Tag Archives: history

Pyloric stenosis in its adult forms (1)

Back in the 1950s I once overheard my parents talking about my oldest (and long deceased) uncle Fred having a stomach ulcer and an operation to deal with this.  I well remember being transfixed and “all ears”, but having been stonewalled so often, I dared not ask my parents the question on my mind.  At this time I would have been about 10 years old, and I had worked out that my prominent and hated belly scar was from an operation I’d had as a baby as I’d developed a blocked stomach (pyloric stenosis, “PS”).  I was keen to know whether my uncle Fred would be sporting a scar just like his young namesake.

When I got to see my uncle in swim-mode some 20 years later I was disappointed: his scar was small and almost invisible, far less disfiguring than mine.  Compared with infant surgery in the 1940s, abdominal surgery on adults and 20 years later was quite tidy.

Gastric ulcer01What I’ve discovered only recently is that infant PS and adult gastric ulcers and PS are often related.  All three conditions and several others have been linked with a high output of gastric acid and this is often a family trait.  So my connection with my namesake uncle (and hero) likely went further than our family realised!

The previous post sets out some of the important similarities and differences between the infant and adult forms of PS.  This post will outline two medical articles on adult PS.

The first report was published in 2010 and deals with the case of a 71 year old male who was diagnosed with PS.  The interested reader is encouraged to use the link to read the full article which has been kindly made available to the public.

In brief, it notes that adult PS is found in two forms.  It is often caused by other conditions: a long history of a mild form of the early version, an earlier stomach problem such as a gastric ulcer, or cancer.  Sometimes, as in this case, no underlying disease was found.  This 71 year old was unaware of any such factors, yet tests and surgery proved this man did indeed have a PS.  His symptoms of “abdominal distension, nausea, and vomiting” had been noticed for (just) 3 months.

It is noted that both forms of PS occur far more often in males than in females, and that they often recur in certain families.

The aim of this report is to be applauded: to raise the awareness of both forms of PS within the medical community, and especially the various ways it can appear in adults.

For those like myself and (I expect) most of our readers, the article’s value is also in its acknowledgement that the infant and adult forms of PS are related, and that the infant form does not necessarily end with a simple surgery.  Far from it, as many of us have well come to know!

The second report can thankfully also be read in full by those interested in more detail.  It outlines the very large decline in the number of adult PS sufferers needing surgery.  I have already posted about this.

downward_graph_smallThis study was undertaken by a York (UK) body gathering data on peptic ulcer disease, and based on the statistics from the 3 kinds of stomach surgery done on 4,178 adults and how often adult PS was found during these procedures.  The study ran from 1929 to 1997 and included people born between 1889 and 1959.  It found that the age at surgery fell during these years, that PS was found in 17% of the earliest patients, and just 3% in the last group, and that gastric surgery rates fell markedly (although not uniformly) during the almost 70 years under the lens.

These results show very clearly the effectiveness of modern medical treatment for stomach conditions and introduced in 1977; this includes acid-suppressing medication which reduces the formation of gastric ulcers and resultant scarring of the stomach wall and pylorus.  However, the reduction of PS numbers was even greater than the falling numbers of stomach surgery, suggesting that a number of factors are at work, including diet, medication, and the management of upper bowel disease.

Once again, the great majority of readers will be less interested in the medical messages of the report than in what it might mean for interested lay people.  What do these figures mean for you and me whose history includes PS?

  • yay1People who have had infant PS are less likely to have serious long-term effects than they might have expected some 40 years ago or earlier, thanks to better diet options and medication.
    The fact that today we can read much more about the long-term problems experienced after infant PS is a reflection of our access to the media, not of rising numbers.
  • People who have had infant PS are ever less likely to need further surgery for ongoing problems including a renewed stomach blockage. We need to be aware that for some of us these problems are significant, testing, and often interminable.
    The report states what many have found (as I have read), that surgical responses to such problems are not only severe but also likely to be ineffective in the longer term.
  • Peptic ulcer disease continues today but it now very rarely results in PS.

So – generally good news for the PS-aware community!  My next post will review several other medical articles on adult PS.

