Category Archives: History

Pyloric Stenosis’ Game-changer

The German Dr Conrad Ramstedt’s surgical remedy for infant pyloric stenosis was announced to the world at a medical conference and publication in 1912.

This event hardly affected the great majority of the human race, but it was of course rather significant for someone who underwent that surgery 33 years later to save his life just 10 days after his mother gave him birth.  And because pyloric stenosis (“PS”) affects between 3 and 5 babies in every thousand born in developed countries, and most of these are treated surgically, there are many people alive today because of Ramstedt’s discovery.

However, one only has to research the history of this condition and its treatment to realise that whilst the German doctor realised he had made a significant discovery, he was also the unwitting cause of trauma in at least some and perhaps many PS babies and their parents.  Let me explain…

In 1912, the medical treatment of PS babies was the rule but very risky, and almost half the infants died despite it.  Several surgical techniques were then being offered as an alternative for PS babies, but these were so drastic and severe on a tiny, malnourished and dehydrated baby that the great majority died of surgical shock, infection, and other related causes.  Most parents took their chances with the available medicines… and prayed.

RamstedtConrad operating

Dr Conrad Ramstedt operating

Dr Conrad Ramstedt’s accidental discovery in 1911 was published in October 1912 and represented a major breakthrough: see this post and this one.  The Ramstedt pyloromyotomy was rapidly adopted as the remedy of choice in most developed countries around the world, and in four decades after 1912, deaths from PS fell to almost nil in most countries.  However, even in the 1940s, some countries (including Great Britain) continued to report their PS mortality was still at 25%.  I have been shocked by how many mentions there are on the web of relatives dying of PS, even in the 1950s.  Despite all this, Ramstedt’s technique and better health standards in hospitals have done much to make death from PS most uncommon today.

How did the Ramstedt pyloromyotomy contribute to this?

Pic 13It made treating PS relatively easy and simple for surgeons, hospital staff, and parents. For surgeons the technique requires practice and care, but is essentially one of the simplest surgical procedures on the surgeries list.  The surgery usually ends the violent and deadly vomiting; although some continued vomiting and reflux occur quite often, it is fairly rare that an incomplete myotomy (division of the pyloric muscle) or the muscle’s redevelopment requires a repeat of the surgery.  So: anxious parents are greatly relieved, the surgeon immediately becomes a warrior-hero, and the baby quickly starts to make up for weight lost: I gather that my post-op photo is quite typical!

Apart from the great relief of all concerned, the Ramstedt pyloromyotomy saves pediatric ward staff and the bay’s parents from having to manage (or endure) weeks (and often two months) of medical treatment, with each of the sick baby’s feeds requiring medication be administered beforehand to a rigid schedule, milk having to be given slowly and carefully, daily weighing, and regular consultations with the hospital clinic or paediatrician.  Why put yourself through all that when surrendering your baby for just an hour or so to the gowned and skilled surgical staff produces what often seems like an instant fix?

Some babies are best treated surgically, and of the babies treated medically, up to 20% will not respond sufficiently well to avoid belated surgery.

Superman MD1On the other hand, almost all Ramstedt pyloromyotomies seem to be fully effective, certainly in the immediate sense.  And although the worldwide web includes many thousands of complaints and stories of a long list of troublesome ongoing effects from their PS or its surgery, it is just as clear that the vast majority of survivors and their parents are satisfied enough not to air their troubles.  The possible effects of the surgery are many and real, and sometimes severe, but many PS survivors report little or no gastric or abdominal discomfort, few or no problems with their scar or adhesions, and no trauma.  And this silence of the vast majority of PS patients has enabled most of the medical world to assure anxious and worried parents that “PS and its surgery will have no after-effects on your dear child”.

What I have written so far gives me some cause for concern, however.

Ramstedt’s discovery at once saved my life (and I’ve had more than 70 very good years so far), and it has also been responsible for the trauma I and not a few others have had to deal with (often chiefly in private) for most of our lives.

