“Slow – but there was progress!”
This series of looks at the history and practice of infant surgery as it applied to infant pyloric stenosis (PS) has come to the 1960s, and it’s not surprising that the treatment of PS continued in most ways as it had in the previous decades. In 1912 the German Dr Conrad Ramstedt hit upon and published a surgical method of treating the swollen stomach valve that has continued to be the essential part of almost all of the numerous PS operations on babies. But there were also signs of continued if slow progress.
- In the English-speaking countries, Ramstedt’s surgical technique continued to be considered “the standard remedy” for PS infants. But as mentioned in previous blogs, in several other countries from which we have information many cases continued to be treated medically with relaxant drugs such as atropine and eumydrine, often reporting a high degree of success.
- In most countries, the midline and para-midline (upper rectus) vertical incisions continued to be used (see previous posts) but the transverse (cross) and gridiron or subcostal (diagonal under the right ribs) incisions were increasingly being used, especially in the USA. The reasons for this change, and the benefits and drawbacks of each method of surgical access, will have to wait for another time.
- As in the 1950s, many surgeons and researchers apparently decided that reports and discussions on the symptoms, diagnosis, causes and treatment of PS had had enough journal space. Such articles and statistical reports did continue to be written, but much that was published were reports on rather specialised aspects (the physiology of the swollen pyloric muscle), or it revisited and reaffirmed already well-established knowledge (the blood groups or inheritance relationships of PS patients).
Due to my own and others’ experiences I have not always enjoyed what I have found by delving into the history of treating PS, so it was wonderful to get a nice surprise.
This past week I devoted much of my available time to checking the internet for material that has been posted (or that I had missed) since I started collecting files 15 or so years ago.
I also decided to save not only the articles but also their web addresses, to make it easier for readers to share in more of my exploration.
What? No anesthetic for babies?
During the past 5 years several well-researched U S sources have shocked those involved with infant surgery with the revelation that until the mid to late 1980s, some or many pediatric surgeons (at least in the US) did not use anesthetics but instead paralysing drugs and physical restraints for their surgery on babies and infants. These medical people believed (as has been promoted by some pediatricians since the 19th century) that “babies do not feel and in any case cannot remember pain.” Besides, no anesthetic comes without risk, especially when it is given to a new-born and physiologically immature infant, so it was attractive to silence the screaming with paralysing drugs whilst assuring the parents that their baby would soon be thriving like topsy… which many babies do after this surgery. No thought was given to the possibility that the trauma might have long-term effects.
The attitude that babies aren’t affected by strong pain is still held by some today in regard to the circumcision of male infants, a relatively quick and certainly very painful procedure that is medically unnecessary and ritualistic. And increasing numbers of men today resent it deeply.
Many who have experienced infant surgery and/or circumcision without analgesia profess not to remember or know it, or be affected by it, or don’t want to discuss it. But many others have lived with lifelong symptoms of PTSD that they have only recently understood and learnt to manage.
The good news
I am grateful that my review of the available articles has revealed that a good number of late 1950s and 1960’s journal material tells us that general anesthetics were used for all the PS surgery done by the respective writers, several of whom practised at leading US hospitals.
After finding earlier that not a single U.S. sourced article from the dozens of medical journal selections I had been able to access made any reference to pain relief for PS surgery, I was becoming rather suspicious. Had a blanket of silence and denial been drawn across this subject to protect those U S doctors who had adopted that unbelievable 19th century dogma that “infants don’t feel or remember pain”?
The professionally polite silence about those who operated without pain relief continued, but at least there were those who made it known that they always used local or general anesthesia for work on babies. Among the 1950s and ‘60s reports I now have on file there are at least half a dozen clear references to ether or local anesthesia being used on all or almost all the cases reported on! Some examples:
- A report written in California in 1959 mentions a preference for open-drop ether anesthesia. This report explained that the choice of incision for PS surgery may depend on the surgeon’s training and confidence; it may also depend on where the “pyloric olive” is located.
This article also included the earliest mention of sub-cuticular suturing of the PS surgery wound: this for me marks the beginning of the end of using staples or silk or catgut stitches through the baby’s soft skin that have left my and many others’ PS scars looking like a giant caterpillar or (as somebody put it) a TV antenna! I am so thankful that most scars today are much finer and neater.
- A 1960 article refers to a report that open-drop ether anesthesia was preferred for the 1199 PS operations performed at the Children’s Medical Center in Boston between 1939 and 1952 and that this practice was continuing in 1959. This hospital is mentioned several times in the medical literature of the time and was clearly had a leading influence.
- Another 1960 report mentions that “inhalation anesthesia” was used for a recent PS operation at a hospital in Bronx, New York.
- A comprehensive review of anesthesia for the 978 PS babies treated at Toronto’s main children’s hospital between 1957 and 1965 reports that all its cases included anesthesia (and almost all of these general). The in-depth article discusses the considerable challenges of giving general anesthetic to PS infants, but there was not a word about it being regarded as optional across the border. Could it be that smaller hospitals with surgeons and anesthetists untrained or inexperienced in pediatric work represented the great majority of those who took umbrage in the “babies don’t remember trauma” mantra?
It is exactly 40 years ago since my treasured wife and I welcomed our first child. Two weeks ago this daughter gave birth to our 9th grandchild. No wonder our family has reflected several times recently on the huge changes in obstetric beliefs and practice over just 40 years. Thank God that the medical world is continuing to learn and improve!