Category Archives: Anesthesia & analgesia

Infant Surgery & PTSD – Links to Publications & Websites

Sometimes it is better not to know…

Some of those who owe their life to infant surgery in times past have become aware of the fact that safe and effective pediatric anesthesia and analgesia have only become almost generally used in developed countries in fairly recent years.

The medical mantra that “a baby does not feel, let alone remember pain” was widely believed and acted on in the medical world.  We can be thankful that many medical workers did nevertheless learn to work on infants using the available rudimentary anesthetic drugs and procedures. A powerful code of silence blanketed what was really happening and how widespread infant surgery without anesthesia was practised.

In 20 years of lay research and networking about this issue, I have yet to find a statistical report or journal article on the relevant facts and figures.  Understandably, parents were never told about the darker facts around their child’s operation, and those who dared to asked were most likely fobbed off – and certainly did not dare to share their concerns with their child in later years.

I have networked with an uncomfortable number of people who like me are grateful to be alive because of early surgery but have always been mystified by living with some of the symptoms of post-traumatic stress.

The medical mantras  about infants feeling and remembering pain were publicly challenged and steadily corrected only since 1987. I have written other posts here about this.

Here is a reading list for those who are interested in learning more about this matter.

Again: sometimes it is better not to know . . .

Inadequate pain management

New York Times – Researchers Warn on Anesthesia, Unsure of Risk to Children – http://www.nytimes.com/2015/02/26/health/researchers-call-for-more-study-of-anesthesia-risks-to-young-children.html (link)

Jill R Lawson, Standards of Practice and the pain of premature Infants – (pdf file incl additional articles) – http://www.recoveredscience.com/ROP_preemiepain.htm (link to Jill Lawson’s article only)

McGrath Patrick J – Science is not enough, The modern history of pediatric pain – Moderna historia dolor pediatrico.pdf – (file) – http://www.dolor.org.co/articulos/MOderna%20historia%20dolor%20pediatrico.pdf (link)

Pail’s Health Blog Nov 2010 – A Story of Babies in Pain and the Barbaric Malpractices of Medicine – http://www.theherbprof.com/blog/?p=66 (link)

Louis Tinnin, Awake and Paralyzed during Surgery – http://ezinearticles.com/?Awake-And-Paralyzed-During-Surgery&id=182472 (link)

Dvorsky, George, Why are so many Newborns still being denied Pain Relief? – http://gizmodo.com/why-are-so-many-newborns-still-being-denied-pain-relief-1755495866 (link)

 

Infant Memory

Chamberlain David B – CV & publications.pdf – (file)

Website – Birth Psychology – A Bibliography of Dr David B Chamberlain’s writings – https://birthpsychology.com/journals/volume-28-issue-4/chamberlain-bibliography (link)

David B Chamberlain, Babies are Conscious – (file)

David B Chamberlain, Babies Don’t Feel Pain – a Century of Denial in Medicine http://www.nocirc.org/symposia/second/chamberlain.html – (link)

Levine, Peter A, Waking the Tiger – Healing Trauma, North Atlantic Books, 1997 (book title)

Van der Kolk, Bessel, The Body Keeps the Score – (book & summary article title) http://www.franweiss.com/pdfs/sensorimotor_vanderkolk_1994.pdf (link)

Van der Kolk, Bessel, Brain, Mind and Body in the Healing of Trauma – http://www.shrinkrapradio.com/436.pdf (link)

Van der Kolk, Bessel, Developmental Trauma Disorder – (book & summary article title) http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf (link)

Van der Kolk, Bessel, The Limits of Talk – http://www.traumacenter.org/products/pdf_files/networker.pdf (link)

 

PTSD from Infant Trauma

K J S Anand & P R Hickey, Pain and its Effects in the Human Neonate and Fetus – http://www.cirp.org/library/pain/anand/ (link)

The New York Times, 24 Nov 1987, Philip M Boffey, Infants’ Sense of Pain Finally Recognized – http://www.nytimes.com/1987/11/24/science/infants-sense-of-pain-is-recognized-finally.html (link)

The New York Times Magazine, 10 Feb 2008, Annie Murphy Paul, The First Ache, http://www.nytimes.com/2008/02/10/magazine/10Fetal-t.html?_r=1&ex=12 (link)

Monell, Terry – When Pediatric Surgery causes Permanent Damage.docx (file)

