fluid replacement, and all the operations on hospital patients were done by the resident staff including the interns, a feature which demonstrated the safety of PS surgery even in inexperienced hands, provided good standards were maintained. Quite a difference!
Of greatest interest to me in this article, however, was Mr Zachary’s next statement: “Since coming to Sheffield I have abandoned general anaesthesia in favour of … local anesthetic after sedation … I now feel sure that local anesthesia is better. The ill child will stand the procedure, pre-operative therapy is needed less often, the post-operative course is smoother, and babies are on full feeds and ready for home on the third day.”
Why the switch from general to local anesthesia for surgery on PS babies? Why did the majority of Americans favour general anesthesia during the 1940s and ‘50s whilst in the U K and Europe, local was preferred by most?
In writing this series of posts, I have reread a considerable number of medical journal articles which are freely available on the web. I don’t have the training or any need to evaluate or adjudicate between the arguments for and against each, but I’d like to pass on at least some of the main issues that were raised at the time. This will I believe help us who are lay people but interested to understand something of the pros and cons of each way of controlling the pain of infant surgery – even today, and why teaching, practical training and work experience have tended to result in different “camps” of surgical preference and practice.
A note of caution. I have tried to digest and pass on some rather technical information in a way I could understand it – several dozen articles, written two or three generations ago, with claim and counter-claim – don’t expect a simple and clear-cut picture. But I hope it helps me and the interested follower “get the picture” a little better.
Considerations related to local anesthesia for infant surgery in the 1940s and 1950s
- Small, starved and weakened patients, even more than vulnerable adults, take general anesthetics badly and so benefit by the use of local anesthesia instead.
- But the chief difference in anesthetizing children and adults is the unstable and irregular respiration caused by the size and structure of babies’ lungs and the lack of their muscles’ strength.
“… babies and young children do not behave like scaled-down adults but present many unexpected problems of their own. Babies develop obstructed airways at the slightest provocation, their tidal exchange is so small that the normal respiratory valves on gas-oxygen apparatus are unsatisfactory, and the absence of dead-space and avoidance of carbon dioxide build-up become of paramount importance. The smooth induction of anaesthesia is difficult, and the choice and introduction of tracheal tubes demand much consideration.”
- Because of the small volume of a baby’s breathing, the open drop method of administering ether was found unsatisfactory by many (despite some reporting on their good record in using it). When the ether is vaporized on a mask the very low temperature of the vapour was a hazard. It could be warmed but this complicated ether’s use.
Dr DeForest Willard reported: “When it is recalled that the surface of the air vesicles is far greater than that of the body’s surface, the chilling effect of ether can be well recognized… The semi-closed method is preferable to the open drop method, as it not only prevents refrigeration but preserves the carbon dioxide necessary to maintain the pH of the blood.”
- Ethyl chloride was often used, but because of its accumulative effect, the anesthesia continues to deepen for a few minutes after stopping administration, making it unsafe for operations lasting more than a few minutes.
- “Induction [of general anesthesia] in nervous and irritable children may be done with the child in the arms of the nurse as, in addition to the excessive secretion caused by crying, the sobbing respiration frequently persists and necessitates a deeper degree of anesthesia to obtain the proper diaphragmatic immobility…”
- Because local anesthesia does not suppress respiration (breathing) it was more easily controlled and no hazardous intubation (insertion of an endotracheal or air tube) was needed.
- Local pain control was easier to manage: it avoided having to find the appropriate level of gas administration to achieve a level of anesthesia that was sufficient and not excessive for the procedure. Several surgeons reported that light and variable anesthesia was ideal for their PS surgery but most seem to have struggled with this area.
- Local anesthesia enabled the surgeon to work unhurried by the danger of extended general anesthesia and other drugs, this helping the surgeon to work more patiently and gently.
- Local anesthesia ensured a speedier post-operative convalescence without vomiting in reaction to ether which strained the wound. “It enables the child to be fed by the mouth three hours after operation and it enables the surgeon to abolish from his mind all consideration of intravenous therapy.”
- Pediatric anesthesia did not become a specialist field until about 1940. Before this time, babies and children were anesthetised by pediatric surgeons or by anesthetists working on patients of all ages. Sometimes this worked well enough, other times it must have been hazardous. We can only assume that the successes were reported on more readily than the casualties and high mortality rates which remained a fact, notably in the U K.
- As mentioned above, the lungs of infants and adults are radically different mechanically: babies have small lung capacity and a fast respiratory (breathing) rate. Therefore anesthetising babies should reduce rather than further increase the respiratory rate.
