German Dr Conrad Ramstedt’s surgical remedy for infant pyloric stenosis was announced to the world at a medical conference and publication exactly 100 years ago last week.
This anniversary was of course rather significant for someone who underwent that surgery 33 years later to save his life just 10 days after his mother gave him birth. And because pyloric stenosis (“PS”) affects between 3 and 5 babies in every thousand born in developed countries, and most of these are treated surgically, there are many people alive today because of Ramstedt’s discovery.
However, one only has to research the history of this condition and its treatment to realise that whilst the German doctor realised he had made a significant discovery, he was also the unwitting cause of trauma in at least some and perhaps many PS babies and their parents. Let me explain…
In 1912, the medical treatment of babies with PS was general but very risky, and almost half the infants died despite it. Several surgical techniques were then being offered as an alternative for PS babies, but these were so drastic and severe on a tiny, malnourished and dehydrated baby that the great majority died of surgical shock, infection, and other related causes. Most parents took their chances with the available medicines… and prayed.
Dr Conrad Ramstedt’s accidental discovery in 1911 and published in October 1912 represented a major breakthrough: see my previous post and an earlier one. The Ramstedt pyloromyotomy was rapidly adopted as the remedy of choice in all countries around the world, and in four decades after 1912, deaths from PS fell to almost nil in most countries. However, even in the 1940s, some countries (including Great Britain) continued to report their PS mortality was still at 25%. I have been shocked by how many mentions there are on the web of relatives dying of PS. Despite all this, Ramstedt’s technique and better health standards in hospitals have done much to make death from PS most uncommon today.
How did the Ramstedt pyloromyotomy contribute to this?
It made treating PS relatively easy and simple for surgeons, hospital staff and parents. For surgeons the technique requires practice and care, but is essentially one of the simplest surgical procedures on the OR list. The surgery usually ends the violent and deadly vomiting; although some continued vomiting and reflux occur quite often, it is fairly rare that an incomplete myotomy (division of the pyloric muscle) or its redevelopment requires a repeat of the surgery. So: anxious parents are greatly relieved, the surgeon immediately becomes a successful warrior, and the baby quickly starts to make up for weight lost: I gather that my post-op photo is quite typical!
Apart from the great relief of all concerned, the Ramstedt pyloromyotomy saves pediatric ward staff and the bay’s parents having to manage (or endure) weeks (and often two months) of medical treatment, with each of the sick baby’s feeds requiring medication be administered beforehand to a rigid schedule, milk having to be given slowly and carefully, daily weighing, and regular consultations with the hospital clinic or paediatrician. Why put yourself through all that when surrendering your baby for just an hour or so to the gowned and skilled surgical staff produces what often seems like an instant fix?
Some babies are best treated surgically, and of the babies treated medically, up to 20% will not respond sufficiently well to escape surgery.
On the other hand, almost all Ramstedt pyloromyotomies seem to be fully effective, certainly in the immediate sense. And although the worldwide web includes many hundreds of complaints and stories of a long list of troublesome ongoing effects from their PS or its surgery, it is just as clear that the vast majority of survivors are satisfied enough not to air their troubles. The possible effects of the surgery are many and real, and sometimes severe, but many PS survivors report little or no gastric or abdominal discomfort, few or no problems with their scar or adhesions, and no trauma. And this silence of the vast majority of PS patients has enabled most of the medical world to assure anxious and worried parents that “PS and its surgery will have no after-effects on your dear child”.
What I have written so far gives me some cause for concern, however.
Ramstedt’s discovery at once saved my life (and I’ve had more than 65 very good years so far), and it has also been responsible for the trauma I and not a few others have had to deal with (often chiefly in private) for most of our lives.
It was quite unintentional, but it is nevertheless true that Ramstedt’s surgical solution for PS effectively and inexorably moved the medical community’s interest away from perfecting the already (and still today) quite effective treatment of PS with cheap and simple medication and careful maternal nursing. The Ramstedt pyloromyotomy is (as stated above) in itself what many surgeons call “elegant”: it is easy, quick and usually effective. But until quite recently the surgery and what came with it could be very severe and traumatic on the baby and also on the parents, and it was associated with more (and more severe) risk factors than the medical alternative.
Thus the Ramstedt pyloromyotomy helped fuel the ascendancy of the power and prestige of the surgeon with which some of us are all too familiar today! We must remember that specialist and high technology medical science has been very largely responsible for our rising health standards and life expectancies, but in fact PS is one of the maladies that can in most cases be brought under control by medical means and with surgery kept as a last resort. In some countries, PS continues to be managed in this manner.
So Ramstedt’s operation short-circuited interest in understanding and managing the causes, pathogenesis (biochemical development such as proposed by Dr Ian M Rogers) and even prevention of PS.
Whilst I am deeply grateful for the operation that saved my life and realise that in my case surgery may well have been the only responsible remedy, I have often wished that I could have been treated more gently, without a disfiguring scar, and without inflicting life-long trauma on my parents and me.
And in this wish I am not alone.