Dr Louis Tinnin – Infant Surgery without Anesthesia 130707.docx (file) – https://ltinnin.wordpress.com/ and https://ltinnin.wordpress.com/2010/12/30/infant-surgery-without-anesthesia/  (link)

Wendy P Williams – Are Your Symptoms due to Infant Surgical Trauma? – http://restoryyourlife.com/ptsd-post-traumatic-stress-disorder-dr-louis-tinnin-infant-surgery-without-anesthesia-pyloric-stenosis/ (link)

Wendy P Williams – Ten things to remember about pre-verbal Infant Trauma – http://restoryyourlife.com/preverbal-infant-trauma-preverbal-memory-emotions-sensations-breath-anxiety/ (link)

National Institute of Mental Health (USA) – comprehensive introductory brochure on PTSD – https://infocenter.nimh.nih.gov/nimh/product/Post-Traumatic-Stress-Disorder/QF%2016-6388 (link to brochure)

Ten things People with PTSD-related Dissociation should know – http://healthiest.pw/10-things-people-with-ptsd-related-dissociation-should-know/ (link)

 

Personal accounts

Kyle Elizabeth Freeman – Blogger at “Gutsy Beautiful Complicated”, Childhood Medical Trauma – 36 Years Later – https://gutsybeautifulcomplicated.com/2012/11/03/coming-to-terms-with-trauma-thirty-nine-years-later/kyle.elizabeth.freeman@gmail.com

 

N B – Chamberlain, Dvorsky, Van der Kolk and some others listed here have other material online and/or for sale

 

N B – this List is a work in progress

Advertisements

Pyloric stenosis surgery – “somewhat improved”

Has the treatment of infant pyloric stenosis (“PS”) improved with the years?

Yes!  In a recent post I listed many of the clear and obvious ways it has.

Adults struggling with IBS, adhesions, or PTSD may well doubt that; any and all of these can at times be linked with their infant surgery.

The mother I read about recently must surely also doubt that much has been learnt: she was diagnosed with PTSD a few months after suffering with her newborn through several weeks of slow and shoddy diagnosis followed by “last minute, life-saving” PS surgery.

And the continuing avalanche of parents’ posts on social forum sites like Facebook and BabyCenter show this hapless mother is far from alone.

However, what I wrote in the above-mentioned post stands: it is beyond doubt that, thank God and thanks to the medical community, infant surgery including the treatment of PS has made huge progress.

Infant surgery03Last year I read the summary of a 2014 report that supports the claim that the actual surgery to remedy PS has also improved – but only marginally.  The survey evaluates the records of 791 little PS patients of a pediatric surgeon over a 35 year period (1969-2003).

Most of the results reported in the Abstract of this article (sadly, all that is publicly available) merely confirm the usual facts about PS, information that will not surprise those who know something about this condition.

  • 82% of the patients were male and 18% were female.
  • The average age (presumably at surgery) was 38 days and ranged from 7 days to 10 months.
  • Only 5% were not Caucasian.
  • 10% had a family history.
  • 15 babies (3.1%) were premature at the time of diagnosis (so in fact, many more).
  • 9% had other conditions or abnormalities.
  • 10 babies (1.2%) developed PS after surgery for another condition.
  • 13 (1.7%) were treated medically and avoided surgery.
  • All the pyloromyotomy operations were done by open surgery: the incisions used were sub-costal, transverse, or upper midline.
  • 14 babies (1.7%) had other surgical work done (presumably including herniation).
  • 87 of the operations (10%) were followed by complications: 1.1% happened during the surgery, and 9% post-operatively.
  • 2 babies died.
  • Other evaluation results showed some areas of improvement.
  • When ultrasound imaging was used, the age at diagnosis was reduced by about 10 days.
  • All the operations were done using general anesthesia and endotracheal intubation (breathing tube).
  • From 1982, precautionary antibiotics were given before surgery and this resulted in wound infections being reduced to 3.9%.

This surgeon was also responsible for correcting the inadequacy of the work of some non-pediatric surgeons, and these statistics make grim reading:

  • There were 13 such little patients, 12 of them transferred from non-pediatric surgeons.
  • These 13 accounted for 16 complications including one death.
  • 5 of the babies needed further surgery: 4 for an incomplete pyloromyotomy and the other for a perforation of the pyloric canal.

