By the 1950’s medical interest in the main facts and options around the character, diagnosis and treatment of infant pyloric stenosis had faded. Two medical people commented in 1943:
When a disease has ceased to be a therapeutic problem, scientific interest in it is likely to wane. Not infrequently successful measures of treatment are devised before the fundamental problems of a disease have been solved, and in such instances the consequent lack of interest will be reflected in the neglect of the related, less practical but basically important, questions.
It is clear that this happened to PS: even today, many questions about it have not been answered and are probably in the medical schools’ “to hard” or “doctoral dissertation subjects” baskets… but we know what manages the malady. So in the 1950s, medical journal articles about PS continued to appear but almost all reflected a shift to researching and reporting on what would appear to lay people like me to be interesting but secondary or rather specialised aspects of the condition:
– PS in premature or older babies and in identical and non-identical twins;
– the age of PS onset in relation to other factors such as home and hospital
birth and 3 or 4 hourly feeds;
– how many babies are born with pyloric tumours but don’t develop PS;
– the recurrence of PS and similar symptoms after surgery;
– the pathology of the hypertrophied (over-developed) pyloric muscle;
– historical reviews of PS treatment during the past century; and
– PS incidence in particular geographic regions and possible causes.
Several things stood out when I read through the numerous 1950s medical articles and reports.
The medical versus surgical treatment debate continued as in previous decades. This was the single largest issue in the material I have been able to read. As I have commented several times, in North American and the U.K., surgery was much the majority-preferred course for PS babies, sometimes as soon as medically possible, sometimes only if medical treatment with drugs like eumydrin had been found ineffective. Those few European journals I have been able to access tend to give a much more favourable emphasis to medical treatment as being feasible and effective; paediatricians sent relatively few PS babies to the surgeon. Medical treatment remained lengthier and more demanding but was nevertheless found to be cheaper, more accessible, more natural and less traumatic for all concerned; it was found that after initial drug treatment the baby could continue the therapy as an outpatient and with less risk of cross infection.
Because so few articles of this period give details of the surgical treatment it is risky to draw too many firm conclusions, but it seems that the traditional vertical incisions remained favoured in the UK, Europe, and its “Empire” countries, whilst the various transverse (angled under the ribs, high or lower cross) incisions became the standard (although not universally preferred) in the USA.
Do babies need anesthesia? Britain and Europe as well as in countries including Australia, Canada, Germany and South Africa evidently continued to relieve the pain of babies undoing surgery. Several 1950s journal articles from these countries included mention of this, the only difference being that some writers used ether and others local anesthesia.
Of great interest to me is the sudden and sharp fall in the number of articles on PS surgery from the US in the 1950s, and that those few articles that are available today are silent on a matter that has come to light only in more recent times.
Dr Terry Monell has researched, written and spoken about infant surgery without anesthesia in the USA prior to 1987; she mentions Boston as a centre that led the non-anesthesia-for-babies movement over many years from no later than 1848. Yet in a previous blog I mentioned that a Boston pediatric surgeon moved to Britain after World War 2 and abandoned using general anesthetic in favour of the British preference for local. Clearly there was no absolute uniformity in the beliefs about and practice of infant surgery.
Several of my links (right) are to web-based material that deals with the American Academy of Pediatrics and the American Society of Anesthesiologists recognising in 1986 that babies do feel and can remember pain, and that this can cause trauma in later life, although (as with other forms of abuse) the brain records and struggles with those experiences in ways that are not usually immediately obvious. These two powerful professional associations rewrote their standards and practices, but it took more years of struggle to get US paediatricians and anesthetists to adopt and actually follow the new protocol.
So on the basis of the material that is readily available, I have not been able to assess how widespread infant surgery without analgesia was before 1990. Nor can I say to what extent this practice occurred outside the USA. I can say that Terry Monell in the Spring 2011 issue of the Journal of Prenatal and Perinatal Psychology and Health reports that no anesthesia was used for babies as a rule in the 19th Century and into the 20th. I understand she is referring only to the U.S. However, before about 1940 almost all the articles I’ve read, including Ramstedt himself and several from the US, mention the way the writer or hospital team did their anesthesia, with reasons and relevant details, and there is (understandably?) no mention of it not being used.
I am therefore suspicious that no post-1940 article from the US that I’ve had access to mentions the subject of anesthesia at all; but this is not true of the non-US articles; is that just strange, or actually significant?
The various medical associations changing their protocols, their members needing time and pressure to fall into line, and hospitals each having their own policy – these are all mentioned by Terry Monell and the first and last of them is mentioned in medical journals elsewhere too. This would fit in with my supposition that the non-use of anesthesia for babies, at least about 1940-1990, was largely in a problem in the USA and that actual practice there (as elsewhere) varied among doctors, hospitals and medical schools.