Tag Archives: 1950s

Infant surgery without anesthesia (1): choices have had consequences

Last week something happened that was highly significant for me and the reason for this blogsite.

On the site of my fellow-blogger Wendy Williams, a correspondent called Dean made this Comment

?????????????????????????????????????????????????????????I have for a long time known that I had PTSD and knew that I had been through an experience where I was near death, but I struggled and struggled to know where it came from.  Now I am sure.  I have had the nightmares of operation lights and surgeons standing over me with the accompanying teeth grinding and terror response along with the neurosis that accompanies these nightmares.  I couldn’t believe that people (doctors) would be so ignorant as to think that babies did not feel pain.  I started research on the web and found your site.  Now at 55 years of age I am confident of where these visions come from…

Please follow the link and read Dean’s several Comments in full.

Why are these comments so significant?

Dean reported the same key symptoms of PTSD resulting from infant pyloric stenosis surgery as Wendy has done on her blogsite.  There is just a small community of people who have not only recognized their symptoms of post-traumatic stress disorder (“PTSD”) as being caused by infant surgery, and who have also written publicly about this.

Baby unhappy01These PTSD symptoms have much in common but also differ from person to person.  My symptoms are very similar to “Mark’s” who also follows Wendy’s and my blogsites.  All four of us had surgery to remedy pyloric stenosis in very early infancy, but it seems that both Dean and Wendy have lived with an almost identical set of painful after-effects which like Mark’s and mine are clearly linked with their infant PS surgery as it was often done (at least in the USA) before the late 1980s.

If “one swallow does not make a summer”, two swallows and many similar birds must be significant!

The medical records of people of our age have long been destroyed and our parents are not only deceased but were of a generation that didn’t say much about painful experiences.  This has made it impossible to verify any details of our respective surgeries, and explains why I am so enthusiastic whenever I “meet” somebody who has experienced what I have!

Why would long-ago infant surgery leave people with lifelong PTSD ?

Several of the links to the right will take the reader to reports of infant surgery without general or local anesthesia, using curare (a paralysing drug) to immobilize the baby – which in turn required “intubation”, the insertion of a breathing tube to maintain the paralysed baby’s respiration.  During the past 25 years we have established that although babies’ immature brains cannot recall such early trauma, their bodies can carry what are called “somatic memories” of pain and harrowing experiences.

Baby crying1Is it any wonder that some of those who have been through this kind of early and body- and mind-overpowering trauma continue to carry nightmares clearly related to the operating room, times of feeling frozen in fear and helplessness with agonized teeth grinding, and a phobia for things such as people in white coats, lying down in a vulnerable situation (such as a doctor’s consulting room), and bright lights?

It is not possible to discover with 100% certainty what actual technique(s) of infant surgery traumatised people 40, 50, 60 or more years ago.  But in my next post I want to record some of the discussions held and comments made in medical journal articles of the 1930s to 1960s on the subject of using anesthetic for surgery on PS babies.  I believe this is a key issue.

Only in the late 1980s did Drs K J S Anand and P R Hickey (1987) publish the results of research into the possible effects of early infant trauma after medical procedures.  The New York Times (1987) and writings such as those of Dr David B Chamberlain (1989) and Dr Louis Tinnin have brought Dr Anand’s work to the attention of the public.

bub sick1So in the USA (at least) it was not until 1987 that the apparently common practice of not anesthetising babies for surgical procedures ranging from heart operations to male circumcisions started to become indefensible.  Hospitals and associations of medical professional reviewed and enforced their policies.  Parents were demanding to be more involved.

Up to that time it was believed by many people within and apart from the medical world that “babies don’t feel pain” and / or “babies cannot remember pain.”  It seems that such mantras were less commonly heard outside the U.S.  After all, pediatric anesthesia had become a separate discipline since the late 1940s.

Next week: how was some pediatric surgery done before 1987 and why?

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Ramstedt’s pyloromyotomy (3) – 40 years later

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr Jacoby’s criteria for assessing infants with pyloric stenosis

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

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

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

Mr R B Zachary compared his experience in the Children’s Hospitals in Boston (a US city with a high medical reputation) and Sheffield in the UK.  He noted that in Boston, pyloromyotomies were using general anesthesia administered by nurse anesthetists and resident staff including interns, with a lower mortality than in the UK.  However, coming to Sheffield he had learnt to prefer local anesthesia: The ill child will stand the procedure, pre-operative therapy is needed less often, the post-operative course is smoother, and babies are on full feeds and ready for home on the third day.

