Reading a 1959 medical journal article about the significance of Dr Conrad Ramstedt’s technique for treating infant pyloric stenosis (“PS”) brought home to me again how God-blessed and inwardly thankful I am to have been born (like everyone who reads this) after the Ramstedt pyloromyotomy was introduced.
As I wrote in my first blog in this series about Ramstedt, before 1912 most parents of a PS baby faced a terrible choice: should they try medical treatment and accept an even chance of losing their baby after several agonising weeks or even months? Or should they surrender their tiny infant for major surgery with an even higher likelihood of death?
In my previous post I passed on Dr Kenneth Tallerman’s advocacy of medical treatment for PS as being preferable to surgery for most babies. However, I belonged to one of the groups Dr Tallerman advised should go to an operation as soon as their condition had been stabilised.
All the more reason to be very grateful that my pyloric stenosis could be dealt with by the Ramstedt pyloromyotomy I had when I was 10 days old. It took me much of my life to gain a sense of pride and ownership of the gnarly scar it left; it took even longer to understand and work through (as best I could) the post-traumatic stress that resulted from the effects of 1940s-style infant surgery on me and my parents. But I am a survivor, I’ve been able to enjoy a long, healthy and productive life, and I’ve avoided what a surgeon might have tried pre-1912 in his well-meant attempt to save a tiny life, to reward the hope and trust of anxious parents, to develop his skill, and perhaps to advance medical knowledge.
To most of us, none of these surgical techniques were justified, due to the shocking deathrates and the suffering inflicted on the little patients without their consent.
A year ago I wrote about the treatment of PS just before 1920, in the decade immediately after Conrad Ramstedt’s discovery of his “extra-mucosal pyloromyotomy”. Why was his innovation so significant? We only have to compare it with the kind of “procedures” the 1959 article listed as being used before 1912…
Dr Selwyn Taylor tells us that Treatment of pyloric stenosis in those early days was of three kinds, dilatation of the pylorus, various forms of pyloroplasty and gastro-enterostomy.
Sadly, he fails to even mention the medical treatment of PS which was reported to have been the safest and most common treatment before 1912. Besides this, as reported in the speech by Dr Tallerman (see above) the medical option (using atropine and its derivatives) has continued to be a responsible choice for most PS cases as well as being non-invasive, less traumatic, able to be managed by the parents (usually at home), and often less costly.
So here, we consider the three options Dr Taylor mentions:
Dilatation of the pylorus is still done very occasionally today, endoscopically. The article tells us that the technique was first used in 1884 with adult patients whose pyloric passage had been blocked by scarring caused by a stomach ulcer. Dilating the pyloric ring was then (and for many years since) done by open surgery: the abdomen was opened with an upper midline incision, the stomach was then opened, and the surgeon would push one and then two fingers into the pylorus. Despite the uncertain results from such major surgery, by 1900 this technique was used in the UK on PS babies, with a metal dilator being used instead of fingers, this allowing greater small-scale control. By 1906, a London surgeon was gaining a reputation for success with this technique. The article states that the surgeon introduced [into the pylorus] a series of Hegar’s dilators through an incision in the stomach until the muscle coat was felt suddenly to give way… Probably this was the most successful surgical treatment of pyloric stenosis at that time.
Pyloroplasty in various forms was the second surgical PS remedy offered pre-Ramstedt. Pyloroplasty was explained and illustrated in the previous post: it is also still used and is less harrowing than the form of pyloric dilatation used at the time. The French surgeon Pierre Fredet (1877-1955), more than any other, gave us this technique, although his name is still today sometimes linked also with Ramstedt’s pyloromyotomy. Like dilatation, pyloroplasty too was derived from a technique already used on adults.
Although other forms of pyloroplasty were introduced in the UK from 1902, Fredet was the first to cut and split the enlarged muscular ring around the pyloric passage without damaging the mucosal membrane (inner lining). Thus we speak today of an “extra-mucosal pyloroplasty or pyloromyotomy”: not breaching the gastric passage eliminated a major source of possible complications.
Fredet then stitched the gash transversely, across the pylorus, as clearly shown in the last post’s illustration. This weakened the muscle, giving it time to relax and the body time to overcome the enlargement. Fredet introduced this technique in 1907, and very soon doctors in Germany and Scotland were also advocating the benefits of extra-mucosal pylorolasty.
For reasons the article does not make clear, Fredet was apparently never enthusiastic about his extra-mucous pyloroplasty and continued to use gastro-enterostomy as the method of choice for treating pyloric stenosis until 1921.
Gastro-enterostomy was the most severe surgery resorted to in the pre-Ramstedt era’s attempts to remedy PS by surgery, and despite being the most used PS surgery in 1909, it also had the highest mortality. Interestingly, autopsies and later surgery have shown that the pylorus remains hypertrophied (enlarged) when bypassed – unlike when it is incised and the cut spread open.
Gastro-enterostomy is still used today but very rarely on PS babies; it involves bypassing the pylorus and creating a direct link between the stomach and a lower part of the alimentary canal, usually the jejunum or the small intestine.
Each of the three surgical techniques mentioned above is clearly more severe and harrowing than Ramstedt’s pyloromyotomy, which was described in the previous post. Small wonder that the world’s surgeons went with Ramstedt’s technique as simple, tidy, elegant, and effective… that of course very much from a narrowly technical and professional point of view.
In many previous posts I have lamented this narrowly-based evaluation of Dr Conrad Ramstedt’s PS surgery. In my case it was quite likely the only responsible option to safeguard my future. Apart from that, while it is certainly simple, quick and almost always immediately effective, Ramstedt’s pyloromyotomy is for most PS babies unnecessary in view of simpler and less aggressive and traumatic treatment options that are just as safe and successful.
One of the this blogsite’s main aims is (like a Facebook group and many forum sites) to share information about and personal experience of surgery for PS (and to some extent other conditions of infancy). I trust that by raising our general awareness of PS and its related issues, some of the parents of PS babies will feel a little better informed about the available options, and that those of us affected lifelong by our surgery will be able to better understand ourselves and others concerned.