It was quite unintentional, but it is nevertheless true that Ramstedt’s surgical solution for PS effectively and inexorably moved the medical community’s interest away from perfecting the already (and still today) quite effective treatment of PS with cheap and simple medication and careful maternal nursing.  The Ramstedt pyloromyotomy is (as stated above) in itself what many surgeons call “elegant”: it is easy, quick and usually effective.  But until quite recently the surgery and what came with it could be very severe and traumatic on the baby and also on the parents, and it was associated with more (and more severe) risk factors than the medical alternative.

Thus the Ramstedt pyloromyotomy helped fuel the ascendancy of the power and prestige of the surgeon with which some of us are all too familiar today!  We must remember that specialist and high technology medical science has been very largely responsible for our rising health standards and life expectancies, but in fact PS is one of the maladies that can in most cases be brought under control by medical means and with surgery kept as a last resort.  In some developed countries, PS continues to be managed in this manner, and in many developing countries, medical treatment is far more affordable and widely available, and thus the first option.

So Ramstedt’s operation short-circuited interest in understanding and managing the causes, pathogenesis (biochemical development such as proposed by Dr Ian M Rogers) and even prevention of PS.

Whilst I am deeply grateful for the operation that saved my life and realise that in my case surgery may well have been the only responsible remedy, I have often wished that I could have been treated more gently, without a disfiguring scar, and without inflicting life-long trauma on my parents and me.

And in this wish I am not alone.

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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 in the developing world – a sample

People who have experienced pyloric stenosis (“PS”), either in their early infancy or as the parents of a very sick baby, will probably realize that such babies would most likely have starved to death if they had been born more than a century ago.  During the first 30 years after the publication of an effective surgical treatment for PS (Ramstedt’s pyloromyotomy) in 1912, the death rate fell from close to 100% to below 5% in most wealthy countries, and today it is well below 1% in those countries.

But that is still not true everywhere.  Do we ever stop to think what it’s like to have a PS baby today in an underdeveloped and poor country?

In the week before Christmas this subject will get some attention in this post.  I have found 3 medical reports from Africa on which to base this piece, but sadly and to me inexplicably, these articles are only available to the general public in “Abstract” form: read “a very brief summary”.  Most of us cannot afford US$40 per article to read such material, and surely these 3 reports are not “of rolled-gold value” to the medical world;  they were written well over 20 years ago and relate to data even older and from very needy countries far from the domains of most of our readers.  Besides, they aim to improve what may be rather basic pediatric skills and treatment.

Grrrr!  In fact I feel anger and disgust at the medical publishers who (according to recent news reports) maintain this choke hold on medical information… in the interests of medical science? Shareholders? Raw opportunism? Who knows?

Africa map2The 3 Abstract reports relate to PS cases in Ghana between 1974 and 1988, in five years before 1991 in Dar-es-Salaam in Tanzania, and in Addis Ababa (Ethiopia) between 1981 and 1986.  Click on the links to read them in their complete Abstract form.

Here are some of the things I found interesting…

  • The 15 year Ghanaian study of 84 infants saw 9 boys having surgery for every girl, far more than the usual incidence ratio which has been found to range between 2.6:1 and 5:1.
    The 5 year review from Dar-es-Salaam saw only 15 PS babies, with a male: female ratio of 6.5:1, also higher than among Caucasian (white) populations.  The PS incidence rate was (as is well known) much lower among Tanzanian Africans: about 1:5,500 live births.
    The report from Ethiopia related to 34 babies seen over 6 years, and saw an incidence rate approaching Caucasian levels: between 2.7 and 3.6:1,000.  The male:female ratio was 4.7:1, also much closer to the Caucasian ratio.
  • It is also well-known that first-born babies have a higher risk of developing PS.  Almost 24% of the Ghanaian babies and 26.5% of the infants seen in Addis Ababa were first-born.  The Abstract of the report from Dar-es-Saalam did not mention this statistic.
  • The Ghanaian article reported a 3.6% mortality rate: 6 of the 84 infants.  Two of the 15 babies followed in the Tanzanian study died after their Fredet-Ramstedt pyloromyotomy, a relatively high mortality rate of 6.7% (but on a very small number).  In the Ethiopian report, none of the 40 patients died after surgery but 7 developed complications.
  • The report from Ghana mentioned that 10.7% of the 84 babies followed had other congenital abnormalities, which is consistent with studies elsewhere and a much higher figure than among the general population.  The Abstract did not mention which other abnormalities were found but other reports often mention intestinal malrotation, defects of the urinary tract, and esophageal atresia; inguinal (groin) hernias also occur often in infants after PS but these are probably collateral damage from the strains of PS rather than genetically, biochemically or otherwise developmentally linked.
  • The report from Ghana stated that fully 1/3rd of cases started vomiting in their first week after birth.  “The peak-age of presentation and diagnosis was between the second and sixth weeks of life.”
    The Tanzanian article’s Abstract did not include this subject.
    The report for Addis Ababa stated that 76% of babies started vomiting during their first month, and that all babies started to show symptoms during their first 3 months with an average age of 3 weeks.
  • The Ethiopian report included several other findings that are quite typical of PS:
    – 23.5% of the babies were from the higher socio-economic groups (well above average);
    – no seasonal variations were found (contradicting several other reports);
    – a “pyloric olive” (a tumour that could be felt) was detected in 35% of babies.

