- Email: [email protected]
Pierre Fredet and pyloromyotomy
Journal of Pediatric Surgery (2009) 44, 1842–1845
www.elsevier.com/locate/jpedsurg
Historical review
Pierre Fredet and pyloromyotomy Pyloromytotomy for hypertrophic pyloric stenosis is one of the most important operations of the 20th century. A hundred years ago, few infants with this disease survived. Now every baby with pyloric stenosis should live. We owe a great debt to the surgical pioneers, such as Pierre Fredet, who brought about this remarkable accomplishment. There had been scattered reports of infants with pyloric obstruction before 1888 when Harald Hirschprung, head physician of the Queen Louise Children's Hospital in Copenhagen (Denmark), described the clinical course and pathologic condition of 2 babies who died with hypertrophy of the pyloric muscle [1,2]. In view of the eventual surgical treatment, he made an important observation: “the mucosa showed 6 ledgelike parallel columnae protruding along the entire length of the canal. These ledges form a rosette, which projected into the cavity.” Pyloric muscle hypertrophy caused the obstruction. Many physicians attributed pyloric hypertrophy to spasm and treated these babies with gastric lavage, electrical stimulation, diet, and drugs. Surgery was the treatment of last resort. Gastroenterostomy with more than 50% mortality was the most commonly performed operation until 1907. Various forms of pyloroplasty, including stretching the muscle with dilators passed through the stomach, improved the mortality rate from 16% to 40% [3]. The best results were reported by James Nicoll, a Scottish surgeon, who in 1905 performed a V-Y plastic operation on the pyloric muscle combined with transgastric divulsion of the pylorus [4]. On September 1, 1907, Pierre Fredet, a Paris surgeon, performed a Heinecke-Mickulicz pyloroplasty upon a severely emaciated infant who had been vomiting for 1 month. The operation consisted of a longitudinal cut through both muscle and mucosa that was then sutured in a horizontal fashion. When his sutures cut through the mucosa, Fredet sutured the duodenal serosa to the pyloric antrum. The infant died the next day after “abundant hematemesis.” A month later, a second infant with vomiting and 800-g weight loss was admitted to the Hospital St Louis-enfants. He had a distended stomach, a palpable pyloric mass, and scant urine, but “his face was good, and he had a good cry.” The 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.05.013
attending physician, Henry Dufour, and Dr Fredet decided to operate upon the baby before there was further malnutrition. An intern gave chloroform, and Dr Fredet carried out a double extramucosal pyloroplasty. There were 2 instructive intraoperative complications. The hugely distended stomach had to be emptied with a trocar, and the small intestine was eviscerated because of insufficient anesthesia. Dr Fredet learned to empty the stomach with a catheter before surgery and refined the anesthetic technique. This infant survived, and a month later, Dr Fredet operated upon another infant who also survived. On November 15, 1907, Dufour and Fredet [5] presented their work to the Societe Medicale des Hopitaux de Paris. “We have the honor to present to you an infant, now 3 months of age, diagnosed with hypertrophic pyloric stenosis, upon which Monsieur P. Fredet, surgeon of the hospitals, at the age of 2 months, performed a double submucous pyloroplasty, and who is now well.” Dr Fredet described the operation as follows: “With the stomach emptied, the pylorus is immediately recognized beneath the liver and grasped by the operator between the index finger and thumb. It gives the impression of a little tumor about the size of a cherry and extraordinarily hard. One considers a pyloroplasty, an operation which seems a priority, the easiest and least dangerous with an incision about 2 cm long on the axis of the pylorus in the middle of the superior aspect. This longitudinal incision carries through the peritoneum and the muscularis to the exclusion of the mucosa. The bistoury cuts a white tissue, edematous and very hard, creaking under the instrument, having every appearance of certain uterine myomas. The incision cuts entirely through the sphincter to a depth of several millimeters, and the lips of the wound are gently spread. A series of sutures of linen, placed according to the method of Heinecke and Mikulicz, transform a longitudinal wound into a transverse wound, a plastic procedure, which manifestly enlarges the pylorus. The sutures, to the number of 6 or 7, take the entire thickness of the muscle mass and are tied successively to avoid their cutting through. Then to attempt to obtain a still greater
Historical review enlargement of the pylorus, one attempts to repeat the same plastic procedure lower down on the anterior aspect. But the suture offers very great difficulties, and it is necessary to leave a little lozenge-like space without coverage, the threads cut as one attempts to approximate the 2 ends of the longitudinal incision.”
