Ramstedt’s pyloromyotomy (3) – 40 years later

As mentioned in the previous post, I owe my life to very early surgery for pyloric stenosis (“PS”) in 1945; this operation was named after the German Dr Conrad Ramstedt and remains the standard surgical technique for this all-too-common malady in babies.

This surgery traumatised me and my parents so that we would never talk about it.  But from an early age I wanted to “own” it.

  • What is Infant Pyloric Stenosis?
  • How can it be treated?
  • What did the operation / surgery do?
  • Could I have escaped being scarred for life so early?
  • Why have I felt so deeply about it?

In 2009 I discovered a 9 page medical journal article* dated 27 April 1951 reporting on a discussion among members of the Royal Society of Medicine (“RSM”) in the UK about the then-current treatment of PS.  It answered many of my questions – and said much more!

Despite being a rather common condition (250 per 1000 births) in 1951, the treatment of PS was still controversial.  The RSM’s then-President, Dr Kenneth H Tallerman, reported that he had until 1944 regarded its treatment as “essentially surgical”. In 1938 he had reported on a series of 102 cases, all but four of which had been treated surgically by him and two colleagues, with a mortality of 14%, which he states was quite common at the time, although other contemporaries in the UK and USA were reporting lower death rates.

Breast-fed babies operated on showed a lower death rate than bottle fed infants: Dr Levi had reported in 1941 on having operated on 100 breast-fed babies without fatality and on 46 artificially-fed babies in the same series with an 11% death rate.

It had struck Dr Tallerman that although a 15% mortality rate in UK hospitals did not seem “uncommonly high”, other centres had reported much lower death rates from medical treatment: two European doctors reported in 1933 and 1935, each with 5.5% mortality, which prompted UK doctors to increase their proportion of medical treatment for PS, using Eumydrin (a proprietary preparation of atropine methylnitrate).

One of Dr Jacoby’s illustrations: splitting and dividing the swollen pyloric muscle to disable it from blocking the passage of food from the stomach. Dr Tallerman believed many cases could be treated more safely without this surgery.

Dr Tallerman reported:  Since the autumn of 1945, I have deliberately set out to treat every case of pyloric stenosis by medical means.  If the patient has failed to respond satisfactorily and symptoms have persisted I have then resorted to surgical treatment.  In order to ensure that an infant is not in poor condition and therefore a bad operative risk I am, generally speaking, in favour of seeking surgical help if there is still vomiting and failure to gain weight after about seventy-two hours from the beginning of treatment.

So Dr Tallerman treated 67 cases in exactly 5 years from 1 November 1945, with 6 patients (9%) dying.  41 (61%) of these were successfully treated with Eumydrin (as above), and 26 (39%) were submitted to surgery after failing to respond satisfactorily to the medical regime.  He considered that 5 of these 26 were given an insufficient dosage of the atropine methylnitrate.  The doctor noted that of the 41 babies treated medically only one died – and that was at home after treatment had been withdrawn.  Of the 26 operated on 5 died, and he believed this was not due to their being in a worse condition.

No baby aged 2 months or older at admission needed surgery, and the average duration of PS symptoms before admission was 13 days: Dr Tallerman concludes that babies older than 5-6 weeks at the onset of PS should be regarded as best suited to medical treatment.

He concludes that about ⅔rds of PS patients can be treated medically – with a lower death-rate, and that most little PS patients should be given the opportunity to respond to medical therapy.  He dismisses the objection that this requires a longer hospital stay with the risk of cross-infection, quite high in the 1940s.  He states that the average hospital stay for surgical patients was 13 days and for medical patients 20 days, a fairly small difference.  But he also mentions that 4 of the 67 patients in his study were never admitted, and that medical treatment could also be given on an out-patient basis or after a short hospital stay followed by out-patient monitoring.

Recognising that most PS babies need a day or two after diagnosis and hospital admission for hydration and electrolyte correction before they are fit enough for surgery, Tallerman urges that this period be used to try atropine methylnitrate therapy which may avert the need for surgery.