Some remarks

Although my comments can only be based on three very succinct Abstracts of much more detailed reports, several things are significant to me.

  1. A blast from the past? This Ugandan lad has had recently had PS surgery - but with a very crude wound closure

    A blast from the past? Click on this image to see that this Ugandan lad had fairly recent PS surgery – but with a very crude wound closure

    Developing countries 20 or more years ago were struggling to catch up with the wealthier countries, reflected here in their surgical treatment of PS.  Having followed the flow of generally available medical reports on PS related issues from all over the world since 1997, it is clear to me that while many “centres of excellence” have emerged in the developing world during this time, there are also many signs that little has changed in many poor countries, under-resourced hospitals and the skills of surgeons trained and working in them.

  2. It is probably true the these three Reports reflect that the more recent progress in many of the planet’s poorer countries mirrors in a delayed way the progress that took place in Europe and North America in the earlier decades of the 20th century.
  3. None of these three Abstracts mentions treating PS medically as the safer, cheaper and less technology- and skills-demanding alternative to surgery, a recommendation that I have read recently for contexts such as the African one. One wonders whether self-interest or good management drives this obvious preference for surgery that is usually unnecessary and certainly more traumatic for parents and baby.
  4. Comparing these three reports reminds me of
    (1) the many standard features, variations and mysteries that remain around PS, and
    (2) something of what PS surgery was like when I was born in 1945.

There has been progress world-wide!  When I was born almost 70 years ago, most PS babies outside the developed world would have died.

But even in the 1980s this was no longer true!  What will the next 70 years bring?

100 years of Pyloric Stenosis surgery – an academic’s review

In October 2012 I posted a tribute and three reflective articles on the centenary of the publication of the German Dr Conrad Ramstedt’s surgical technique to relieve pyloric stenosis (“PS”).

This operation saved my life less than two weeks after my birth in 1945, and it has become the most used treatment of this condition and the most common non-elective infant surgery.  However, debate continues on issues such as –

  • Can PS be more promptly diagnosed more often so that more treatment options are available?
  • Should medical (rather than surgical) treatment be tried on more PS babies, with surgery as a later option?
  • How important is it to choose a surgical technique that reduces scarring in later life?
  • Can the symptoms reported by PS surgery survivors (PTSD and a long list of immediately or later evident abdominal complaints) be linked with PS or its treatment, and perhaps avoided?
  • Do the medical journal articles on PS and pyloromyotomy (PLM) deal with great repetition on just a small number of the related issues and avoid other significant matters?

Last year I found only one or two medical journal articles prompted by the centenary of Ramstedt’s pyloromyotomy: these were available only upon what would be for many a costly subscription, and the Abstract (supplied by only one publisher) gave nothing significant away.

Raveenthiran Prof Dr V 2012.bmpHowever, I am very thankful that during the past week, the Indian Prof. Venkatachalam Raveenthiran published an online review of the past 100 years of PS surgery which he generously made available to anyone interested.  There is also a ‘pdf version available on the web.

So once again I’d like to report on a medical journal report:  to summarise it, highlight the main points, and where necessary “translate” it and sometimes comment on it for general reading.

