Category Archives: History

Infant surgery used to be a killer. Most of today’s bubs survive and thrive, but sometimes with some pain.

Reflecting on my 70th

Birthdays and anniversaries are times for celebration, and reaching “three-score years and ten” years is certainly worth a big three cheers! But they are important for reflection as well.

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Renmark Reunion September 2015

Gratitude to God and to the most important people in my life over these 70 years are features I’d like to be emblematic of me.  I am still surrounded with so many loving and kind people, I have enjoyed wonderful peace and excellent health, and my contribution in several circles is still wanted and apparently appreciated.

Ten days ago Helen and I gathered to celebrate my 70th birthday with our 4 children, their spouses and our 11 beautiful grandchildren.  A wonderful 5 days . . .

October 6th is ten days after my birth-day and  marks the 70th anniversary of the life-saving surgery I had in the Netherlands.  I would not be writing this but for that day in my life!

Together with the country of my birth and background, my weary and expecting parents were struggling to emerge from the ordeal of World War 2.  And then I arrived, their long-awaited first child, but soon clearly defective: scary, uncontrollable and life-endangering vomiting (infant pyloric stenosis – “PS”).  And these were times when medical science was pretty rough and ready by today’s standards and when people didn’t dwell on what they’d rather forget.

Pic 12

Mother with me – October 1945

So October 6th marks what I now realise was the gift of a new and wonderful second start in life, but also the beginning of a life-shaping journey of exploration and discovery – outside of me and within.

Outside, my parents were unwilling or unable to answer my reasonable questions about the 10 cm scar on my belly, and this drove me to look for information elsewhere.  But until the advent of the web, this search yielded only cold textbook medical data about PS and the then 33 year old surgical fix for the condition.  And explanations of my deeper issues were nowhere to be found: there were no pointers to where these might be unearthed and no ways of identifying people who could help me to realise (as I do now) that my pain was by no means wacky.

Book coverWithin, I was tormented with private pain from the dawn of my self-consciousness until recent years.  Even now I am still working to piece my private pain-puzzle together, although the web has given me access to much information, clarification and to networking with fellow-survivors, all of which has enabled me to receive and share much healing.  Since 2012 I have blogged about my journey, and in 2014 a pediatric surgeon friend and I published a small book, in which he explained what many still regard as the elusive cause of PS and I outlined my personal experience of this condition. It so happens (in Australia at least) that October 6 falls in “Mental Health Week” – and my own story has certainly helped me to feel a sense of identity with people challenged by mental health issues.

Time changes things!  The past 70 years have taught us the value of openness in the home, the importance of both listening and speaking for healing, of collaboration in achieving goals, and (by no means least) we have learnt much about trauma.

70 years have also brought huge changes to surgical technique and to holistic care in the hospital and home.  Time seems to have done less to change the unhelpful attitudes of some in the medical profession – but that’s due to human nature being far from perfect.

What do these changes (and their lack in some respects) mean?

120327-07-WgHcThe kind of trauma symptoms I struggled with is rare among more recent PS survivors.  Their surgical scars are sometimes almost indiscernible, usually tidy and very rarely as gnarly.  Affected children’s and their parents’ questions are typically answered much more fully and sympathetically, and the children are helped to understand, “own” and even feel pride about their story.

As I see it, I have discerned this is the growth in myself.  I am indeed a survivor from a bygone era of medical practice and parenting, and my scar is an exhibit of mid-20th century surgery.  I know it’s not socially correct for a cultured older gentleman like me to proudly show off his scar as an 8 year old lad might… but I’m catching up on lost joys and enjoying it!

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Infant surgery then and now

Infant surgery has seriously affected some of us whose lives were saved by it.

This is especially true of those like me who are now at the older end of life: we have been affected emotionally and psychologically despite having no conscious memories of the surgery we had so early in our lives.  Our bodies record potent trauma even when our mind cannot.  This does not seem to affect everybody but others’ stories and tell-tale signs are too similar to reject as fiction.

Surgery in the past was rather basic, especially when performed on infants and in the light of current practice. Often in the not-too-distant past no safe general anesthetic and trained pediatric (children’s) anesthetist were available: general anesthetic agents were hazardous for infants in their first two years unless a very careful and experienced anesthetist was available.