These 2 successes reflect the wisdom of an early operation and technique by Dr Fredet of extramucosal pyloromyotomy that avoided spillage of gastric contents and bleeding from the mucosa. He had learned from his earlier experience. In 1908, Dufour and Fredet [6] published a meticulous statistical analysis of 72 reports describing the 135 operations performed for pyloric stenosis before December 1907. The authors differentiated congenital pyloric atresia from stenosis by the asymptomatic period after birth and stressed the importance of forceful vomiting, using the term projectile. They noted the absence of bile in the vomitus, visible gastric peristalsis, and a palpable pyloric tumor. Dufour and Fredet [6] were among the first to recommend an early operation to avoid severe malnutrition. They also analyzed gastric contents to demonstrate the elevated chloride levels that later explained the metabolic alkalosis in babies with pyloric obstruction. In 1910, Fredet and Guillemot [7] reviewed the world's literature on pyloric stenosis, even to finding the report of Hezekiah Beardsley, an American physician, who described the clinical history and autopsy on a child with pyloric stenosis in 1788. They noted the increased incidence in males and stressed forceful vomiting, weight loss, oliguria, gastric hyperperistalsis, and the pyloric tumor. They also advocated gastric lavage to rule out the presence of bile and to determine hyperchlorhidria and hyperacidity. The authors illustrated the gross and microscopic appearance of the pyloric muscle and the infolded mucosa. They advocated reduced feedings, gastric lavage, and atropine, but if there was not a prompt response, surgery was indicated. Fredet again reviewed the various operations including his own extramucosal pyloroplasty. He mentioned Weber of Germany who had independently performed the same operation in 1908. Weber [8] gave Fredet credit for the operation, but the German literature gave priority to Weber. In 1912, Fredet and Guillemot [9] brought the literature review up-to-date, and Dr Fredet reported that the extra mucosal pyloroplasty could not be done if the pyloric muscle was too large. He said, “La gastroenterostomie a le grand avantage d'etre applicable a tous les cas, indistinctement.” This may have been because, in one case, he was unable to suture the muscle horizontally and performed a gastroenterostomy. The baby died. He evidently was still concerned about leaving the muscle open. During the First World War, Dr Fredet was a military surgeon and did not address pyloric stenosis again until 1921, when he reported 11 cases, 9 of which had gastroenterostomies [10]. In this article, he referred to the success of Ramstedt with a
1843 pyloromyotomy. Although Dr Fredet expressed confidence in his extramucosal pyloroplasty, he did not think it could be done when the pyloric mass was large, and he would not leave the mucosa exposed. In 1927, Dr Fredet [11] made another major contribution to the treatment of infants with pyloric stenosis. His opening sentence indicated his preference for pyloromyotomy. “La stenose hypertrophique est facilement curable par une operation simple. In la section du sphincter musculaire ou pylorotomie longitudinale extramuqeuse.” He had abandoned horizontal suturing of the muscle and left the mucosa exposed. In this article, he points out, possibly for the first time in the surgical literature, how to avoid perforation of the duodenal mucosa while at the same time sectioning all the muscular fibers. He illustrated the protrusion of the pyloric muscle beneath the duodenal mucosa and pointed out the inevitability of death after an unrecognized duodenal perforation. He used subcutaneous fluids (clysis), preoperative gastric lavage, and emphasized the importance of keeping the infant warm during surgery. Although many surgeons used a local anesthetic, Fredet preferred chloroform in “infinite doses” while incising the skin, replacing the stomach within the abdomen and closing the incision. The anesthetic was “suspended” at other times. After surgery, the infant was placed in a warm chamber, given more subcutaneous saline injections, and 2 hours after surgery, oral glucose was started. In this series of 25 pyloromyotomies, one baby with extreme cachexia died immediately