I have found that some of Prof. Raveenthiran’s observations are of real interest to one who has learnt to be thankful for the discovery of this surgery – despite the many years of my struggle with some of its after-effects.

  • The discovery of a surgical technique that brought to an end the very high mortality rate of PS babies has not reduced the interest in the condition.  In fact, in recent years the number of research reports about PS and PLM published annually has increased, and several of the formerly accepted data have been contradicted or rejected.
    However, I (Fred) am not alone in having observed that much of this output is very repetitive and sometimes even trite (stating what is already established).
  • US measures PLM01-1Dr Raveenthiran observes and discusses the growing reliance on diagnosing PS by ultrasound (U/S) technology rather than by simply palpating “the olive” (feeling for the swollen pylorus).  Others and I have reported this also.  The Professor reviews some of the current rather rigid diagnostic criteria, their failings, and their nature which show the need for more research if U/S is to be a more reliable and effective tool.
  • Another current “discovery” is questioned and analysed by the doctor: the widely quoted Danish study that claimed that bottle-fed babies had 4.6 times as much risk of developing PS as breast-fed infants.  This research report also contradicts the “established belief” of earlier years, and Dr Raveenthiran asks some pertinent questions.
  • Plm Lap single port01During the last 20 years circumbilical (around the umbilicus or navel) and Minimal Access Surgery (MAS, also laparoscopic) techniques and equipment have been increasingly applied to infant surgery, including PLM.  In recent years, as this website page shows, MAS using miniaturised equipment (still leaving three but smaller scars) and single-incision laparoscopy (SILS) through the umbilicus have come into use, for both adult and infant patients, and most reports state that after a learning process is completed, the results with the new techniques show no major disadvantages plus the benefit of an improved cosmetic outcome.
    Prof. Raveenthiran expresses bemusement at this string of claimed improvements, questions the practicality of SILS, and mentions yet another new technique, endoscopic PLM (removing the blockage from inside the gastric canal) which has not yet been used on human subjects.
    At this point I (Fred again) recalled reading a recent report that found most pediatric surgeons who had graduated more than 20 years ago were still using open incisions for their PLMs.  As they say,  It’s hard to teach an ol’ dog a new trick.
    As one of the countless PS survivors whose main after-effect has been our struggle to come to terms with an eye-catching and ugly scar, I say (as strongly as I can):  Hey! Please! Yes!  All other considerations being equal, bring on more cosmetically-considered infant surgery!
    Note: See also Dr Raveenthiran’s comment below.
  • In his final paragraph, Prof. Raveenthiran castigates the common attitude that “PS doesn’t have any after effects”.  My comment on this: Hear! Hear!
    He mentions something else I and others have often pointed out: the almost total lack of long-term follow-up of PLM patients, and of research into the long-term effects of PS and PLM.  He touches on some of the problems that have been discovered (but largely ignored and unknown): significantly lower cognitive, receptive language and motor scores, irritable bowel syndrome, and chronic functional dyspepsia and functional abdominal pain at a later age.  He calls for much more long-term study of these problems.

On a personal level, I was once again gratified and reassured as I found that almost everything Prof. Raveenthiran chose to mention and highlight in his essay was a matter that I have also raised, discussed and advocated for in these blogs – albeit without the benefit of medical training and without supposed academic status.  Isn’t it wonderful that the web allows any and all of us to dig out information for our own and others’ help and healing?

Another new year has dawned… Here’s to the victory of truth!

Thanksgiving – a time to count blessings

Many around the world are covetous of the United States’ Thanksgiving Day tradition.  I’m writing this on the fourth Thursday in November, when Americans at home and abroad gather to enjoy a celebratory meal followed by a long weekend.  They’re giving thanks for a number of particular reasons, flowing from the founding of their nation as marked by the arrival of the Pilgrim Fathers at Plymouth Rock late in 1620, these settlers’ first harvest a year later, and the breaking of a serious drought in 1623.  The original thanksgiving occasions took the form of grateful Christian worship meetings rather than a high-calorie meal!

The Netherlands is my country of origin and Australia my adopted country: sadly, neither has anything like Thanksgiving… nor do many other countries (other than Canada) to my knowledge.