Local anesthesia affects the tissue at the operative site, making it hard to work on, so many surgeons would also exclude its use.  So the squirming baby was strapped down, and quite often given a shot of whisky or a sugar cube laced with rum to somewhat distract it.  Or a paralysing drug was injected and a breathing tube inserted.  No picnic for the baby, and it must have been tough on the operating room staff.

The hospital regime then was also “different”.  Two weeks or more in hospital was standard after an “uneventful” pyloric stenosis (“PS”) operation, and often the mother was allowed no contact for fear of infection, which still killed about 50% of PS babies post-op in UK public hospitals after WW2.  I understand my mother had to deliver breast milk daily over 15 km to the hospital for 2 weeks but was never allowed near me, let alone nurse me.  (My surgery was at 10 days so what an introduction to nursing her first baby I was for her…)

Starvation pre-op plus surgical shock plus maternal deprivation – none of it remembered of course, but it has really affected me and others of that generation long term.  Add to that: some years later, these baby-boomer and earlier parents were totally unaware and incapable of managing their own and their growing child’s developing ptsd.

Woodstock-1But hey!  Ever since Dr Conrad Ramstedt and others began publicising their newly discovered “pyloromyotomy procedure”, most of us PS babies no longer died of dehydration and starvation.  Even those who had the PS op in its early days have mostly lived to tell their tales and have often lived well.

But I am also very thankful that despite the many post-op issues reported on Facebook and other form sites, some of the old damage is no longer being inflicted today.  Infant surgery today, even in its most severe forms, is now far less traumatic for all concerned, and most hospital regimes are sensitive and aware.

Pyloric stenosis then and now

Medical science has made huge progress in the past century.

  • If I had been born 30 years earlier my infant pyloric stenosis (“PS”) would have given my parents a horrible choice: Submit your long-awaited 10 day old firstborn son for major and horrific surgery (probably without an anesthetic) that killed around 75% of babies, many of shock, blood loss or infection – or see your little one die of thirst and starvation.
  • Modern medicine01My father suffered from mild diphtheria and tuberculosis – diseases that are now virtually unheard of in developed countries.  My family is thankful that Dad does not seem to have been seriously affected.
  • One of my grandmothers was almost blind for the last decade of her life and although my father was able to have his cataracts removed, it meant several days in hospital and wearing thick and heavy glasses for the rest of his life.  My eye problems were solved with three day-surgery procedures: a retinal detachment restored 95% of sight in that eye and my 2 cataracts were replaced by lens implants that make life much easier than having to wear glasses.
  • My mother-in-law had 4 children, then suffered post-natal depression and never recovered, dying at age 90; in this sad and dark condition she had another 5 children.  My wife and I have been able to manage our fertility and enjoy life as well as loving the family we planned.

The several PS Groups’ Pages on Facebook and other internet forum sites (e.g., BabyCenter, MedHelp, PatientUK, and Topix) make it clear that even today, the distress of having a baby with PS does not always end after the scabs from the surgery fall off.  Even in adult life, the long-term effects, although not universal, can be inescapable and extremely troublesome. But just think of the changes from what PS and its surgery were like when the older readers of this post (and their parents, most now passed on) experienced it…

  • General anesthesia, especially for a baby and even today, will always carry a small risk and may still be found to have long-term effects, but it is nevertheless always used and widely regarded as very safe.
  • breastfeeding1PS babies undergoing surgery no longer suffer maternal deprivation: the danger of infection is usually well-managed and hospital rules and staff are no longer as severe as they were.  Mother and baby only need to separate for only an hour or two.  In my case in 1945 it seems to have been some 2 weeks – and both Mum and I continued to feel it.  Today almost all babies can be held and nursed almost immediately after they recover from the operation, and most are cleared to return home within 2 – 3 days.
  • Single port pyloromyotomy scar

    Single port pyloromyotomy scar

    Surgical techniques have improved vastly.  PS surgery once involved an incision which left a scar that grew to an average of 10 cm (4 inches) and usually became quite indented and puckered.  The wound was closed with sutures that left significant additional dimple scars.  No wonder many of the generations who were disfigured by their life-saving surgery took years to come to accept their scar – if ever.  Single port laparoscopic surgery for PS has now become “best practice”: all the work is done through one port (or tube) which is inserted through the navel, and if it is well done and under the right conditions this leaves no visible scarring.