- Because a baby’s muscle tone is almost nil, deep anesthesia and strong immobilisation drugs should be unnecessary to relax the baby; artificial ventilation of a paralysed baby is easier than of an adult. Muscle relaxation should not or hardly be needed when working on infants, unlike with adults where paralysis is needed to 1) help control respiratory movement, 2) relax the muscles in the surgical area, and 3) reduce irritation caused by an endotracheal tube. All three of these are not a major problem in babies, and several surgeons reported having abandoned the use of relaxant and paralysing drugs in infant surgery.
- General anesthesia avoids local anesthetic drugs’ interference with the relaxation of the tissue around the surgical site and its slowing of the healing of damaged tissue.
- The intrusion of the abdominal contents into the surgical wound is less with general than with local anesthesia, but was believed to be caused by other factors than muscle strength.
- Both spinal and local anesthetics were regarded as unsuitable for use with young children: 1) psychic complexes are produced by the fear which frequently accompanies and follows their use; 2) the throat and chest become congested by the tears, mucus and saliva caused by crying; 3) over-ventilation of the lungs results in a list of evils including the reduction of carbon dioxide level in the blood (acapnia) and irregular breathing (apnea); 4) a further danger is the possibility of excessive fluid being secreted into the lungs.
- Despite difference between the infant and adult trachea sometimes causing injury, “the advantages to be derived from intubation are very great, in that the tube ensures a reliable airway and enables the lungs to be readily inflated, and is an invaluable insurance against the dangers of gastric regurgitation, which is very common in the obstructive (gastric blockage) group of cases.”
“An endotracheal tube may be employed and is a definite asset if some assistance to respiration is required. But again, the latter is not a method to be employed except by those well versed in pediatric anesthesia.”
Some quotations, some conclusions and recommendations for the times…
Dr Alanson Weeks commented on a 1935 California and Western Medicine (journal) report of a San Francisco colleague, Dr Mary E Botsford who was the choice of the region’s top specialists who needed anesthesia to be administered to their infants. He said that Dr Botsford “… has trained anesthetists from all parts of the world. She has induced general anesthesia for us in at least a hundred babies suffering from congenital pyloric stenosis, without a single death as a result of such anesthesia.
“We are glad to see that she still allows us to use ether in babies, even though she so strongly favors nitrous oxide and oxygen. We have insisted for years that good relaxation in abdominal surgery gives the operator a better chance to handle his tissues gently. Even though light anesthesia may be a little safer, the necessary abuse of tissue is altogether too great because of the lack of relaxation. It has been perfectly possible for us to do abdominal operations on babies under local anesthesia and with insufficient relaxation, but the time necessary under such circumstances to replace an omentum, which eternally fights to get as far out of an open abdomen as possible, will do more harm to the babies than will a little more of a less safe anesthetic agent.”
“The anesthetization of infants from birth onward may be safely done provided that bodily heat be conserved during and after operation; that ether, when not contraindicated by respiratory or renal dysfunction, be vaporized at a distance of at least 18 inches – which insures its being delivered at room temperature – and that the degree of anesthesia be as light as consistent with the needs of the surgeon.”
“Many necessary operations, which formerly were not done at all or performed without anesthesia because of its presumed danger, are now undertaken confidently under general anesthesia.”
“Infants, particularly in the first six weeks of their lives, are well able to stand surgical operations and anesthetics, and are as tenacious of life, as far as shock is concerned, as at any other time of their lives, provided certain precautions are observed, and these are that their vitality shall not have been lowered by starvation and their body heat shall not have been lowered by exposure during operation.”
“To these precautions might be added certain other factors making for safety in these small patients, which are as light anesthesia as is consistent with the needs of the surgeon and a short duration of the anesthesia.”
- The majority of U S reports of the 1940s and 1950s favour the use of general anesthesia for infant surgery.
- For PS surgery the tranverse incision was gaining favour over the vertical ones in the USA. I want to explore this change in a later blog.
- In the U K and Europe, pioneering German surgeon Conrad Ramstedt’s preference for a vertical incision to access the infant pylorus remained the preferred option, but (contrary to his practice) local anesthesia with or without mild sedation had clearly been found more satisfactory than the available general anesthetics.
- The articles I have read only very, very rarely mention longer-term follow-up studies and pay scant or no attention to the possible effects of infant surgical practices. The world has only recently started to address the issue of post traumatic stress, whether that be from war, abuse in it various forms, or medical procedures.
- About 1986 US health bodies revised their code of policy and practice about infant surgery, officially recognising that infant do feel and register pain, both immediately and in the long term; evidently increasing numbers of doctors started to anesthetise their infant and child patients.
However, from the medical literature I have had access to, there is a total silence about this change and the belief that “infants don’t feel or remember pain”. From the evidence generally available it is only after about 1986 that the medical community in the U S started to acknowledge this attitude and seek to revise its practice of infant surgery.
- It also seems that during this period there were at least some U S paediatricians and surgeons who were more enlightened about infant surgery and did manage the pain of infant surgery.