Eight other doctors made brief observations or asked a question.

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

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

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

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

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

_______________________________________________________________________________

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

Pyloromyotomy has made progress

Unlike much infant surgery, many pyloric stenosis (“PS”) operations and almost all circumcisions are not necessary to save life.

Circumcision is almost always done for religious or traditional reasons; however, most doctors no longer regard it as routine or desirable, and informed parents are also regarding it as an unnecessary and potentially damaging physical and emotional assault on their baby.

Pyloric stenosis surgery is a more complex matter.  It is advised, validly I believe, for very young and / or emaciated babies and for those who do not respond to several days of medical therapy.  It is advised in many countries, invalidly I believe, for almost all clear cases of infant PS.  However, most PS babies are more than 3 weeks post-natal and if competently diagnosed will not be close to death; most of these (reportedly more than 80%) will respond well to a few weeks of careful feeding and medical management.  After some weeks of treatment, they will outgrow their PS.

However, in most “developed” countries the medical training and self-interest have conditioned doctors (MDs, GPs, paediatricians and surgeons) to advise pyloromyotomy surgery as quick and effective (which it is).  What our medical people rarely tell parents is that this operation is “attractive” mostly to the surgeon concerned: it is easy (once the technique is mastered), quick (and thus profitable) and its effect on a violently sick baby is usually immediate (meaning parents astounded with surprise and overwhelmed with gratitude)!  What very few specialists tell the parents (except as part of the usual routine list) is that many of these babies may have a continuing or long-term problem as a result of the surgery: the documented list includes the effects of trauma on the parents, and for the baby the risk of gastric issues, hernias, adhesions, post-traumatic stress, and emotional responses to their scars – some these quite common.

However, it also true that the unwanted effects of infant PS surgery were more common in the past, when specialist pediatric care, good anesthesia, minimal access surgical pathways, short hospital stays, and parent education were nowhere near what they often are today.

My own experience of infant PS surgery in the mid-1940s has given me much grief and I have tried to work out the reasons for this throughout my life – until recently with little progress.  However, the web has made available a steady stream of enlightening data, and also made worldwide networking easy.  As a result, I now understand my story to a satisfying degree – although hey, I’ll never know what my parents refused to disclose and the records my hospital destroyed after a statutory period.

Recently I found a fascinating reflective address by Dr C Everett Koop, the US Surgeon-General in the 1980s under President Ronald Reagan.  Dr Koop graduated in 1941 and had a distinguished career practising and teaching pediatric surgery, which became a separate discipline only in the mid-1940s, up to which time doctoring babies and children (including surgery and anesthesia) was done without special training and experience.  How scary does that seem now!  In his 1990 address Dr Koop overviewed some of the massive changes that took place in his domain in the almost 50 years since his graduation.

Here are some of Dr Koop’s observations that struck me (the words are his, the bold highlighting is mine) –

  • In 1946, we who were on the curing edge of a new discipline, later to be known as pediatric surgery, considered ourselves to be working in a field of ultimate surgical sophistication.  Even had that been true for disciplines in adult surgery, the attention given to children with surgical problems was a disgrace.
  • Everyone was an expert in circumcision.  There were probably more Gomco clamps in the hospital than there were abdominal retractors.
  • The real challenge of general pediatric surgery of the 1950s lay in the congenital defects incompatible with life but amenable to surgical correction… The mortality for a simple colostomy was in the neighbourhood of 90%.
  • The thought of giving general anesthesia to a child struck terror to the hearts of most surgeons, but instead of this being an impetus to research into the unique responses of infants and small children to pharmacologicals, anesthetic agents, and blood loss and replacement, operations were postponed or never done rather than face the problems of high mortality from anesthesia.
  • In 1946, William E Ladd, the pioneer of pediatric surgery in the United States had retired… A Chair had been endowed in his name, funded by $6,000…  The Boston Children’s Hospital was the only place in the United States where one could say there was anything like a training program in child surgery.
  • I learned early on that it was easier to put children under anesthesia than it was to wake them up.  Hence, a lot of my time in the first two years [after being appointed in 1946] was devoted to the development of techniques and safeguards in pediatric anesthesia.  Indeed I spent more concern and effort there than I did in surgery.
  • If there was such a thing as oncology in those days, I had not yet heard about it.
  • To say that child surgery was an unpopular development in the field of surgery in 1946 is a gross understatement.  General surgeons felt that the log of surgery had been splintered enough; there were enough sub-specialities without contemplating a new one.
    But the insult added to that potential injury was that child surgeons said they could do any surgery in children better than anatomical specialists because of their understanding of the pathological physiology of infants under stress and understood better the management of their very limited reserve.  It may sound brash at this late date, but it really was true in 1946.
  • I was invited by a popular Philadelphia talk show hostess to come and discuss “the new and wonderful things” I was doing at Children’s Hospital”… When I told her I would be discussing childhood cancer, she bristled: “Don’t you dare use that horrid word on my program.”
  • Many surgeons are unaware of the damage caused by the palpating fingers on small children.  I learned this from William E Ladd, who told me never to operate on a pyloric stenosis if the paediatricians had a go at feeling the “olive”.  He said he had learned by bitter experience that such trauma produced so much pyloric edema that no matter how well the operation was performed. The child vomited for days thereafter.
    I have opened the abdomens of children with pyloric stenosis, unaware of the fact that my rules had been broken about pre-operative palpation.  In addition to the edema of the pylorus, actual hemorrhages can be seen in the transverse megacolon from what I’m sure the perpetrator would hgave called “gentle” palpation.
  • As I look back over the last half century, it’s hard to believe how little we all knew when I graduated from medical school and what tremendous advances there have been in medicine during my lifetime.