  • Parents and PSers now have access to information, networks and therapies that can help them to understand the physical long-term damage and the psychological and emotional effects that are possible after infant surgery.  When fully effective treatment healing is not possible, the availability of the above help and support will still give many benefits.

This blog, like many of the parents and adult PSers who subscribe to the online forums, wants to see PS becoming more quickly recognised more often, its immediate and long-term after-effects better understood, acknowledged and managed, and not a small number of the medical profession having a much better (more respectful, informative and honest) attitude to PS parents and patients. But I also want to take note of and celebrate the progress that has occurred in important aspects of this condition… in my next post.

Growing our understanding of pyloric stenosis

If you look up information about infant pyloric stenosis (PS) on the web or in a book, you may well come across the word “idiopathic”, meaning that PS “arises spontaneously or from an obscure or unknown cause”.

Sadly, this is medical jargon being used to cover up the facts that despite –
knowing since 1717 that babies have died of PS or gone to surgery for it,
– PS being the most frequent reason for infant surgery, and
– PS affecting between one and five (or even more) babies and their families in every 1,000 births
we haven’t yet done enough research to agree on what causes PS and how we can reduce its incidence.  Using a “big word” (idiopathic) may also be a convenient way of saving words and time to explain what we do know about PS.

breastfeeding1There is on the web a recently published medical journal editorial article with the title Beyond the Firstborn Son that argues that PS is not “idiopathic” at all.  Sadly, this editorial and the major report on a PS research project are two of countless valuable articles that lay people like me and most of our interested readers cannot afford to access: only the first page of the editorial and a brief abstract of the major report are freely available, but even these I recommend as “good reads”.

The editorial article’s subtitle also uses medical language which is worth working out: Epidemiology to enlighten the Parthenogenesis of Hypertrophic Pyloric Stenosis means: studying the incidence, distribution, and possible control of PS can help us to understand its causes.

The 21 October 2013 issue of this medical Journal features the major study by a Seattle team to which I referred in a previous post.  It studied 714 confirmed PS babies over 7 years (2003 – 09) to map what they had in common and compared these results with a 10 times larger control group: a very large project.

Among the discoveries made or confirmed –
– the incidence of PS declined during these 7 years from 1.4 to 0.9 per thousand births;
– during these years breastfeeding increased from 80% to 94%;
– compared with the controls, PS babies were more likely to be bottle feeding after birth (19.5% vs 9.1%),
– any duration or proportion of bottle feeding affected the risk factor,
– smoking (identified as a risk factor in previous work) was found to increase the risk of PS 1.5 fold,
– firstborns (and thus younger mothers) run a 1.8 fold higher risk, and
– older mothers’ risk of having a PS infant is halved.

Bottle feeding1These and other comparisons led the team to conclude that especially bottle feeding is associated with an increased risk of HPS, and that this effect seems to be strongest in older women and mothers of more than one child.  It was also found that although smoking increases the risk of a baby having PS it did not change the risk factor of the way the baby was fed.

This study and the large Danish study published in 2012 came to much the same conclusions.  They are also examples of the fact that discovering the causes of many medical conditions will likely be a slow and laborious process akin to assembling a huge jigsaw puzzle!

What can we conclude from the Danish and US studies showing the value of breastfeeding in lowering the risk of a baby having PS?

Mother and baby31                    It shows the way for more studies.  We know that PS is multi-factorial and the more we know about each risk factor, the better we can research whether and how these interact.  The findings about bottle feeding and smoking mentioned above are an example of this.

2                    The Seattle study confirmed previous findings that PS has been a Caucasian malady by a considerable margin, and that older mothers do not have a higher chance of having a PS baby (despite earlier studies coming to the opposite conclusion).

3                    The editorial points out that studies between 1975 and 1983 noted a rising rate of breastfeeding and incidence of PS and drew link between the two.  This new and large study has given significant reason to reject the earlier correlation.