after surgery. Another died with an intercurrent infection at 8 days. Dr Fredet demonstrated radiographs showing normal gastric emptying in his patients years after surgery. He also demonstrated, microscopically, how the pyloric muscle is reconstituted to normal after pyloromyotomy [12]. He also reported on the perfectly normal function of his first 2 patients operated upon in 1907, 32 years later [13]. The life of Pierre Fredet from 1870 to 1946 is all the more remarkable because it spanned periods of political unrest and 3 terrible wars between France and Germany. He was born in Clermont-Ferrand, where his father was a professor of medicine. At medical school in Paris, he won competitive examinations to become an extern and then an intern. After a year of military service, he returned to Paris to pursue a career in surgery as an intern to Felix Terrier. He learned asepsis with “inflexible rigor” and became a prosector in anatomy in 1898. His doctoral thesis was on the anatomy and surgical approaches to the uterine artery. These studies led to ligation of the uterine artery in cases of inoperable uterine cancer [14,15]. He did original anatomical and embryological research on the prepancreatic and mesocolic fascias, the formation of the renal capsules, and the terminal segment of the Wolffian duct in women. Dr Fredet also published on the pathologic anatomy of hernias and thyroglossal duct cysts. In the years following school and before the war, Fredet worked with Joseph Arrou, “an impeccable clinician and scrupulous operator.” It was
1844 during this period that Dr Fredet did his early work on pyloric stenosis. For 25 years, he was an associate or head of a department of surgery at the Charite and the Pitie hospitals. Dr Fredet was a true general surgeon who performed abdominal surgery, treated thoracic empyema, and developed new techniques for treating tuberculosis of the knee and fractures of the patella. He also published on the treatment of Dupuytren's contracture, articular foreign bodies, and missile injuries of the mediastinum. He was a precise surgeon and an exacting educator who said, “There are 2 categories of interns, the pests and the useless. Try to be only useless help.” When an intern demonstrated improvement, he would smile and say, “Well! Not bad progress!” [16]. At a meeting of the Society of Surgery in 1926, a fellow surgeon Victor Veau said, “In pediatric surgery, Fredet is the greatest benefactor of our generation” [17]. This remarkable man also adapted sterilizers to electric power, invented an inhalation device for chloroform, and anticipated modern anesthesia technique with a combination of preoperative sedation, intravenous barbiturates, and nitrous oxide. In addition to his hospital and surgical work, he labored to improve the health of railway workers. In 1929, he visited the United States to study industrial medicine. Pierre Fredet earned many rewards and honors, including the Legion of Honor for his surgical work during World War I and was elected to many professional societies. He was elected president of the National Society of Surgery, and in 1936 as the first president of the Academy of Surgery, he presided over the reestablishment of the Academy in the grand amphitheater of the Sorbonne. Even after his retirement from hospital practice, Dr Fredet made many contributions to surgery, anesthesia, and sterilization. He gave most of his presentations before the Academy of Surgery. In 1940, Dr Fredet moved to his property in the country where he remained with his family until the end of the War. He returned to Paris, became active in the Academies, and was elected president of the Society of Anesthesia. Sadly, he became ill and died on May 29, 1946. Wilhelm Weber of Dresden gave Fredet credit when he reported 2 babies operated upon with the extramucosal pyloroplasty in 1910. In 1911, Conrad Ramstedt [18] set out to do a “Fredet-Weber” partial pyloroplasty but was unable to suture the muscle. He left the mucosa exposed. This patient, and another operated upon with the same technique, survived. When he reported his operation in 1912, he did not mention the work of Fredet but attributed the operation to Weber. There were no references to the work of Fredet in the United States until Langley Porter and Lawson Tait gave him credit for his operation at a meeting of the American Medical Association in 1919 [19]. The “Ramstedt” operation, as it was known, was quickly adopted, especially in the United States. The operation was
