Pyloric Stenosis would most likely have robbed me of life less than two weeks after my birth if I had been born just a third of a century before I was.
It was in September and October 1912 that a German military surgeon first shared with the medical world his discovery of a quick, simple and effective surgical remedy for Pyloric Stenosis (“PS”). I was born exactly 33 years later, by which time Dr Conrad Ramstedt’s surgical technique had become almost universally adopted. What has become known as the Fredet-Ramstedt Pyloromyotomy was published in a German medical journal dated 20 October 1912. *
So while the world has been marking the centenary of the Titanic’s maiden voyage and tragic loss, of British explorer Robert Falcon Scott’s successful but ill-fated expedition to the South Pole, of the first parachute jump from an aircraft, the patenting of stainless steel, the identification of vitamins, and of the formation of the Republic of China, the international Scout and Guide movements and the African National Congress, there are millions like myself for whom the centenary of Ramstedt’s pyloromyotomy operation is far more significant in 2012 – although most of us PS survivors probably don’t realise it.
I have posted earlier that although PS had been recognised since 1627, it was not until the late 19th century that surgical remedies began to be attempted. But neither the medical nor surgical treatment did much to reduce an appalling death rate. The several surgical techniques suggested around 1900 were severe, involved mortality rates well over 60% and were rejected by most parents and doctors. The death-rate of PS treated conservatively (by small feeds, stomach washes, medication and attempts to stretch the pyloric passage) was then between 10 and 46% at the time.
In 1908 the French surgeons H. Doufour and Pierre Fredet published the description of their new PS operation, “extramucosal pyloroplasty”, which had given better results: they split the pyloric muscle lengthwise down to the mucosa (the passage’s inner lining was left intact) and then stitched it to make the incision cross the muscle. In their own words –
“Incision of about two centimetres in the axis of the pylorus, on the middle of the anterior surface. This longitudinal incision goes through the peritoneum and muscularis but excludes the mucosa. The bistoury [a long, narrow surgical knife for minor incisions] cuts a tissue which is white, mottled, bloodless, very hard, squeaking under the instrument, having the same appearance as certain uterine myomas. The incision thus divides the sphincter for some millimetres in depth (more than five certainly) and the lips of the wound part voluntarily. A series of linen sutures are placed as in the procedure of Heinicke-Alikulicz, transforming the longitudinal wound into a transverse wound, an autoplasty [a repair using only that body part] which manifestly enlarges the pylorus.”
As I have written elsewhere, after doing two Fredet pyloroplasty operations Dr Conrad Ramstedt discovered accidentally that it was unnecessary to stitch the pylorus to reshape the split. It is appropriate to read about this in his own words –
“An incision five centimetres long opens the abdomen in the mid-line at the level of the pylorus. The stomach is enormously dilated. The pylorus is thicker than a thumb, cylindrical in shape, glistening reddish-white, hard as cartilage. Division of the thickened muscles on the anterior surface of the pylorus; only one circular suture at the point of change from pylorus to duodenum was necessary. The incision gaped widely and was left uncovered. Pylorus replaced, abdominal wall closed. Plaster bandage. Duration of the operation fifteen minutes. Ether narcosis.”
YouTube offers several videos that show how a Ramstedt pyloromyotomy is performed, nowadays with laparoscopy (keyhole surgery); be aware that these videos are graphic!
The Ramstedt operation for pyloric stenosis involves splitting the hypertrophied (enlarged) muscle down to the mucosa (inner lining of the gastric passage), forcing and then leaving the cut to gape open (lengthwise), and then closing the abdomen. This technique was discovered by Dr Ramstedt by accident followed by good observation, and it remains the essential element of the operation today, although there have been several ways of gaining access to a pesky problematic pylorus.
One of Conrad Ramstedt’s colleagues made a prediction in the early 1920s, when he introduced Ramstedt to his students: „Von diesem Mann werden Sie einmal mehr hören als die heutigen Pädiater und Chirurgen ahnen.“ – “One day you will be hearing more about this man than our current pediatricians and surgeons can possibly imagine at present.”
How right that was!
* In researching for this post I was frustrated and annoyed. I found that not only ground-breaking and research-based medical articles are locked up in high-cost medical journals – that is reasonable and understandable. However, several journal articles have marked the centenary of Dr Ramstedt’s pyloromyotomy with historical and celebratory articles which would be of no monetary value to anybody; others are a century old and of historical value only. But all of the former and many of the latter are only available to well-heeled subscribers or to grateful and interested survivors like me at a cost of over US$30 per item. Having worked for the welfare of others as a Christian pastor all my life I sometimes wonder how others who have also committed to a life of service can sleep at night.
And, this post about 100 years of Ramstedt pyloromyotomies is also my 100th SIS post. I am grateful for well over 20,000 reader “hits” and so much appreciative, interesting and encouraging response.