In this post I would like to register some of my thanks at a personal level and in regard to my writing these posts, which are a modest part of the centenary of infant pyloric stenosis (“PS”) surgery.  I regard God (as I’ve come to know God through Jesus Christ) as the ultimate maker and giver of everything that is good, and so I honour and thank God  –

  • For the gift of life which most of us today in the developed world take for granted, but which my PS scar keeps reminding me is always a tenuous gift.
  • That PS is so readily treatable by a course of medication or by surgery.  Although I have hated my scar and still have mixed feelings about it (as I do about my other personal inadequacies and battlefields), I have come to realise that without prompt surgery I might not be writing this today.  And of all the abdominal conditions of infancy, PS is not only by far the most common, but also the one that is the most easily corrected and with the least “collateral damage”.
  • For my parents who, even though as people of their time they were ill-equipped to help me understand and “own” the trauma and pain my PS surgery caused me, nevertheless suffered much and loved me through what was for them too a horrendous experience.
    More generally, I am grateful for strong women who can become assertive and even pushy mums.  The web is littered with stories of mothers who stood their ground when they are put down by a condescending doctor who belittled their prior experience of PS, their parental research, and their motherly instinct that something was seriously wrong with their baby.
  • For the hospital staff who nursed me during those first weeks of life in such a way that despite the rough-and-ready way infant surgery that was done at the time, I wasn’t added to the medical morbidity (complications) and mortality statistics.  (The psychological/ emotional after-effects were another story, but unknown at the time.)
  • That medical science, researchers and writers have during the past 100 years added unimaginably much to our understanding and skills in treating life-threatening and life-affecting medical conditions.  Whether it’s the risk factors of a relatively obvious abnormality like PS or the mapping of the brain or genes, we are far from in control, but we do feel increasingly empowered.
    More generally again, I give special thanks for doctors with good diagnostic skills which allow PS babies to start treatment before they are near death, to surgeons who know their stuff and have a deep respect for their tiny patient’s emotional and cosmetic well-being, and to parents, pediatric specialists and hospital sections with the courage and kindness to advise and try medical treatment of PS rather than letting the surgeon set the agneda.
  • That support communities and forum interaction are so common and easily formed and developed today!  As one who was deeply affected at the personal level by my PS experience, I know what it was like to live in isolation from information, explanations and others with the same nagging questions and deep aches.
  • That my two years of weekly posting at this address has met with such a strong and positive response.  Although comments have been fairly infrequent apart from those of my faithful co-blogger, they have been invariably positive, appreciative, and in harmony with my passion here.  Often they have been a complete surprise and most heartening.  And the number of visits far, far outnumbers the comments.
  • For the fact that none of my children and grandkids have developed PS.  Infant PS is known to result from any of several factors, and it seems more likely that my stressed out mother was involved in my first problem than my genetic code.
  • Generally again, I thank God that in the developed countries at least, babies today rarely die of PS.  Until some 50 years ago, there were some terrible mortality rates due to delayed diagnosis, the unavailability of suitable treatment, and surgical and post-operative complications.  Times have certainly changed!

Ramstedt’s pyloromyotomy (4) – what did it change?

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:

A diagram showing how dilatation is done today – with a small balloon (from a French website)

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.

Two pyloroplasty techniques

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.

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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.

Pyloric stenosis surgery makes a century! (2) – the difference Dr Ramstedt made

German Dr Conrad Ramstedt’s surgical remedy for infant pyloric stenosis was announced to the world at a medical conference and publication exactly 100 years ago last week.

This anniversary was of course rather significant for someone who underwent that surgery 33 years later to save his life just 10 days after his mother gave him birth.  And because pyloric stenosis (“PS”) affects between 3 and 5 babies in every thousand born in developed countries, and most of these are treated surgically, there are many people alive today because of Ramstedt’s discovery.

Dr Conrad Ramstedt operating

However, one only has to research the history of this condition and its treatment to realise that whilst the German doctor realised he had made a significant discovery, he was also the unwitting cause of trauma in at least some and perhaps many PS babies and their parents.  Let me explain…

In 1912, the medical treatment of babies with PS was general but very risky, and almost half the infants died despite it.  Several surgical techniques were then being offered as an alternative for PS babies, but these were so drastic and severe on a tiny, malnourished and dehydrated baby that the great majority died of surgical shock, infection, and other related causes.  Most parents took their chances with the available medicines… and prayed.

