Unlike much infant surgery, many pyloric stenosis (“PS”) operations and almost all circumcisions are not necessary to save life.
Circumcision is almost always done for religious or traditional reasons; however, most doctors no longer regard it as routine or desirable, and informed parents are also regarding it as an unnecessary and potentially damaging physical and emotional assault on their baby.
Pyloric stenosis surgery is a more complex matter. It is advised, validly I believe, for very young and / or emaciated babies and for those who do not respond to several days of medical therapy. It is advised in many countries, invalidly I believe, for almost all clear cases of infant PS. However, most PS babies are more than 3 weeks post-natal and if competently diagnosed will not be close to death; most of these (reportedly more than 80%) will respond well to a few weeks of careful feeding and medical management. After some weeks of treatment, they will outgrow their PS.
However, in most “developed” countries the medical training and self-interest have conditioned doctors (MDs, GPs, paediatricians and surgeons) to advise pyloromyotomy surgery as quick and effective (which it is). What our medical people rarely tell parents is that this operation is “attractive” mostly to the surgeon concerned: it is easy (once the technique is mastered), quick (and thus profitable) and its effect on a violently sick baby is usually immediate (meaning parents astounded with surprise and overwhelmed with gratitude)! What very few specialists tell the parents (except as part of the usual routine list) is that many of these babies may have a continuing or long-term problem as a result of the surgery: the documented list includes the effects of trauma on the parents, and for the baby the risk of gastric issues, hernias, adhesions, post-traumatic stress, and emotional responses to their scars – some these quite common.
However, it also true that the unwanted effects of infant PS surgery were more common in the past, when specialist pediatric care, good anesthesia, minimal access surgical pathways, short hospital stays, and parent education were nowhere near what they often are today.
My own experience of infant PS surgery in the mid-1940s has given me much grief and I have tried to work out the reasons for this throughout my life – until recently with little progress. However, the web has made available a steady stream of enlightening data, and also made worldwide networking easy. As a result, I now understand my story to a satisfying degree – although hey, I’ll never know what my parents refused to disclose and the records my hospital destroyed after a statutory period.
Recently I found a fascinating reflective address by Dr C Everett Koop, the US Surgeon-General in the 1980s under President Ronald Reagan. Dr Koop graduated in 1941 and had a distinguished career practising and teaching pediatric surgery, which became a separate discipline only in the mid-1940s, up to which time doctoring babies and children (including surgery and anesthesia) was done without special training and experience. How scary does that seem now! In his 1990 address Dr Koop overviewed some of the massive changes that took place in his domain in the almost 50 years since his graduation.
Here are some of Dr Koop’s observations that struck me (the words are his, the bold highlighting is mine) –
- In 1946, we who were on the curing edge of a new discipline, later to be known as pediatric surgery, considered ourselves to be working in a field of ultimate surgical sophistication. Even had that been true for disciplines in adult surgery, the attention given to children with surgical problems was a disgrace.
- Everyone was an expert in circumcision. There were probably more Gomco clamps in the hospital than there were abdominal retractors.
- The real challenge of general pediatric surgery of the 1950s lay in the congenital defects incompatible with life but amenable to surgical correction… The mortality for a simple colostomy was in the neighbourhood of 90%.
- The thought of giving general anesthesia to a child struck terror to the hearts of most surgeons, but instead of this being an impetus to research into the unique responses of infants and small children to pharmacologicals, anesthetic agents, and blood loss and replacement, operations were postponed or never done rather than face the problems of high mortality from anesthesia.
- In 1946, William E Ladd, the pioneer of pediatric surgery in the United States had retired… A Chair had been endowed in his name, funded by $6,000… The Boston Children’s Hospital was the only place in the United States where one could say there was anything like a training program in child surgery.
- I learned early on that it was easier to put children under anesthesia than it was to wake them up. Hence, a lot of my time in the first two years [after being appointed in 1946] was devoted to the development of techniques and safeguards in pediatric anesthesia. Indeed I spent more concern and effort there than I did in surgery.
- If there was such a thing as oncology in those days, I had not yet heard about it.
- To say that child surgery was an unpopular development in the field of surgery in 1946 is a gross understatement. General surgeons felt that the log of surgery had been splintered enough; there were enough sub-specialities without contemplating a new one.
But the insult added to that potential injury was that child surgeons said they could do any surgery in children better than anatomical specialists because of their understanding of the pathological physiology of infants under stress and understood better the management of their very limited reserve. It may sound brash at this late date, but it really was true in 1946.
- I was invited by a popular Philadelphia talk show hostess to come and discuss “the new and wonderful things” I was doing at Children’s Hospital”… When I told her I would be discussing childhood cancer, she bristled: “Don’t you dare use that horrid word on my program.”
- Many surgeons are unaware of the damage caused by the palpating fingers on small children. I learned this from William E Ladd, who told me never to operate on a pyloric stenosis if the paediatricians had a go at feeling the “olive”. He said he had learned by bitter experience that such trauma produced so much pyloric edema that no matter how well the operation was performed. The child vomited for days thereafter.
I have opened the abdomens of children with pyloric stenosis, unaware of the fact that my rules had been broken about pre-operative palpation. In addition to the edema of the pylorus, actual hemorrhages can be seen in the transverse megacolon from what I’m sure the perpetrator would hgave called “gentle” palpation.
- As I look back over the last half century, it’s hard to believe how little we all knew when I graduated from medical school and what tremendous advances there have been in medicine during my lifetime.
Dr Koop’s reflections about pediatric surgery between 1941 and 1990 has helped me to realise more fully the enormous development of infant surgery during my lifetime – and the reason anesthesia for infants undergoing surgery was rather rare in the mid-20th century.
Is it any wonder that some of us who had infant surgery at that time have struggled to overcome problems which arose from the illness that caused it, from its management and from the effect it had on our parents in an age when most people didn’t talk about “unpleasant” things such as cancer – or early surgery.
Dr C Everett Koop died on 25th February 2013 at the age of 96. A most appreciative tribute and comments were posted that same week on Jolene Philo’s Different Dream blogsite which is “a gathering place for the parents and friends of special needs children”. Dr Koop was certainly a pioneer who did much to improve the prospects of such little ones!