4                    It is noted in the editorial that “bottle feeding” is difficult to define for the purposes of research.  I have mentioned the matter of the duration and proportion of bottle feeding.  The formula is another variable which could play a significant role in the acidity that is a key factor in the development of PS, as Dr Ian Rogers has shown (as reported in several posts).

5                    It does seem possible to conclude that the feeding mode of the first 6 months is more influential than the age of the mother, smoking, and how many children she has had.

6                    The editorial states: For a disease as common as pyloric stenosis, it is of benefit to have precise estimates of the common risk factors.  I might add that all the risk factors identified and quantified in these two studies are worthy of parents’ consideration.  However, other risk factors such as genetics or inheritance cannot be reduced by us – although I have come across at least two couples who knowingly grew their risk profile: both partners had a PS history – and of course had PS children.

It must be clear that although these two studies on the relationship between how an infant is fed and its chance of developing PS only deal with a small number of risk factors and issues around PS and infant surgery.  They are nevertheless significant to us all in several ways, and especially to new parents, to the pediatric medical community, and to those like me who would like to understand PS better and work to see its incidence fall.

Past Pylorix Pages – Pyloric Stenosis treatment in the 1960s

“Slow – but there was progress!”

This series of looks at the history and practice of infant surgery as it applied to infant pyloric stenosis (PS) has come to the 1960s, and it’s not surprising that the treatment of PS continued in most ways as it had in the previous decades.  In 1912 the German Dr Conrad Ramstedt hit upon and published a surgical method of treating the swollen stomach valve that has continued to be the essential part of almost all of the numerous PS operations on babies.  But there were also signs of continued if slow progress.

  • In the English-speaking countries, Ramstedt’s surgical technique continued to be considered “the standard remedy” for PS infants.  But as mentioned in previous blogs, in several other countries from which we have information many cases continued to be treated medically with relaxant drugs such as atropine and eumydrine, often reporting a high degree of success.
  • In most countries, the midline and para-midline (upper rectus) vertical incisions continued to be used (see previous posts) but the transverse (cross) and gridiron or subcostal (diagonal under the right ribs) incisions were increasingly being used, especially in the USA.  The reasons for this change, and the benefits and drawbacks of each method of surgical access, will have to wait for another time.

    Vertical incisions long remained the standard access to an out-of-control pyloric muscle. During the 1930s a preference developed (esp. in the USA) for the "sub costal" (under the right ribs) route.

  • As in the 1950s, many surgeons and researchers apparently decided that reports and discussions on the symptoms, diagnosis, causes and treatment of PS had had enough journal space.  Such articles and statistical reports did continue to be written, but much that was published were reports on rather specialised aspects (the physiology of the swollen pyloric muscle), or it revisited and reaffirmed already well-established knowledge (the blood groups or inheritance relationships of PS patients).

Due to my own and others’ experiences I have not always enjoyed what I have found by delving into the history of treating PS, so it was wonderful to get a nice surprise.
This past week I devoted much of my available time to checking the internet for material that has been posted (or that I had missed) since I started collecting files 15 or so years ago.
I also decided to save not only the articles but also their web addresses, to make it easier for readers to share in more of my exploration.

What?  No anesthetic for babies?

During the past 5 years several well-researched U S sources have shocked those involved with infant surgery with the revelation that until the mid to late 1980s, some or many pediatric surgeons (at least in the US) did not use anesthetics but instead paralysing drugs and physical restraints for their surgery on babies and infants.  These medical people believed (as has been promoted by some pediatricians since the 19th century) that “babies do not feel and in any case cannot remember pain.”  Besides, no anesthetic comes without risk, especially when it is given to a new-born and physiologically immature infant, so it was attractive to silence the screaming with paralysing drugs whilst assuring the parents that their baby would soon be thriving like topsy… which many babies do after this surgery.  No thought was given to the possibility that the trauma might have long-term effects.
The attitude that babies aren’t affected by strong pain is still held by some today in regard to the circumcision of male infants, a relatively quick and certainly very painful procedure that is medically unnecessary and ritualistic.  And increasing numbers of men today resent it deeply.
Many who have experienced infant surgery and/or circumcision without analgesia profess not to remember or know it, or be affected by it, or don’t want to discuss it.  But many others have lived with lifelong symptoms of PTSD that they have only recently understood and learnt to manage.

