Hypertrophic Pyloric Stenosis in Infancy Treated with Methyl Scopolamine Nitrate

The treatment of hypertrophic pyloric stenosis in infancy has provoked many lively discussions and papers during the last 20 years in which the rival claims of medical and surgical treatment have been ably demonstrated. At the same time, increasing interest and skill in diagnosis of the disorders of early infancy have enabled large series of cases to be collected. A review of the literature shows a steadily decreasing mortality rate from this disorder, due not only to improvement in both medical and surgical treatment, but also to the lessened risks of hospital cross infection which have been effected by higher standards of nursing care and hospital accommodation for sick infants. Still (1924), using medical treatment, reported a mortality of 32.50o in 234 cases. At the Royal Society of Medicine discussion on this subject in 1941, Paterson quoted six deaths in 95 cases treated by Rammstedt's operation at The Hospital for Sick Children, Great Ormond Street, London, in the year 1939. Levi (1941) treated 100 con-secutive breast-fed infants surgically with no mortality. Dobbs (1941) successfully treated 31 cases with methyl atropine nitrate, although in a further 12 infants medical treatment failed, and surgery became necessary; Mackay (1941) also reported a series treated with this drug. The consensus of opinion at that time was in favour of surgical treatment, largely owing to the short period in hospital necessary and the quick cure in experienced hands, medical treatment being mainly advocated for babies in good condition who were more than 8 weeks of age when first diagnosed. More recently in America, Ladd, Ware and Pickett (1946) reported a 5 90o mortality rate in 588 surgical cases, and in this country Wood and Smellie (1951) reported 300 cases treated surgically with four deaths. The series of 100 cases, with 11 deaths in 10 years, reported by Ward-McQuaid and Porritt (1950) is a reminder that even with modern skill surgical treatment can carry quite a considerable mortality rate. In 1951, when this subject was again discussed at the Royal Society of Medicine, Tallerman reported one death in 41 cases treated with methyl atropine nitrate and 26 surgical cases with five deaths, and Denis Browne (1951) reported 407 unselected cases treated surgically with a 2O0 mortality rate in London between the years 1943 and 1945. Davison (1951) quoted a 30o mortality rate in the last 500 cases treated in Newcastle-on-Tyne. Dobbs rightly pointed out that the trend of falling mortality for this disorder corresponded closely with that for the total infant population, suggesting that the same factors might well influence mortality rather than specific improvements in medical and surgical treatment. During this discussion emphasis was properly laid on the importance of early diagnosis, and adequate attention to the minute details of infant care whether medical or surgical treatment was employed. At Bristol Royal Hospital for Sick Children, in the seven years immediately preceding this investigation, there were 267 cases of pyloric stenosis treated by Rammstedt's operation, 12 of which died, a mortality rate of 4-5°,. In the years 1946-49 this rate had improved. as in 132 cases there were only three deaths, a mortality rate of 23%c. While surgery seems to have been the treatment of choice in most large centres in Britain, medical treatment has continued to evoke interest. In Scandinavia particularly. fresh encouragement was given by Svensgaard (1935) who first advocated the use of methyl atropine nitrate (eumydrin'). Jacoby (1946) reported the successful treatment of 50 consecutive cases with this drug and emphasized the part played in medical treatment by a restricted feeding regime. Todd (1947) reported a series of 112 cases treated medically in Leicester, in which 12 deaths occurred. He rightly stressed the factor of locality, and that operation, unless carried out by a skilled surgical and anaesthetic team may give considerably less good results than those reported from the large centres.