Historical review introduced to the Babies Hospital in New York in 1914 and from then until 1920, 165 operations were performed with a 7.1% mortality. In infants operated upon within 4 weeks of the onset of symptoms, the mortality was less than 8%. Dr Downes gave Pierre Fredet credit for the essential features of the operation [20]. This delay in recognizing the work of Dr Fredet was likely due to Franco-German antagonism in the years leading up to World War I, and for Americans, German was the language of science and medicine at that time. Many American doctors took postgraduate courses in Germany, and as late as the 1940s, premedical students were advised to study German to read the medical literature. Thus, the work of Ramstedt became well-known in the United States. After the article by Dr Downes and with an increased understanding of the disturbances in fluid and electrolytes, the mortality rate for infants with pyloric stenosis decreased for the next 30 years to less than 1% in centers devoted to the care of children [21,22]. Today, the diagnosis is often made by ultrasonography within a day or two of the onset of symptoms and surgery performed by video-assisted laparoscopy. The essential step in the procedure, extramucosal separation of the pyloric muscle, is the same as that described by Pierre Fredet. We should now salute him for the extramucosal pyloromyotomy, his insistence on early operation, and his advice on avoiding duodenal perforation. He exhibited flexibility in his choice of operation and his advice on preoperative and postoperative care is as cogent today as a hundred years ago. The writings of Dr Fredet reflect rigorous honesty, and long before the days of computer searches, he meticulously researched and analyzed the surgical literature in 3 languages. With no more guidance than his writings, a few drops of chloroform, a scalpel, and a few hemostats, today's surgeons can successfully treat babies with pyloric stenosis—even when the electricity fails.
Acknowledgments Constance Smith, administrative secretary; Pr Michel Lacombe, librarian; Pr Bernard Launois, president; and Jacques Poilleux, editor-in-chief of the Academie Nationale De Chirugie, Paris, France, provided invaluable assistance with translation and biographic material about Pierre Fredet. Ronald Sims, Special Collections Librarian, Galter Health Sciences Library, Northwestern University, Chicago, IL, discovered many helpful articles in the literature.
John Raffensperger Northwestern University (emeritus) Children's Memorial Hospital Chicago, IL, USA (emeritus) E-mail address: [email protected]
Historical review
References [1] Mack C. A history of hypertrophic pyloric stenosis and its treatment. Bull Hist Med 1942;XII:465-485, 595-615, 666-689. [2] Hirschprung H. Falle Von Angeborener Pylorustenose, Beobachtet bei Sauglingen. Jahrb D Kindeh 1885;27:61-8. [3] Mack, p. 602. [4] Nicoll JH. Several patients from a further series of cases of congenital obstruction of the pylorus treated by operation. Glasgow MedicoChirurgical Journal 1906;2:65:253. [5] Dufour H, Fredet P. La Stenose Hypertrophique Du Pylore Chez le Nourrison Et Son Traitement Chirurgical. Bulletin et Memoires. Societe de Medecine De Paris 1907;24, 1221, 208-217. [6] DuFour H, Fredet P. La Stenose Hypertrophique Du Pylore Chez Le Nourrisson et son traitment chiruggical. Rev Chir 1908;37:208-53. [7] Fredet P, Guillemot L. La Stenose du Pylore par Hypertrophic musculaire Chez les Nourrissons. Ann Gynecol Obstet 1910;67: 604-29. [8] Weber W. Ueber einen Technische Neuerung bei der Operation der Pylorus Stenoses des Sauglings. Berlin Klin Wehschr 1910;47:763. [9] Fredet P, Guillemot L. La Stenose Du Pylore Par Hypertrophie Musculaire Chez Les Nourrissons. Congres National Periodique de Gynecologie, D'Obstetrique et De Pediatrie VI me Session. Toulouse, Septembre 1910 Memoires and Discussions: Publies Par J. Audebert.: Toulouse Imprimerie ed Librairie Edouard Privat 1912:242-323. [10] Fredet P, Pironneau P. La Stenose Hypertrophique du Pylore. Bull Mem Soc Natl Chir de Paris 1921;47:1021.