The good news

I am grateful that my review of the available articles has revealed that a good number of late 1950s and 1960’s journal material tells us that general anesthetics were used for all the PS surgery done by the respective writers, several of whom practised at leading US hospitals.
After finding earlier that not a single U.S. sourced article from the dozens of medical journal selections I had been able to access made any reference to pain relief for PS surgery, I was becoming rather suspicious.  Had a blanket of silence and denial been drawn across this subject to protect those U S doctors who had adopted that unbelievable 19th century dogma that “infants don’t feel or remember pain”?
The professionally polite silence about those who operated without pain relief continued, but at least there were those who made it known that they always used local or general anesthesia for work on babies.  Among the 1950s and ‘60s reports I now have on file there are at least half a dozen clear references to ether or local anesthesia being used on all or almost all the cases reported on!  Some examples:

  • A report written in California in 1959 mentions a preference for open-drop ether anesthesia.  This report explained that the choice of incision for PS surgery may depend on the surgeon’s training and confidence; it may also depend on where the “pyloric olive” is located.
    This article also included the earliest mention of sub-cuticular suturing of the PS surgery wound: this for me marks the beginning of the end of using staples or silk or catgut stitches through the baby’s soft skin that have left my and many others’ PS scars looking like a giant caterpillar or (as somebody put it) a TV antenna!  I am so thankful that most scars today are much finer and neater.
  • A 1960 article refers to a report that open-drop ether anesthesia was preferred for the 1199 PS operations performed at the Children’s Medical Center in Boston between 1939 and 1952 and that this practice was continuing in 1959.  This hospital is mentioned several times in the medical literature of the time and was clearly had a leading influence.
  • Another 1960 report mentions that “inhalation anesthesia” was used for a recent PS operation at a hospital in Bronx, New York.
  • A comprehensive review of anesthesia for the 978 PS babies treated at Toronto’s main children’s hospital between 1957 and 1965 reports that all its cases included anesthesia (and almost all of these general).  The in-depth article discusses the considerable challenges of giving general anesthetic to PS infants, but there was not a word about it being regarded as optional across the border.  Could it be that smaller hospitals with surgeons and anesthetists untrained or inexperienced in pediatric work represented the great majority of those who took umbrage in the “babies don’t remember trauma” mantra?

It is exactly 40 years ago since my treasured wife and I welcomed our first child.  Two weeks ago this daughter gave birth to our 9th grandchild.  No wonder our family has reflected several times recently on the huge changes in obstetric beliefs and practice over just 40 years.  Thank God that the medical world is continuing to learn and improve!

Past Pylorix Pages – Pyloric Stenosis treatment in the 1940s (1)

In this fourth post in this series, we look at the decade in which I was born and started my story with the infant form of pyloric stenosis (PS).  Each decade during the 20th century saw more professional medical interest in and discussion of this condition, more medical journal reports and studies were published, and the survival rate of PS babies rose further.

It is not surprising that the differences about treatment that we noted in the previous blog continued and even intensified during the 1940s.

  • Should medical treatment always be considered, or should PS now be regarded as the scalpel’s territory?
  • What are the advantages and disadvantages of local and general anesthesia?
  • Which incision should be used to access the overgrown pylorus?
  • How can the deathrate be lowered further?

I writing this overview I have been able to read dozens of medical journal articles, and they give a picture that I find tremendously interesting.  They show the medical community was quite divided on the above and some other related questions – sometimes sharply and deeply so.  These accounts have also given me the key to knowing and understanding much more about my own PS surgery than my parents would ever tell me (or knew), even though it’s now 66 years after the event!  The web is wonderful.

The article I found the most valuable by far was included in the July 1947 issue of the Archives of Disease in Childhood.  It reviewed the carefully kept records of 112 PS cases treated in a large regional English hospital from 1938 to 1945, seeking especially to discover why there could be such a wide variety of results of both medical and surgical treatment of PS, as well as assessing its own practice.