The report drew these conclusions:

  • IHPS should be considered in any vomiting infant.
  • Ultrasound examination allows earlier diagnosis.
  • Serious complications are uncommon and avoidable, but recognizable and easily corrected.
  • Surgeons who do more than 14 pyloromyotomies per annum see fewer complications.

This report (as stated above) deals only with the actual surgical treatment of PS, and not the complaints of many about the total management of this condition.  The report featured does not survey the standard of the diagnosis of PS, nor the often uninformed, sweeping, and simplistic reassurances given about the possible short- and long-term after-effects of PS and its surgical treatment, about which so many doctors and parents seem to be quite “in the dark” (or possibly in denial).

RUQ PLM-3This blogsite and the social media posts of countless parents and patients express gratitude for the survival of almost every PS baby, ever since the Ramstedt pyloromyotomy (surgical operation) rapidly became the standard treatment after 1912.

It is often remarked that the Ramstedt pyloromyotomy is one of the few surgical techniques that has continued as the standard and virtually unchanged since it was introduced.  It is relatively quick and simple to perform, and almost always immediately effective (as much as can be expected of any surgical procedure).

What the report implies but fails to acknowledge is that many older surgeons continue to perform Ramstedt’s pyloromyotomy using the old and often disfiguring open incisions.  Other recent statistics show that the new and cosmetically superior laparoscopic surgery is now used in over half of PS operations.  Understandably but sadly, many older surgeons resist mastering current best practice.

What then is clear from the material collected and reviewed in the two posts (this one and the linked post)?

  • The overall management of PS has seen huge progress.
  • The actual surgery for PS has changed little in a century, but continues to be marginally and slowly improved on.
  • There remain several areas of immediate and significant concern to PS patients and their parents which the medical community is loathe to recognise, let alone seriously tackle.

And therefore numerous PS parents and patients will continue to speak up, network – and post!

Are Pyloric Stenosis problems history yet?

In my previous post I explored the horrible old mantra that “babies have no brain and therefore will not feel or remember pain”.

When I was just 10 days old I had my first surgical operation, for a pyloric stenosis (“PS”, a blockage at the stomach’s outlet) which occurs fairly commonly in between 2 and 5 baby boys and about one girl in every 1,000.  In 1945 (and for several decades after this) the trauma easily caused by what is today regarded as simple surgery was not understood –

  • the operation was often done without a general anesthetic, sometimes even without local pain control because of the major hazards and possible side-effects of each;
  • hospital stays after such an operation were routinely 2 weeks;
  • in hospital sick and recovering babies were routinely separated from their mother to reduce the danger of infection and they were fed on bottled milk;
  • the effects of these practices on the infant’s parents were usually discounted and masked by a code of silence, which often made them even more toxic in the long-term on parent and patient.
  • What I have outlined here has had a lifelong effect on me, and most likely also my parents, although they maintained their silence to their deaths many years ago.

Nerdy MD2One effect of this on me has been a lifelong and obsessive interest in PS and infant surgery.  In recent years what I have learnt and continue to learn has been channelled into teaching and advocacy for the a list of “issues” around these two subjects –

  • What is PS and how was it treated yesterday and is it treated today?
  • Can surgery for infant PS be avoided?
  • How can PS and its surgery affect the infant’s parents?
  • How can they affect the patient in the immediate and long-term?
  • Why is the diagnosis of PS often so frustratingly delayed and what can be done about this?
  • How can parents deal with the problems babies frequently have after the operation?
  • How can PS survivors deal with some remarkably similar problems that all-too-often arise in adult life?
  • Do babies feel and remember pain and other trauma of their pre-verbal stage of life?
  • What are the symptoms of PTSD that seem linked to early infant surgery, and what therapies and programs are available to those affected?
  • Since gaining access to the internet in 1997, I have learnt much about all the “issues” listed, from websites, blogs, social forums, and some valuable personal interactions and friendships that have resulted.

In 2015 I plan to continue sharing and interacting with the PS community via this blog, as well as on several social forums, notably the various Facebook Groups committed to offering support, sharing information and raising awareness about PS.

SeatonHarlan age 4 Fb 140502-2PS survivors and their parents on Facebook sometimes express their profound gratitude that some of the issues I have listed above are now largely becoming consigned to the historical record.

Greatly improved support for parents, good pain management, new surgical techniques that much reduce disfigurement, and short hospital stays are now standard.  Parents may also remark that there seems to be a slowly growing change in the medical professions’ awareness of PS and their attitude to PS parents: less professional paternalism, arrogance and conceit.  Changing social attitudes and better education in medical school seems to be germane to this.