Dr Koop’s reflections about pediatric surgery between 1941 and 1990 has helped me to realise more fully the enormous development of infant surgery during my lifetime – and the reason anesthesia for infants undergoing surgery was rather rare in the mid-20th century.

Is it any wonder that some of us who had infant surgery at that time have struggled to overcome problems which arose from the illness that caused it, from its management and from the effect it had on our parents in an age when most people didn’t talk about “unpleasant” things such as cancer – or early surgery.

Note

Dr C Everett Koop died on 25th February 2013 at the age of 96.  A most appreciative tribute and comments were posted that same week on Jolene Philo’s Different Dream blogsite which is “a gathering place for the parents and friends of special needs children”. Dr Koop was certainly a pioneer who did much to improve the prospects of such little ones!

Past Pylorix Pages – Pyloric Stenosis treatment in the 1950s

By the 1950’s medical interest in the main facts and options around the character, diagnosis and treatment of infant pyloric stenosis had faded.  Two medical people commented in 1943:
When a disease has ceased to be a therapeutic problem, scientific interest in it is likely to wane.  Not infrequently successful measures of treatment are devised before the fundamental problems of a disease have been solved, and in such instances the consequent lack of interest will be reflected in the neglect of the related, less practical but basically important, questions.

It is clear that this happened to PS: even today, many questions about it have not been answered and are probably in the medical schools’ “to hard” or “doctoral dissertation subjects” baskets… but we know what manages the malady.  So in the 1950s, medical journal articles about PS continued to appear but almost all reflected a shift to researching and reporting on what would appear to lay people like me to be interesting but secondary or rather specialised aspects of the condition:
– PS in premature or older babies and in identical and non-identical twins;
– the age of PS onset in relation to other factors such as home and hospital
birth and 3 or 4 hourly feeds;
– how many babies are born with pyloric tumours but don’t develop PS;
– the recurrence of PS and similar symptoms after surgery;
– the pathology of the hypertrophied (over-developed) pyloric muscle;
– historical reviews of PS treatment during the past century; and
– PS incidence in particular geographic regions and possible causes.

Several things stood out when I read through the numerous 1950s medical articles and reports.

The medical versus surgical treatment debate continued as in previous decades.  This was the single largest issue in the material I have been able to read.  As I have commented several times, in North American and the U.K., surgery was much the majority-preferred course for PS babies, sometimes as soon as medically possible, sometimes only if medical treatment with drugs like eumydrin had been found ineffective.  Those few European journals I have been able to access tend to give a much more favourable emphasis to medical treatment as being feasible and effective; paediatricians sent relatively few PS babies to the surgeon.  Medical treatment remained lengthier and more demanding but was nevertheless found to be cheaper, more accessible, more natural and less traumatic for all concerned; it was found that after initial drug treatment the baby could continue the therapy as an outpatient and with less risk of cross infection.

Because so few articles of this period give details of the surgical treatment it is risky to draw too many firm conclusions, but it seems that the traditional vertical incisions remained favoured in the UK, Europe, and its “Empire” countries, whilst the various transverse (angled under the ribs, high or lower cross) incisions became the standard (although not universally preferred) in the USA.