So far Dr Tallerman’s presentation.  The article then publishes the discussion that followed, several doctors responding at some length with their views and experience – though not always interacting with their President’s report!  I summarise…

Mr Denis Browne: Because PS babies are already in poor condition when diagnosed they should be treated as quickly as possible, which (for him) meant surgery.  He used local anesthesia only for all PS babies to avoid additional hazards for the weakest babies and to retain familiarity with the complexity of its use for what he termed as “major surgery”.
To help surgeons refine their technique from his mode of practice, Mr Browne published several sketches and a step-by-step procedure, which from what I have read reflects most accurately and clearly how the majority of PS cases were treated in the 1940s and ‘50s – including my own surgery in 1945.
He reported that of the 407 PS cases he treated in 1943-45 in London’s Hospital for Sick Children, the mortality was just 2%: he claims none of these died from the operation, but rather from associated conditions as pneumonia, enteritis, abscesses, or congenital defects.

Another eminent London surgeon, Dr David Levi, reported next.  He stressed what he had urged with a passion in other publications: that the death-rate from PS could be much reduced if only hospitals gave scrupulous attention to hygiene standards and infection control, which were reportedly unbelievably horrific in some (or perhaps many) hospitals at the time.
He showed a film to his colleagues to illustrate his technique, and like (it seems) most surgeons at the time he used local anesthesia.  In his series of 125 from two London region hospitals during 1940-51, there was only one death.
Dr Levi tellingly concluded:  I should like to… express a hope that more babies will be breast fed and that their attendants will wash and be clean.

Dr Jacoby’s criteria for assessing infants with pyloric stenosis

The third surgeon, Dr N M Jacoby, reported that in 1941 his chapter preferred surgical to medical treatment.  However, I was interested that he disagreed with the (rather weak) argument for this policy, and also with initial medical treatment for all babies; instead, he presented a set of criteria he had developed which set down sound criteria to distinguish which infants could be treated medically and which surgically.  He presented a 3-5 day procedure (considerably shorter than the normal hospital stay for surgically treated babies), and if vomiting did not stop within this time, he advocated surgery.
His surgery was done by the Levi method, using local anesthesia and with every case managed on its merits rather than by a standard routine.

Dr George Davidson reported on 1,100 PS cases treated in Newcastle-on-Tyne between 1925 and 1951, with an early mortality of 27% falling to quite low levels in later years (1.5% over the last 500 cases).  However, he estimated that mortality in smaller UK hospitals was still between 15 and 20%.
Most of the recent deaths in Newcastle were caused by too late diagnosis, and he urged that basic medical training give greater attention to the prompt diagnosis of PS.

Dr Richard H Dobbs, the next to report, dwelt on the statistics that Dr Conrad Ramstedt himself had collected between 1919 and 1933 which suggested that even in 1933, medical treatment of PS with atropine was not only still widely practised but more often successful than his own surgical technique, with significantly lower mortality!
His analysis of the relevant statistics leads him to conclude that hospital infection is the real enemy of the infant suffering from pyloric stenosis.

Mr R B Zachary compared his experience in the Children’s Hospitals in Boston (a US city with a high medical reputation) and Sheffield in the UK.  He noted that in Boston, pyloromyotomies were using general anesthesia administered by nurse anesthetists and resident staff including interns, with a lower mortality than in the UK.  However, coming to Sheffield he had learnt to prefer local anesthesia: 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.

Eight other doctors made brief observations or asked a question.

By listening in to this discussion I gained a wealth of information to fill in many of my blanks!

When I had my PS surgery 33 years after Dr Ramstedt’s publication of his simple but effective “fix”, his surgical technique should have been a lot less common, and the medical treatment option should have been the standard for the majority of PS cases.  As I wrote in my previous post, powerful men seem to have used Ramstedt to further their own ends.

I also learnt that in my case, an operation was probably unavoidable.  Like most PS babies, I had lost a lot of weight and condition when I was diagnosed, but at only 10 days old it would have been too dangerous to wait any longer for the atropine to take effect.

The use of local anesthesia for babies undergoing PS surgery seems to have been standard in all but the best and largest hospitals at the time.  This is clear from European as well as British reports; it seems evident also from US articles.  This would also help me to understand why this surgery traumatised some of the patients as well as our parents.