Dr Conrad Ramstedt’s accidental discovery in 1911 and published in October 1912 represented a major breakthrough: see my previous post and an earlier one.  The Ramstedt pyloromyotomy was rapidly adopted as the remedy of choice in all countries around the world, and in four decades after 1912, deaths from PS fell to almost nil in most countries.  However, even in the 1940s, some countries (including Great Britain) continued to report their PS mortality was still at 25%.  I have been shocked by how many mentions there are on the web of relatives dying of PS.  Despite all this, Ramstedt’s technique and better health standards in hospitals have done much to make death from PS most uncommon today.

How did the Ramstedt pyloromyotomy contribute to this?

It made treating PS relatively easy and simple for surgeons, hospital staff and parents. For surgeons the technique requires practice and care, but is essentially one of the simplest surgical procedures on the OR list.  The surgery usually ends the violent and deadly vomiting; although some continued vomiting and reflux occur quite often, it is fairly rare that an incomplete myotomy (division of the pyloric muscle) or its redevelopment requires a repeat of the surgery.  So: anxious parents are greatly relieved, the surgeon immediately becomes a successful warrior, and the baby quickly starts to make up for weight lost: I gather that my post-op photo is quite typical!

Apart from the great relief of all concerned, the Ramstedt pyloromyotomy saves pediatric ward staff and the bay’s parents having to manage (or endure) weeks (and often two months) of medical treatment, with each of the sick baby’s feeds requiring medication be administered beforehand to a rigid schedule, milk having to be given slowly and carefully, daily weighing, and regular consultations with the hospital clinic or paediatrician.  Why put yourself through all that when surrendering your baby for just an hour or so to the gowned and skilled surgical staff produces what often seems like an instant fix?

Some babies are best treated surgically, and of the babies treated medically, up to 20% will not respond sufficiently well to escape surgery.

On the other hand, almost all Ramstedt pyloromyotomies seem to be fully effective, certainly in the immediate sense.  And although the worldwide web includes many hundreds of complaints and stories of a long list of troublesome ongoing effects from their PS or its surgery, it is just as clear that the vast majority of survivors are satisfied enough not to air their troubles.  The possible effects of the surgery are many and real, and sometimes severe, but many PS survivors report little or no gastric or abdominal discomfort, few or no problems with their scar or adhesions, and no trauma.  And this silence of the vast majority of PS patients has enabled most of the medical world to assure anxious and worried parents that “PS and its surgery will have no after-effects on your dear child”.

What I have written so far gives me some cause for concern, however.

Ramstedt’s discovery at once saved my life (and I’ve had more than 65 very good years so far), and it has also been responsible for the trauma I and not a few others have had to deal with (often chiefly in private) for most of our lives.

It was quite unintentional, but it is nevertheless true that Ramstedt’s surgical solution for PS effectively and inexorably moved the medical community’s interest away from perfecting the already (and still today) quite effective treatment of PS with cheap and simple medication and careful maternal nursing.  The Ramstedt pyloromyotomy is (as stated above) in itself what many surgeons call “elegant”: it is easy, quick and usually effective.  But until quite recently the surgery and what came with it could be very severe and traumatic on the baby and also on the parents, and it was associated with more (and more severe) risk factors than the medical alternative.

Thus the Ramstedt pyloromyotomy helped fuel the ascendancy of the power and prestige of the surgeon with which some of us are all too familiar today!  We must remember that specialist and high technology medical science has been very largely responsible for our rising health standards and life expectancies, but in fact PS is one of the maladies that can in most cases be brought under control by medical means and with surgery kept as a last resort.  In some countries, PS continues to be managed in this manner.

So Ramstedt’s operation short-circuited interest in understanding and managing the causes, pathogenesis (biochemical development such as proposed by Dr Ian M Rogers) and even prevention of PS.

Whilst I am deeply grateful for the operation that saved my life and realise that in my case surgery may well have been the only responsible remedy, I have often wished that I could have been treated more gently, without a disfiguring scar, and without inflicting life-long trauma on my parents and me.

And in this wish I am not alone.