Do babies need anesthesia?  Britain and Europe as well as in countries including Australia, Canada, Germany and South Africa evidently continued to relieve the pain of babies undoing surgery.  Several 1950s journal articles from these countries included mention of this, the only difference being that some writers used ether and others local anesthesia.
Of great interest to me is the sudden and sharp fall in the number of articles on PS surgery from the US in the 1950s, and that those few articles that are available today are silent on a matter that has come to light only in more recent times.

Early surgery was crude and often unsuccessful

Dr Terry Monell has researched, written and spoken about infant surgery without anesthesia in the USA prior to 1987; she mentions Boston as a centre that led the non-anesthesia-for-babies movement over many years from no later than 1848.  Yet in a previous blog I mentioned that a Boston pediatric surgeon moved to Britain after World War 2 and abandoned using general anesthetic in favour of the British preference for local.  Clearly there was no absolute uniformity in the beliefs about and practice of infant surgery.
Several of my links (right) are to web-based material that deals with the American Academy of Pediatrics and the American Society of Anesthesiologists recognising in 1986 that babies do feel and can remember pain, and that this can cause trauma in later life, although (as with other forms of abuse) the brain records and struggles with those experiences in ways that are not usually immediately obvious.  These two powerful professional associations rewrote their standards and practices, but it took more years of struggle to get US paediatricians and anesthetists to adopt and actually follow the new protocol.

So on the basis of the material that is readily available, I have not been able to assess how widespread infant surgery without analgesia was before 1990.  Nor can I say to what extent this practice occurred outside the USA.  I can say that Terry Monell in the Spring 2011 issue of the Journal of Prenatal and Perinatal Psychology and Health reports that no anesthesia was used for babies as a rule in the 19th Century and into the 20th.  I understand she is referring only to the U.S.  However, before about 1940 almost all the articles I’ve read, including Ramstedt himself and several from the US, mention the way the writer or hospital team did their anesthesia, with reasons and relevant details, and there is (understandably?) no mention of it not being used.

I am therefore suspicious that no post-1940 article from the US that I’ve had access to mentions the subject of anesthesia at all; but this is not true of the non-US articles; is that just strange, or actually significant?

The various medical associations changing their protocols, their members needing time and pressure to fall into line, and hospitals each having their own policy – these are all mentioned by Terry Monell and the first and last of them is mentioned in medical journals elsewhere too.  This would fit in with my supposition that the non-use of anesthesia for babies, at least about 1940-1990, was largely in a problem in the USA and that actual practice there (as elsewhere) varied among doctors, hospitals and medical schools.

Past Pylorix Pages – PS treatment in the 1940s and 50s – pediatric anesthesia

Just after World War 2 a pediatric surgeon, Mr R. B. Zachary, moved across the Atlantic from Boston (USA) to Sheffield (England).  Some years later he commented on this move in a medical discussion recorded in the December 1951 issue of the Proceedings of the Royal Society of Medicine.  I found it interesting reading.

He observed that his new-found English colleagues believed that successful surgery for infant pyloric stenosis (PS) required amongst other things breast feeding, “parenteral fluid therapy” (intravenous and subcutaneous correction of body chemistry), and local anesthesia.  Yet, he said, in the Children’s Hospital in Boston where the statistics compare favourably with those of any other centre, these factors did not matter: the breast-fed baby was a rarity and general anesthesia was the rule, and it was given by nurse anesthetists in training.  There were also significant differences on the use of intravenous and subcutaneous body fluid replacement, and all the operations on hospital patients were done by the resident staff including the interns, a feature which demonstrated the safety of PS surgery even in inexperienced hands, provided good standards were maintained.  Quite a difference!

Of greatest interest to me in this article, however, was Mr Zachary’s next statement: “Since coming to Sheffield I have abandoned general anaesthesia in favour of … local anesthetic after sedation … I now feel sure that local anesthesia is better.  The ill child will stand the procedure, pre-operative therapy is needed less often, the post-operative course is smoother, and babies are on full feeds and ready for home on the third day.”

Why the switch from general to local anesthesia for surgery on PS babies?  Why did the majority of Americans favour general anesthesia during the 1940s and ‘50s whilst in the U K and Europe, local was preferred by most?

In writing this series of posts, I have reread a considerable number of medical journal articles which are freely available on the web.  I don’t have the training or any need to evaluate or adjudicate between the arguments for and against each, but I’d like to pass on at least some of the main issues that were raised at the time.  This will I believe help us who are lay people but interested to understand something of the pros and cons of each way of controlling the pain of infant surgery – even today, and why teaching, practical training and work experience have tended to result in different “camps” of surgical preference and practice.