However, it is also quite clear that we are far from being able to “move on” and go fishing!

Minimising the pain of infant surgery

“Twenty-five years ago, when Kanwaljeet Anand was a medical resident in a neonatal intensive care unit, his tiny patients, many of them preterm infants, were often wheeled out of the ward and into an operating room.  He soon learned what to expect on their return.  The babies came back in terrible shape: their skin was gray, their breathing shallow, their pulses weak.  Anand spent hours stabilizing their vital signs, increasing their oxygen supply and administering insulin to balance their blood sugar.”

Anand KJS 2014Hickey Paul R 2014The previous post here mentioned Drs K J S Anand and Paul R Hickey, who came to prominence in 1987 by exposing the fact that much infant surgery to that time was being done without sufficient or any pain relief because of the often-heard and widely-held mantra that “fetuses and babies don’t feel or remember pain”.

In a research report in the leading New England Journal of Medicine these men told of the scientific work and findings that had led them to expose this fallacy.  The distinguished New York Times promptly publicised Dr Anand’s work in 1987 and several more times in later years.  A quarter century later, articles in the magazine USA Today in 2005 and in 2008 The New York Times again helped give the Drs Anand and Hickey’s world-wide publicity.  The quotation above is from the latter article; here is another excerpt from journalist Anne Murphy Paul’s February 2008 NYT feature, The First Ache:

“When the surgeon lowered his scalpel to the 25-week-old fetus, [anesthesiologist] Paschall saw the tiny figure recoil in what looked to him like pain.  A few months later, he watched another fetus, this one 23 weeks old, flinch at the touch of the instrument.  That was enough for Paschall.  In consultation with the hospital’s pediatric pain specialist, ‘I tremendously upped the dose of anesthetic to make sure that wouldn’t happen again,’ he says.  In the more than 200 operations he has assisted in since then, not a single fetus has drawn back from the knife.”

The Just Facts website gives a factual summary of the current knowledge of when and how we humans begin to sense and remember pain – starting not in our first years but much, much earlier, in the first months after our conception.  Fetal or pre-natal surgery has become possible for a list of congenital conditions including spina bifida, tumours, and heart defects which can threaten a newborn’s hold on life or its quality.  The proof that foetuses feel pain has clear implications for pre-natal surgery and other medical practices.  And, we might argue, how much more so for newborn infants.

This quotation from the website makes one wonder why the medical world has denied the reality of pre-natal and infant pain for so long:

“Physicians know that foetuses feel pain … because [among other things]: ‘Nerves connecting the spinal cord to peripheral structures have developed between six to eight weeks.  Adverse reactions to stimuli are observed between eight and 10 weeks…. You can tell by the contours on their faces that aborted foetuses feel pain.’”

The ground-breaking study of Drs Anand and Hickey has had far-reaching consequences since 1987.

  • The September 1987 issue of the USA-based Pediatrics journal posted its revision of the policies and protocol of US pediatricians. However, I have noticed that an American Society of Anesthiologists overview of the history of pediatric anesthesia in the USA published in 2011 made many references to major and significant changes in this field but no mention of the landmark work of Dr Anand and others, of the major revision of their policy and practice, nor of the opposition to these changes in some quarters!
  • Baby anesth01Change there has been nevertheless, supported by the growing recognition that pediatric surgery and anesthesia are indeed specialist disciplines, and by the development of safer drugs and management of their use. Crudely performed infant surgery and minimal pain control of medical procedures on infants are increasingly regarded as unacceptable and should become increasingly rare.  The incidence of long-term trauma effects will also be greatly reduced.
  • Dr Anand’s work is part of a growing and worldwide recognition of the trauma that old-style infant surgery could cause. In the previous post I mentioned other specialists in the fields of medicine, psychiatry, clinical psychology and child development who have contributed greatly to this recognition and thus also to its management and treatment.  In coming posts I plan to review the contributions of such people.

Those who have needed infant surgery (and even those subjected to elective infant circumcision) and their distressed parents owe Drs Anand and Hickey and their like a huge debt of gratitude.  As someone who had rather basic pyloric stenosis surgery back in 1945, I have certainly learnt much and been hugely helped in my own self-understanding and healing from the long-term effects of my infant surgery.