1845 [11] Fredet P. La Cure de la Stenose Hypertrophique du Pylore Chez les Nourrissons par la Pylorotomie—extra Muqueuse. J Chir 1927;T. XXIX(4):385-408. [12] Fredet P, Lesne E. Stenose Hypertrophique du Pylore chez les Nourrissons. Resultat anatomique de la Pylorotomie sur un Sujet Traite Gueri Depuis Trois Mois. Bull Mem Soc Chir 1928;32: 1050-60. [13] Mack, loc cit Page 673, Personal communication with Dr Pierre Fredet on Dec. 3, 1939. [14] Fredet P. Recherches sur les Arteres de l'uterus. Journal d'anatomie et de Physiologie 1898;34:79-122. [15] Fredet P, Hartman H. Resultats Eloignes des Ligatures Atrophiantes Faites dans deux cases de Cancer Inoperable de l'uterus. Societe de Chir Paris 1898;24:130-3. [16] Cerbonnet G. Pierre Fredet, 1870-1946. Dernier President de la Societe Nationale et Premier President de l'Academie de Chirurgie,. Chirugie [Memoires de l'Academi] 1986;112(1):13-26. [17] Cerbonnet, 24. [18] Ramstedt C. Zur Operation der Angeborenen Pylorusstenose. Med Klin 1912;1702. [19] Mack 668. [20] Downes WA. Congenital hypertrophic pyloric stenosis, review of one hundred and seventy five cases in which the Fredet-Ramstedt operation was performed. JAMA 1928;75:228-32. [21] Gross RE. The surgery of infancy and childhood. Philadelphia: W.B. Saunders; 1953. p. 143. [22] Potts WJ. The surgeon and the child. Philadelphia: W.B. Saunders Co.; 1958. p. 57.
www.elsevier.com/locate/jpedsurg
Historical review
Pierre Fredet and pyloromyotomy Pyloromytotomy for hypertrophic pyloric stenosis is one of the most important operations of the 20th century. A hundred years ago, few infants with this disease survived. Now every baby with pyloric stenosis should live. We owe a great debt to the surgical pioneers, such as Pierre Fredet, who brought about this remarkable accomplishment. There had been scattered reports of infants with pyloric obstruction before 1888 when Harald Hirschprung, head physician of the Queen Louise Children's Hospital in Copenhagen (Denmark), described the clinical course and pathologic condition of 2 babies who died with hypertrophy of the pyloric muscle [1,2]. In view of the eventual surgical treatment, he made an important observation: “the mucosa showed 6 ledgelike parallel columnae protruding along the entire length of the canal. These ledges form a rosette, which projected into the cavity.” Pyloric muscle hypertrophy caused the obstruction. Many physicians attributed pyloric hypertrophy to spasm and treated these babies with gastric lavage, electrical stimulation, diet, and drugs. Surgery was the treatment of last resort. Gastroenterostomy with more than 50% mortality was the most commonly performed operation until 1907. Various forms of pyloroplasty, including stretching the muscle with dilators passed through the stomach, improved the mortality rate from 16% to 40% [3]. The best results were reported by James Nicoll, a Scottish surgeon, who in 1905 performed a V-Y plastic operation on the pyloric muscle combined with transgastric divulsion of the pylorus [4]. On September 1, 1907, Pierre Fredet, a Paris surgeon, performed a Heinecke-Mickulicz pyloroplasty upon a severely emaciated infant who had been vomiting for 1 month. The operation consisted of a longitudinal cut through both muscle and mucosa that was then sutured in a horizontal fashion. When his sutures cut through the mucosa, Fredet sutured the duodenal serosa to the pyloric antrum. The infant died the next day after “abundant hematemesis.” A month later, a second infant with vomiting and 800-g weight loss was admitted to the Hospital St Louis-enfants. He had a distended stomach, a palpable pyloric mass, and scant urine, but “his face was good, and he had a good cry.” The 0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2009.05.013