A note of caution.  I have tried to digest and pass on some rather technical information in a way I could understand it – several dozen articles, written two or three generations ago, with claim and counter-claim – don’t expect a simple and clear-cut picture.  But I hope it helps me and the interested follower “get the picture” a little better.

Considerations related to local anesthesia for infant surgery in the 1940s and 1950s

  • Small, starved and weakened patients, even more than vulnerable adults, take general anesthetics badly and so benefit by the use of local anesthesia instead.
  • But the chief difference in anesthetizing children and adults is the unstable and irregular respiration caused by the size and structure of babies’ lungs and the lack of their muscles’ strength.
    “… babies and young children do not behave like scaled-down adults but present many unexpected problems of their own.  Babies develop obstructed airways at the slightest provocation, their tidal exchange is so small that the normal respiratory valves on gas-oxygen apparatus are unsatisfactory, and the absence of dead-space and avoidance of carbon dioxide build-up become of paramount importance.  The smooth induction of anaesthesia is difficult, and the choice and introduction of tracheal tubes demand much consideration.”
  • Because of the small volume of a baby’s breathing, the open drop method of administering ether was found unsatisfactory by many (despite some reporting on their good record in using it).  When the ether is vaporized on a mask the very low temperature of the vapour was a hazard.  It could be warmed but this complicated ether’s use.
    Dr DeForest Willard reported: “When it is recalled that the surface of the air vesicles is far greater than that of the body’s surface, the chilling effect of ether can be well recognized… The semi-closed method is preferable to the open drop method, as it not only prevents refrigeration but preserves the carbon dioxide necessary to maintain the pH of the blood.”
  • Ethyl chloride was often used, but because of its accumulative effect, the anesthesia continues to deepen for a few minutes after stopping administration, making it unsafe for operations lasting more than a few minutes.
  • Induction [of general anesthesia] in nervous and irritable children may be done with the child in the arms of the nurse as, in addition to the excessive secretion caused by crying, the sobbing respiration frequently persists and necessitates a deeper degree of anesthesia to obtain the proper diaphragmatic immobility…”
  • Because local anesthesia does not suppress respiration (breathing) it was more easily controlled and no hazardous intubation (insertion of an endotracheal or air tube) was needed.
  • Local pain control was easier to manage: it avoided having to find the appropriate level of gas administration to achieve a level of anesthesia that was sufficient and not excessive for the procedure.  Several surgeons reported that light and variable anesthesia was ideal for their PS surgery but most seem to have struggled with this area.

    Area locally anesthetised for the now rarely used upper right rectus incision to treat infant pyloric stenosis

  • Local anesthesia enabled the surgeon to work unhurried by the danger of extended general anesthesia and other drugs, this helping the surgeon to work more patiently and gently.
  • Local anesthesia ensured a speedier post-operative convalescence without vomiting in reaction to ether which strained the wound.  “It enables the child to be fed by the mouth three hours after operation and it enables the surgeon to abolish from his mind all consideration of intravenous therapy.
  • Pediatric anesthesia did not become a specialist field until about 1940.  Before this time, babies and children were anesthetised by pediatric surgeons or by anesthetists working on patients of all ages.  Sometimes this worked well enough, other times it must have been hazardous.  We can only assume that the successes were reported on more readily than the casualties and high mortality rates which remained a fact, notably in the U K.