Pyloric stenosis can leave post-op problems

If you are the parent of a pyloric stenosis (“PS”) baby you were probably assured that the surgery to remedy this ugly condition is quick, simple and effective, and that the surgery would not leave your baby with any long-term problems.

babies many1Many of us who have had that surgery might agree, at least on a personal basis: PS affects about 4 in every 1,000 in the countries where this blog is read, and let’s face it, if there are millions of PS survivors who have significant ongoing health or wellbeing problems, we’d all know about it!

Nowadays, many websites that give information about PS are more careful in the assurances they give: typically they tell us, Almost all babies who have this operation recover well, and, pyloromyotomy is a successful operation and there are usually no long-term consequences, other than an incision scar. (from the BUPA health insurance site; underlining mine)

So what can go wrong as a result of the surgery, immediately and in later life?

I have already posted about the several parts of the answer to this big question, and my September 2011 post is one of the most read at this blogsite.  Please use the Categories search box to find what you are after.

Here I want to give a brief overview of this subject, with links to some of the more detailed informative posts at this site.

Complications from the surgery

Problems resulting from the actual surgery are a well-known risk, and every surgeon and anesthetist will run through a list of warnings about this with the baby’s parent(s).

  • The anesthetic is probably the most feared risk area but today it very rarely causes major problems or takes a life, although it seems minor problems are fairly common.  Anesthetising a baby is a very special and exacting skill.  Other fairly common warnings on the list of complications are –
  • A breach of the inner lining of the pyloric passage during surgery (when it is immediately repaired); when very sometimes it is unnoticed during the surgery, it is a very serious matter.
  • Incomplete pyloromyotomy also occurs in a small percentage of surgeries: the enlarged muscle is insufficiently cut or can regrow which usually means a second operation.
  • Infection and bleeding in the wound are an ever-present danger, much reduced from the past, but still a hazard.
  • Wound rupture and hernia formation were more common when surgeons worked (as too many still do) through an incision in delicate baby tissue that was already weakened by malnutrition.  The result is more hospital care and usually more disfiguring scarring.

Disturbance of gastric function – infancy

Unhappy and vengeful bowels are an understandable and very common result of fiddling with a baby’s internal body system.  It can take the form of continued (but not life-threatening) vomiting, reflux or GERD (gastro-esophageal reflux disease), irritable or unstable bowels, and unusually fast or slow metabolism (food processing).

1946-01 FLVLike many babies after a pyloromyotomy, I was insatiable and a picture of health a few months later – hardly a problem unless it develops to obesity as some find to their distress.  Other survivors become fussy eaters which is far more trying for concerned parents.

Several small studies have shown that gastric function is indeed affected by PS surgery, but that this troubles only a small percentage to a significant degree.  It is something most doctors don’t want to hear about – it is hard to diagnose the cause and therefore to treat.

Disturbance of gastric function – adulthood

As already mentioned, these effects can and all-too-often do continue into adult life.  In adulthood it becomes even harder to link these problems with infant surgery, and also to recognize their cause and treat them.

But “anecdotally” I note (from 17 years of reading people’s stories via the internet) that there seem to be a great number of people who report abdominal problems after infant PS surgery, many of them able to trace their problems right through their years.  The percentage of PS survivors affected may be relatively small, but this is still a huge number of very troubled people.  I only wish I could let you read some of their accounts, but most are freely available to read on Facebook and web forum sites.

Adhesions are a related but distinct subject with which I dealt (again) in my previous post.  Adhesions are usually (but not always) recognized only in adulthood, but unlike most other gastric problems they are easily linked with infant or later abdominal surgery.

PPTSD, psychology and emotions

The way in which conditions of infancy such as PS were dealt with until fairly recent years has scarred many who only now are recognizing and speaking up about this.

This is arguably a “sleeping issue”: the long-term effects of doing surgery on infants under age 2 years without the necessary pain management and involving lengthy periods of maternal separation is still incalculable.  Who can tell how much of today’s anger, violence, depression and dysfunction in public and private life is caused by subconscious and unrecognised memories and undiagnosed traumatic stress disorder?  We all know how unresolved stress can affect repatriated military personnel but discount or ignore how countless babies may have been affected in their later years by crude surgical and hospital processes.

Most medical doctors decline engaging with this subject, but the links on the right of this blog reflect only some of (1) those who report long-term problems after PS surgery, and (2) the well-informed and reputable psychologists and therapists who have recognized and begun to work in this area in recent years. The 2 pages of personal reports and discussion on one of the Patient UK forums are a good place to start; I have often thought it useful to contribute to this and similar sites.