  • In the light of what I wrote about the 1930s, it is interesting that only 8 of the cases were decided on the basis of x-rays; in the other 104 cases a palpable tumour was taken as confirmation.
  • Nursing mothers were admitted along with their baby, and separate “pyloric stenosis cubicles” were provided for each infant, both to minimise cross-infection.
  • Normally, glucose and salts were given alternately into each armpit and groin until the baby was rehydrated.  So that’s why I have those hidden mystery dimples…
  • Then medical treatment with eumydrin was usually tried, and the stomach was washed out twice daily, with enemas being given if needed – all to rid the little body of gastric residue.
  • It is noted that several studies had found that older babies responded better to medical treatment than the younger ones.  Babies went to surgery when it became clear they were not responding to eumydrin after a few days.
  • 12 of the 112 PS patients died: all had been admitted with “gross” or “serious” dehydration, and it was believed that these could have been saved after rehydration and prompt surgery; low birth weight was another mortality factor, and one baby died of bronchopneumonia that developed less than 12 hours after the careless use of ether (which was often very chilled).

The article reports that a search of medical literature shows that between 1910 and 1944 there was an average of 11.8% mortality from a large number of PS cases, and that these deaths were very evenly divided among the 4,162 treated medically and the 3,508 surgical cases.  It comments that many of the reports giving poor or excellent results for either treatment are not based on comparable techniques and conditions.

The recommendations are not surprising:

1                    Use separate cubicles;

2                    Breast-feeding greatly reduces gastroenteritis infections;

3                    Set clear criteria for the choice of treatment based on (1) the hospital’s and doctor’s experience with the treatment method, (2) the availability of treatment, and (3) the special considerations regarding each patient, including the age of PS onset, the baby’s weight, the duration of vomiting, the degree of dehydration, and the presence of infection.

New dads learning to feed their baby in the 1940s

This hospital also conducted follow-up research which found that the babies’ physical and mental development was unaffected by their illness but that some had continuing gastric problems, including delay in stomach emptying which was most common among those babies who had been in the hospital the longest.

In my next post I will pass on some more of this wealth of material that is so telling about the treatment of PS during the 1940s.

Past Pylorix Pages – Pyloric Stenosis treatment in the 1920s

We all take so much for granted.  Until recently I always assumed my life had always been straight-forward: conception, birth, infancy, growing up and adult life and work are all part of natural process, right?
In recent weeks I have been reading some of the many medical journal reports of the past century about infant pyloric stenosis (IPS), a condition that I now realise could have cut my life very, very short, especially if I had been born just 20 or 30 years earlier.

Great Ormond St Hospital for Sick Children today – old and new

It was during the 1910s and ‘20s that the treatment and outcome of this strange but quite common malady changed hugely.
In the 1910, the treatment of PS was mostly medical and dietary: a drug (atropine sulphate) could reduce the swollen muscle over time, and as I posted last time, daily washing out of the stomach and also feeding the sick baby with thickened milk sometimes helped.  The most desperate parents were offered one of several very extreme surgical techniques, but in the mid 1910’s none of the babies operated on for PS at England premier children’s hospital (Great Ormond Street) survived, and the death-rate for babies treated non-surgically was 80%.

Then in 1912 the German Dr Conrad Ramstedt announced his accidentally discovered surgical technique (“pyloromyotomy”) which was enthusiastically utilised worldwide, although in the UK it was adopted only in 1918.  Initially the death-rate in London fell but was still terribly high (41% in 1919), but during the following decade it fell to a mid-20s percentage – and remained stuck there.  In 1945 (when I was born) the deaths after pyloromyotomy in the UK remained at 25%; in the US it was considerably lower.

This largely explains the many reports in medical journals of the 1920s describing IPS and the various ways of treating it with happier results.  For this review I have drawn on four reports, two from the British Medical Journal and two from Annals of Surgery by U.S. surgeons.  We can be grateful that such material is now readily available on the web; please contact me if you need help finding it.

Diagnosis has changed little except that (as noted in my previous post) none of the four reporters saw a need for x-rays unless diagnosis was unclear.  In the 1920s some paediatricians succeeded in finding the “pyloric olive” every time; others not, but it was agreed that only very rarely was it impossible to diagnose IPS correctly.  How different from today, when many surgeons seem to use x-ray and/or ultrasound routinely (and one may wonder why) to confirm what must almost always be abundantly obvious.