Pyloric stenosis surgery – “somewhat improved”

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

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

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

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

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

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

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

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

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

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

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

The report drew these conclusions:

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

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

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

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

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

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

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

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

Pyloric stenosis then and now

Medical science has made huge progress in the past century.

  • If I had been born 30 years earlier my infant pyloric stenosis (“PS”) would have given my parents a horrible choice: Submit your long-awaited 10 day old firstborn son for major and horrific surgery (probably without an anesthetic) that killed around 75% of babies, many of shock, blood loss or infection – or see your little one die of thirst and starvation.
  • Modern medicine01My father suffered from mild diphtheria and tuberculosis – diseases that are now virtually unheard of in developed countries.  My family is thankful that Dad does not seem to have been seriously affected.
  • One of my grandmothers was almost blind for the last decade of her life and although my father was able to have his cataracts removed, it meant several days in hospital and wearing thick and heavy glasses for the rest of his life.  My eye problems were solved with three day-surgery procedures: a retinal detachment restored 95% of sight in that eye and my 2 cataracts were replaced by lens implants that make life much easier than having to wear glasses.
  • My mother-in-law had 4 children, then suffered post-natal depression and never recovered, dying at age 90; in this sad and dark condition she had another 5 children.  My wife and I have been able to manage our fertility and enjoy life as well as loving the family we planned.

The several PS Groups’ Pages on Facebook and other internet forum sites (e.g., BabyCenter, MedHelp, PatientUK, and Topix) make it clear that even today, the distress of having a baby with PS does not always end after the scabs from the surgery fall off.  Even in adult life, the long-term effects, although not universal, can be inescapable and extremely troublesome. But just think of the changes from what PS and its surgery were like when the older readers of this post (and their parents, most now passed on) experienced it…

  • General anesthesia, especially for a baby and even today, will always carry a small risk and may still be found to have long-term effects, but it is nevertheless always used and widely regarded as very safe.
  • breastfeeding1PS babies undergoing surgery no longer suffer maternal deprivation: the danger of infection is usually well-managed and hospital rules and staff are no longer as severe as they were.  Mother and baby only need to separate for only an hour or two.  In my case in 1945 it seems to have been some 2 weeks – and both Mum and I continued to feel it.  Today almost all babies can be held and nursed almost immediately after they recover from the operation, and most are cleared to return home within 2 – 3 days.
  • Single port pyloromyotomy scar

    Single port pyloromyotomy scar

    Surgical techniques have improved vastly.  PS surgery once involved an incision which left a scar that grew to an average of 10 cm (4 inches) and usually became quite indented and puckered.  The wound was closed with sutures that left significant additional dimple scars.  No wonder many of the generations who were disfigured by their life-saving surgery took years to come to accept their scar – if ever.  Single port laparoscopic surgery for PS has now become “best practice”: all the work is done through one port (or tube) which is inserted through the navel, and if it is well done and under the right conditions this leaves no visible scarring.

  • Parents and PSers now have access to information, networks and therapies that can help them to understand the physical long-term damage and the psychological and emotional effects that are possible after infant surgery.  When fully effective treatment healing is not possible, the availability of the above help and support will still give many benefits.

This blog, like many of the parents and adult PSers who subscribe to the online forums, wants to see PS becoming more quickly recognised more often, its immediate and long-term after-effects better understood, acknowledged and managed, and not a small number of the medical profession having a much better (more respectful, informative and honest) attitude to PS parents and patients. But I also want to take note of and celebrate the progress that has occurred in important aspects of this condition… in my next post.

Are Pyloric Stenosis problems history yet?

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

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

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

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

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

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

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

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

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

Minimising the pain of infant surgery

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

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

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

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

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

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

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

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

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

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

Pyloric Stenosis in the developing world – a sample

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

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

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

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

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

Here are some of the things I found interesting…

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

Some remarks

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

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

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

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

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

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

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

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

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

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

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

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

Prof Dr C Ramstedt

Prof Dr C Ramstedt

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

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

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

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

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

Dr K J S Anand

Dr K J S Anand

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

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

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