Understanding empowers and this gives confidence and peace.  More and more I am able to embrace my story and the response to it of my body and mind.

_______________________________________________________________________________

*  As I have not been able to find this free document on the web since downloading it in 2009, I could not include a link to it.  Anyone interested to read it in its entirety should email me: click on the “About” tab at the top of the homepage.  Please note that making a “Comment” will usually not enable me to send you the file.

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3 thoughts on “Ramstedt’s pyloromyotomy (3) – 40 years later

  1. Wendy

    An invaluable summary of the article and the responses to Tallerman! Thank you so much for summarizing the material. I have read the article, but I like having it presented on your blog in this compact way. Interestlngly, no doctor mentions the well-being of the baby in a holistic sense. Where is the discussion of the comfort of the baby? Where is the consideration about what will traumatize the baby and what will not? I like Tallerman’s approach best: Medical first, then surgical if necessary. Every once in a while in articles about the history of PS, a mention is made of a baby squirming and disrupting the surgery while under local anesthetic, a common practice in the ’30s and ’40s and earlier, I believe. The word “squirming” is not used but some euphemism, such as ‘engaging in disruption.’ I feel queazy reading these descriptions. To me, medical treatment was much more humane.

    I’d like to know the inside story about why medical treatment was abandoned. Did it have to do with insurance companies pressuring doctors to get the baby out as quickly as possible? (When did medical insurance come on the scene?) Was it a matter of machoism–that the medical treatment was wimpy and real men cut? Was it a deification of the surgeon, that all powerful one? I’m of the mind that we should go back to treating PS infants medically first, surgically if needed. My PS surgery was delayed until the third week of my life because my condition was misdiagnosed. In any case, I would have had the surgery because that’s what was done then in the north east urban areas of the US. I wish though that I could have had the chance for medical treatment first. And I wish that for babies now. Surgery is traumatic for infants……..period.

    Reply
  2. Fred Vanderbom Post author

    It will hardly be a surprise, Wendy, that I agree with you fully.
    Who in the medical world will have the courage to write about what really influences a surgeon, both generally and in specific cases? I’m sure there are many motives and considerations in the mind and heart of a surgeon, but also that even the most people-oriented medico will find it hard to buck the training, expectations and routines of what everyone knows is a very powerful and rigid system, also when it comes to a very sick baby and its anxious parents. From the few comments I’ve had and what I know, I realize that all doctors work under many and great pressures, which also stifles reflection, independence and humanity.
    May I share a recent little encouragement with you? Last month my post of June 2 2011 about “Healthy doctors and patients” was visited 297 times from Pakistan! By far my most popular post, going by the stats! And I can only (and would like to) conclude that this post was recommended in a Pakistani medical school. It would be a tiny but good sign that trainee doctors read such a post.
    And like you, I feel quite emotional whenever I read the rather rare reports of why surgeons in the past would choose other than general anesthesia for their little patients, and what that meant… I see myself in those reports and images. I do believe many of these surgeons had a heart for these little infants and did not suspect any long-term consequences. Their training as “scientists” would have reinforced this – and continues to this day to keep them “dispassionate”.
    I’m 100% sure that if my PS had been treated medically I would not have been as much affected as I have been by my first surgery. I’ll never know whether I could or should have been treated medically in 1945 but at least I know now that there were policy guidelines available at the time and that (even) under those guidelines I would have been taken to the OR a.s.a.p. This has helped me to feel reconciled with my late parents and their medical advisors.
    I’ve written before about the studies that have shown that medical treatment was and remains a completely responsible option for most PS babies (e.g., August 20, 2011) – and why it is that despite this the scalpel rules in most “developed” countries. Sadly I’m quite sure that all the possibilities you mention play a role.

    Reply
  3. Wendy

    Wow, 297 hits from Pakistan! How exciting is that! I’m going back to that post and re-read what they were interested in. I’m so glad that the information you are sharing is making bigger and bigger waves. Let it become a tsunami in the best sense–a gigantic wave of cutting edge information! And your point is well taken about the fact that doctors’ training and environment “stifle reflection, independence, and humanity.” Medicine is changing little by little here in the States, so I’m glad for that. Voices like ours can make a dent. Many thanks.

    Reply

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