Treatment in the 1920s varied much more than in English-speaking countries today.  An English surgeon reports finding that in many cases medical treatment should be tried first, and that it is successful in about 80% of cases.  The reports all mention successful medical treatment.  Only babies whose condition had deteriorated greatly and those whose medical care had not arrested their decline would be prepared for surgery.
On the other hand, an American surgeon wrote: “Medical treatment has undoubtedly been successful in a certain number of cases, but it is not improbable that some of the cures were really cases of pyloric spasm, and not hypertrophic stenosis.  It is doubtful if cases of well-marked hvpertrophic stenosis are often cured except by operation.”  This doctor was a strong advocate of the surgical option.
Today the medical treatment of IPS is widely used, but it seems hardly at all in the English-speaking world, where cost and convenience considerations seem to rule and the effects of surgery on the baby’s later life are not mentioned.

Preparation was identified early as one of the keys to the IPS infant’s recovery.  Several of the reports mention a steep learning curve: without experience surgeons regarded the new Ramstedt technique as a sure lifesaver, but the majority of their patients died from “collapse” which must be understood as not being able to withstand surgery or the shock and trauma it added to their already critical condition.  It was soon discovered that “emergency surgery” is fatal to IPS babies, and that a day or two must be given to rehydrate the baby and restore its blood biochemistry.  A New York surgeon reported that of his 104 cases 7 subsequently died, 6 of these being among his first 19 cases.

For many years anesthetic was given by the “open drop” method

Anesthesia is mentioned in all four reports, and remarkably the story is the same every time and on both sides of the Atlantic.  General anesthesia using ether and/or a compound was the rule.  In one case local anesthetic was used at the parents’ insistence and in a very few cases the baby’s respiratory weakness made it advisable.  It was found universally that babies could withstand ether provided it was used carefully and applied lightly.  General anesthetic resulted in relaxation that made surgery faster and easier – as laypeople could well imagine!  With local anesthesia babies strained, causing its viscera to pop out of the wound (complicating the operation and increasing the likelihood of post-operative shock and of adhesions later) and making the wound’s repair more difficult.  The injected local anesthetic also slowed wound healing.
It was in the next decade (the 1930s) that we see a marked move away from rendering babies unconscious during surgery and a widespread but suspicious silence about pain relief.  That is another subject – and quite a subject.

Surgery for IPS was quick.  The reports mention 10-15 minutes as the time needed.  The challenges and dangers in the 1920s were very much those still mentioned today: the perforation of the mucosa (lining of the alimentary passage) or duodenum (large intestine), an “incomplete myotomy” (the pyloric muscle is not sufficiently split which allows it to regrow and the blockage remains or returns), bleeding, and inadequate repair which results in the wound herniating or reopening.
The surgeons who wrote these four reviews used only two incisions, both vertical: the midline approach which Dr Ramstedt used but which carries some hazards, and the paramedian, a centimetre or so to the right of centre and also known as the “upper right rectus” incision.  The transverse (across) opening which became almost standard in the USA and is still widely used today, evidently belongs to later years, as of course do the umbilical and laparascopic approaches to the pylorus.

Iowa Children’s Hospital – Infants Ward 1920

Post surgery care, as has been mentioned in my previous post, was a subject with widely differing reports and outcomes in past years.  As reported by Dr Still (see previous post) the British private hospitals had good results in the 1920s: babies were cared for in separate rooms, sometimes each baby with a trained sister for the first day or two, and some private hospitals employed a specially experienced sister to care for at-risk babies.  In the British public hospitals, however, all these standards left much to be desired.
Although the two US reports reflected here mention a fall in the IPS mortality rate that is similar to that in Britain, neither surgeon mentions the statistics for public and private hospitals.

On a personal note, I was touched by the discovery that the surgical scar I carry is from the very same incision mentioned by Dr Ramstedt in 1912, although it is rarely if ever used today.  I carry a link with my lifesaver’s work!

Also, one of the reports, written by Dr Arthur C Strachauer, practising in Minnesota, clearly reflected him as a notably sensitive, careful, and caring surgeon in his general tone and in the many detailed practical tips he gave for diagnosing, operating on, and caring for PS infants.  I can find much comfort in thinking that my needs just may have been handled by someone like him!