Considerations related to general anesthesia

  • As mentioned above, the lungs of infants and adults are radically different mechanically: babies have small lung capacity and a fast respiratory (breathing) rate.  Therefore anesthetising babies should reduce rather than further increase the respiratory rate.
  • Because a baby’s muscle tone is almost nil, deep anesthesia and strong immobilisation drugs should be unnecessary to relax the baby; artificial ventilation of a paralysed baby is easier than of an adult.  Muscle relaxation should not or hardly be needed when working on infants, unlike with adults where paralysis is needed to 1) help control respiratory movement, 2) relax the muscles in the surgical area, and 3) reduce irritation caused by an endotracheal tube.  All three of these are not a major problem in babies, and several surgeons reported having abandoned the use of relaxant and paralysing drugs in infant surgery.
  • General anesthesia avoids local anesthetic drugs’ interference with the relaxation of the tissue around the surgical site and its slowing of the healing of damaged tissue.
  • The intrusion of the abdominal contents into the surgical wound is less with general than with local anesthesia, but was believed to be caused by other factors than muscle strength.
  • Both spinal and local anesthetics were regarded as unsuitable for use with young children: 1) psychic complexes are produced by the fear which frequently accompanies and follows their use; 2) the throat and chest become congested by the tears, mucus and saliva caused by crying; 3) over-ventilation of the lungs results in a list of evils including the reduction of carbon dioxide level in the blood (acapnia) and irregular breathing (apnea); 4) a further danger is the possibility of excessive fluid being secreted into the lungs.
  • Despite difference between the infant and adult trachea sometimes causing injury, “the advantages to be derived from intubation are very great, in that the tube ensures a reliable airway and enables the lungs to be readily inflated, and is an invaluable insurance against the dangers of gastric regurgitation, which is very common in the obstructive (gastric blockage) group of cases.”
    An endotracheal tube may be employed and is a definite asset if some assistance to respiration is required.  But again, the latter is not a method to be employed except by those well versed in pediatric anesthesia.”

Some quotations, some conclusions and recommendations for the times…

Dr Alanson Weeks commented on a 1935 California and Western Medicine (journal) report of a San Francisco colleague, Dr Mary E Botsford who was the choice of the region’s top specialists who needed anesthesia to be administered to their infants.  He said that Dr Botsford “… has trained anesthetists from all parts of the world.  She has induced general anesthesia for us in at least a hundred babies suffering from congenital pyloric stenosis, without a single death as a result of such anesthesia.
We are glad to see that she still allows us to use ether in babies, even though she so strongly favors nitrous oxide and oxygen.  We have insisted for years that good relaxation in abdominal surgery gives the operator a better chance to handle his tissues gently.  Even though light anesthesia may be a little safer, the necessary abuse of tissue is altogether too great because of the lack of relaxation. It has been perfectly possible for us to do abdominal operations on babies under local anesthesia and with insufficient relaxation, but the time necessary under such circumstances to replace an omentum, which eternally fights to get as far out of an open abdomen as possible, will do more harm to the babies than will a little more of a less safe anesthetic agent.”

Other comments:

The anesthetization of infants from birth onward may be safely done provided that bodily heat be conserved during and after operation; that ether, when not contraindicated by respiratory or renal dysfunction, be vaporized at a distance of at least 18 inches – which insures its being delivered at room temperature – and that the degree of anesthesia be as light as consistent with the needs of the surgeon.”

Many necessary operations, which formerly were not done at all or performed without anesthesia because of its presumed danger, are now undertaken confidently under general anesthesia.”

Infants, particularly in the first six weeks of their lives, are well able to stand surgical operations and anesthetics, and are as tenacious of life, as far as shock is concerned, as at any other time of their lives, provided certain precautions are observed, and these are that their vitality shall not have been lowered by starvation and their body heat shall not have been lowered by exposure during operation.”

To these precautions might be added certain other factors making for safety in these small patients, which are as light anesthesia as is consistent with the needs of the surgeon and a short duration of the anesthesia.”

As I mentioned in the previous blog, several things are of special interest to me:

  1. The majority of U S reports of the 1940s and 1950s favour the use of general anesthesia for infant surgery.
  2. For PS surgery the tranverse incision was gaining favour over the vertical ones in the USA.  I want to explore this change in a later blog.
  3. In the U K and Europe, pioneering German surgeon Conrad Ramstedt’s preference for a vertical incision to access the infant pylorus remained the preferred option, but (contrary to his practice) local anesthesia with or without mild sedation had clearly been found more satisfactory than the available general anesthetics.
  4. The articles I have read only very, very rarely mention longer-term follow-up studies and pay scant or no attention to the possible effects of infant surgical practices.  The world has only recently started to address the issue of post traumatic stress, whether that be from war, abuse in it various forms, or medical procedures.
  5. About 1986 US health bodies revised their code of policy and practice about infant surgery, officially recognising that infant do feel and register pain, both immediately and in the long term; evidently increasing numbers of doctors started to anesthetise their infant and child patients.
    However, from the medical literature I have had access to, there is a total silence about this change and the belief that “infants don’t feel or remember pain”.  From the evidence generally available it is only after about 1986 that the medical community in the U S started to acknowledge this attitude and seek to revise its practice of infant surgery.
  6. It also seems that during this period there were at least some U S paediatricians and surgeons who were more enlightened about infant surgery and did manage the pain of infant surgery.