It was my growing understanding of psychology and our inner self that has motivated me to read and write here – and several others elsewhere.

Infant surgery without anesthesia (3): choices have had consequences

The previous two posts have explained the three ways in which surgery has been done on babies during the past century.  In brief, babies were worked on using general or local anesthesia – and also using no pain control at all.

The effect of infant surgery without any anesthesia on those patients in later life can be severe, lifelong, and even life threatening: the evidence of this is all over this blogsite – by way of readers’ Comments and links to academic reports.

The work and report of Drs K J S Anand and P R Hickey (1987) were crucial in making this terrible practice and resultant damage abundantly clear.  These men’s findings started a major (and still continuing) change in public attitudes to infant surgery without anesthesia, ranging from circumcisions to cardio-thoracic procedures.

The medical professions concerned have also changed their policies and attitudes, sometimes (it seems) under duress.  The available literature suggests that the practice of pediatric surgery in the USA may have been at the forefront and most influential in promoting the convenient and wishful fantasy that “babies do not feel or remember pain”.

How much have practices around infant “procedures” and surgery actually changed?

As stated, here has been significant change at the formal, official level.  Online we can find many reports and postings reflecting hospitals and associations of anesthetic and pediatric specialists that have revised their protocols, policies and (one hopes) their procedures.

Old Doctor1However, also online are far too many mentions of the old attitudes and ways continuing.  It may be that it’s only the “dinosaurs” of the medical profession who are guilty of this: doctors well past retirement age, unwilling or unable to update their methods, but in blind love with their life’s work and/or buoyed up by naively grateful patients.  I have heard and read too many stories about such people.
(I write this as one who during my professional life strove to keep my work “state of the art”, and then “moved aside” on my 65th birthday because I believed my work responsibilities required this.)

It seems also that many of the surgeons persisting with outdated practices are being “sheltered” by small local hospitals – of which there are many.  There can be a clear co-dependency among those interested in their financial and professional well-being rather than referring their youngest patients to more expert and specialist centres.

This blog is dedicated to informing, networking and reassuring those patients and parents who have been troubled by infant surgery.  My own experience with the effects of a 1945 pyloric stenosis operation (which was a lifesaver, but…) has motivated me to compare notes with others who have experienced something quite or exactly similar to what I have.

Below are some of the quite recent and deeply troubling comments about the present practice of infant surgery which I have gleaned from the web.  Read them and judge for yourself.

Hospital small1Dr Rae Brown wrote 21 August 2009 –
The surgical treatment of patients with pyloric stenosis is straight forward; the anesthetic management is not.  Infants still die in the United States because of attempts to manage cases in medical centers that have little to no experience with newborns.  This is usually because a surgeon feels that they can take care of a child but doesn’t consider the other health care professionals involved in the babies management.  This case should only be done in centers that have substantial experience with babies and especially anesthesiologists that take care of infants as a regular part of their practice.

Dr Jeffrey T Jung wrote in December 2010 –
Many hospitals still do circumcisions without local anesthesia, instead tying down the baby’s limbs and cutting with a scissors — or worse, strangulating off the offending tissue with a piece of string (ouch!).  Babies needing surgery for pyloric stenosis are often intubated ‘awake’ – which anyone who understands intubation knows is not a pleasant experience.  Until a couple of decades ago, babies underwent surgery on the heart–including splitting the sternum or breaking ribs – with only a paralyzing agent, for fear that babies wouldn’t tolerate narcotics or anesthesia.

A 1988 report on infant PS operations in the UK stated –
One patient underwent operation under local anaesthesia for religious reasons, but the remainder had general anaesthesia with endotracheal intubation.
Infants were extubated when fully awake.  Opiate analgesics were not prescribed because infants of less than 46 weeks’ gestational age (full term plus six weeks) have an appreciable risk of postoperative apnoea…
A modification of Robertson’s gridiron incision was used in all but the infant having the operation under local anaesthesia.

Finally, a note to the parents of babies who need surgery.

baby trusting1Often the surgery that is advised is life-saving – but not always.  Most pyloric stenosis (“PS”) operations today are done competently – but they may also be unnecessary.  Check the “Categories” box to the right if you’d like to know more about the alternative medical treatment.

