Tag Archives: Conrad Ramstedt

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.

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.

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.

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*  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.

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.

Pyloric stenosis surgery makes a century! (1) – enter Dr Conrad Ramstedt

Pyloric Stenosis would most likely have robbed me of life less than two weeks after my birth if I had been born just a third of a century before I was.

Dr Conrad Ramstedt (1867-1963)

It was in September and October 1912 that a German military surgeon first shared with the medical world his discovery of a quick, simple and effective surgical remedy for Pyloric Stenosis (“PS”).  I was born exactly 33 years later, by which time Dr Conrad Ramstedt’s surgical technique had become almost universally adopted.  What has become known as the Fredet-Ramstedt Pyloromyotomy was published in a German medical journal dated 20 October 1912. *

So while the world has been marking the centenary of the Titanic’s maiden voyage and tragic loss, of British explorer Robert Falcon Scott’s successful but ill-fated expedition to the South Pole, of the first parachute jump from an aircraft, the patenting of stainless steel, the identification of vitamins, and of the formation of the Republic of China, the international Scout and Guide movements and the African National Congress, there are millions like myself for whom the centenary of Ramstedt’s pyloromyotomy operation is far more significant in 2012 – although most of us PS survivors probably don’t realise it.

I have posted earlier that although PS had been recognised since 1627, it was not until the late 19th century that surgical remedies began to be attempted.  But neither the medical nor surgical treatment did much to reduce an appalling death rate.  The several surgical techniques suggested around 1900 were severe, involved mortality rates well over 60% and were rejected by most parents and doctors.  The death-rate of PS treated conservatively (by small feeds, stomach washes, medication and attempts to stretch the pyloric passage) was then between 10 and 46% at the time.

In 1908 the French surgeons H. Doufour and Pierre Fredet published the description of their new PS operation, “extramucosal pyloroplasty”, which had given better results: they split the pyloric muscle lengthwise down to the mucosa (the passage’s inner lining was left intact) and then stitched it to make the incision cross the muscle.  In their own words –

Diagram of a Heinicke-Alikulicz pyloroplasty

“Incision of about two centimetres in the axis of the pylorus, on the middle of the anterior surface.  This longitudinal incision goes through the peritoneum and muscularis but excludes the mucosa.  The bistoury [a long, narrow surgical knife for minor incisions] cuts a tissue which is white, mottled, bloodless, very hard, squeaking under the instrument, having the same appearance as certain uterine myomas.  The incision thus divides the sphincter for some millimetres in depth (more than five certainly) and the lips of the wound part voluntarily.  A series of linen sutures are placed as in the procedure of Heinicke-Alikulicz, transforming the longitudinal wound into a transverse wound, an autoplasty [a repair using only that body part] which manifestly enlarges the pylorus.”

As I have written elsewhere, after doing two Fredet pyloroplasty operations Dr Conrad Ramstedt discovered accidentally that it was unnecessary to stitch the pylorus to reshape the split.  It is appropriate to read about this in his own words –

Four stages of a Ramstedt pyloromyotomy

“An incision five centimetres long opens the abdomen in the mid-line at the level of the pylorus.  The stomach is enormously dilated.  The pylorus is thicker than a thumb, cylindrical in shape, glistening reddish-white, hard as cartilage.  Division of the thickened muscles on the anterior surface of the pylorus; only one circular suture at the point of change from pylorus to duodenum was necessary.  The incision gaped widely and was left uncovered.  Pylorus replaced, abdominal wall closed.  Plaster bandage.  Duration of the operation fifteen minutes.  Ether narcosis.”

YouTube offers several videos that show how a Ramstedt pyloromyotomy is performed, nowadays with laparoscopy (keyhole surgery); be aware that these videos are graphic!

The Ramstedt operation for pyloric stenosis involves splitting the hypertrophied (enlarged) muscle down to the mucosa (inner lining of the gastric passage), forcing and then leaving the cut to gape open (lengthwise), and then closing the abdomen.  This technique was discovered by Dr Ramstedt by accident followed by good observation, and it remains the essential element of the operation today, although there have been several ways of gaining access to a pesky problematic pylorus.

One of Conrad Ramstedt’s colleagues made a prediction in the early 1920s, when he introduced Ramstedt to his students: „Von diesem Mann werden Sie einmal mehr hören als die heutigen Pädiater und Chirurgen ahnen.“ – “One day you will be hearing more about this man than our current pediatricians and surgeons can possibly imagine at present.”

How right that was!

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*  In researching for this post I was frustrated and annoyed.  I found that not only ground-breaking and research-based medical articles are locked up in high-cost medical journals – that is reasonable and understandable.  However, several journal articles have marked the centenary of Dr Ramstedt’s pyloromyotomy with historical and celebratory articles which would be of no monetary value to anybody; others are a century old and of historical value only.  But all of the former and many of the latter are only available to well-heeled subscribers or to grateful and interested survivors like me at a cost of over US$30 per item.  Having worked for the welfare of others as a Christian pastor all my life I sometimes wonder how others who have also committed to a life of service can sleep at night. 

And, this post about 100 years of Ramstedt pyloromyotomies is also my 100th SIS post.  I am grateful for well over 20,000 reader “hits” and so much appreciative, interesting and encouraging response.