But whatever you decide, consider your baby’s future emotional wellbeing by informing yourself of the options – and the possibility of your own child being treated without general anesthesia.

Infant surgery without anesthesia (2): choices have had consequences

In my previous post I wrote about my discovery that people who had had infant surgery to remedy infant pyloric stenosis (“PS”) during much of the 20th century could recognize the symptoms of post-traumatic stress disorder (“PTSD”) in later life.  And that there could be marked and significant similarity in what those affected reported.

So much so that they could link their PTSD symptoms with what we have learnt only in recent years about the way that surgery was done at the time.  Until the late 1980s it was widely believed, certainly in the U.S.A., that “babies do not feel and certainly cannot remember pain”, and much surgery was done on that assumption.

In researching how PS surgery has been done in the century since its development, I have read many medical journal articles and written a lengthy series of posts giving an overview of this material.  The series is entitled “Past Pylorix Pages” and was posted weekly for 4 months starting 27 October 2011: it may be easily referenced using the Archives box on the right of this page.

The research for these posts made clear why some of us who had had PS surgery before 1990 have been affected by PTSD.

Prof Dr C Ramstedt

Prof Dr C Ramstedt

1                    The German Dr Conrad Ramstedt was one of several surgeons who in the years up to 1912 published a promising surgical technique to remedy infant PS.  Interestingly, Ramstedt’s public and published presentations seem to have won him greater recognition than his colleagues have received!
From the start, surgeons differed in their attitude to and use of analgesia (pain control) when working on babies and infants.  Specialist pediatric surgeons and anesthetists were virtually unheard of before 1950, anesthesia was always more hazardous than today, there was no anesthetic equipment designed for babies and children as there is today, and anesthesia was especially dangerous for infants in their first two years.  Nevertheless, Ramstedt advocated the use of a light ether anesthetic for “his” pyloromyotomy surgery.

2                    Those who preferred to use a (light) general anesthetic gave several reasons.  Working on a crying and tied down but flexing baby was difficult, hazardous and upsetting; the straining also affected the closure of the wound.  Skilful use of the available anesthetics could keep the morbidity (complications) and mortality rates down to acceptable levels – considering the alternatives.  Moreover, local anesthetics affected the tissue around the wound in unhelpful ways.

3                    The use of local anesthetics also had advantages.  It avoided the hazards of rendering a baby unconscious with the use of powerful agents difficult to control as accurately as was necessary in infant surgery.  It removed the pressure of time, allowing the surgeon to work at a more comfortable rate.  The use of light anesthesia while safer could be less than effective in controlling pain, whilst the use of more gas required the intubation of the baby to maintain lung function, a traumatic and difficult procedure even for adult patients.
Several reports mention that some surgeons had the policy of giving the baby a sugar cube to suck on, perhaps laced with a little brandy – to help calm it while the surgery was done using local anesthetic.  A safe thing to mention!

4                    If the numbers of medical journal articles are any guide, those favouring each of these techniques were about equal.

5                    While I have not found any articles mentioning or advocating it, there was a third option, very much based on the belief that “babies do not feel or remember pain”.
There was it seems a veil of silence over this third technique, no doubt because it was an uncomfortable matter to discuss in print, and to avoid alarming parents and the general public.

Dr K J S Anand

Dr K J S Anand

If a tiny patient did not suffer or remember pain, it would be much easier to ignore the question of anesthesia or analgesia altogether.  It was only Drs K J S Anand and P R Hickey (1987) who spelt out what that really meant.
These babies were intubated (had a breathing tube pushed into their windpipe) while awake, and were then given a paralysing drug, curare, so that they could not scream or writhe.  When the surgery was complete they were given an antidote to the curare and ventilation could cease.
This approach to infant surgery avoided the hazards and disadvantages of the first two techniques.  It could also be carried out more easily by doctors not experienced in infant surgery and in local and less well-resourced and equipped hospitals.
It is difficult to measure how commonly this third option was used.
It is not difficult to imagine and understand the effect it had on the subconscious or body (“somatic”) memory of a baby, and that it could have major repercussions in the patient’s later life.

While we can be very thankful for the work and advocacy of Dr Anand and others, there needs to be a far greater understanding of how infant surgery, as done in the past, may have affected many people.

This site and others are committed to lifting the veil, raising public awareness, and reassuring and networking those affected, often without their understanding the cause of their particular PTSD symptoms and “black dog”.