attending physician, Henry Dufour, and Dr Fredet decided to operate upon the baby before there was further malnutrition. An intern gave chloroform, and Dr Fredet carried out a double extramucosal pyloroplasty. There were 2 instructive intraoperative complications. The hugely distended stomach had to be emptied with a trocar, and the small intestine was eviscerated because of insufficient anesthesia. Dr Fredet learned to empty the stomach with a catheter before surgery and refined the anesthetic technique. This infant survived, and a month later, Dr Fredet operated upon another infant who also survived. On November 15, 1907, Dufour and Fredet [5] presented their work to the Societe Medicale des Hopitaux de Paris. “We have the honor to present to you an infant, now 3 months of age, diagnosed with hypertrophic pyloric stenosis, upon which Monsieur P. Fredet, surgeon of the hospitals, at the age of 2 months, performed a double submucous pyloroplasty, and who is now well.” Dr Fredet described the operation as follows: “With the stomach emptied, the pylorus is immediately recognized beneath the liver and grasped by the operator between the index finger and thumb. It gives the impression of a little tumor about the size of a cherry and extraordinarily hard. One considers a pyloroplasty, an operation which seems a priority, the easiest and least dangerous with an incision about 2 cm long on the axis of the pylorus in the middle of the superior aspect. This longitudinal incision carries through the peritoneum and the muscularis to the exclusion of the mucosa. The bistoury cuts a white tissue, edematous and very hard, creaking under the instrument, having every appearance of certain uterine myomas. The incision cuts entirely through the sphincter to a depth of several millimeters, and the lips of the wound are gently spread. A series of sutures of linen, placed according to the method of Heinecke and Mikulicz, transform a longitudinal wound into a transverse wound, a plastic procedure, which manifestly enlarges the pylorus. The sutures, to the number of 6 or 7, take the entire thickness of the muscle mass and are tied successively to avoid their cutting through. Then to attempt to obtain a still greater
Historical review enlargement of the pylorus, one attempts to repeat the same plastic procedure lower down on the anterior aspect. But the suture offers very great difficulties, and it is necessary to leave a little lozenge-like space without coverage, the threads cut as one attempts to approximate the 2 ends of the longitudinal incision.”
These 2 successes reflect the wisdom of an early operation and technique by Dr Fredet of extramucosal pyloromyotomy that avoided spillage of gastric contents and bleeding from the mucosa. He had learned from his earlier experience. In 1908, Dufour and Fredet [6] published a meticulous statistical analysis of 72 reports describing the 135 operations performed for pyloric stenosis before December 1907. The authors differentiated congenital pyloric atresia from stenosis by the asymptomatic period after birth and stressed the importance of forceful vomiting, using the term projectile. They noted the absence of bile in the vomitus, visible gastric peristalsis, and a palpable pyloric tumor. Dufour and Fredet [6] were among the first to recommend an early operation to avoid severe malnutrition. They also analyzed gastric contents to demonstrate the elevated chloride levels that later explained the metabolic alkalosis in babies with pyloric obstruction. In 1910, Fredet and Guillemot [7] reviewed the world's literature on pyloric stenosis, even to finding the report of Hezekiah Beardsley, an American physician, who described the clinical history and autopsy on a child with pyloric stenosis in 1788. They noted the increased incidence in males and stressed forceful vomiting, weight loss, oliguria, gastric hyperperistalsis, and the pyloric tumor. They also advocated gastric lavage to rule out the presence of bile and to determine hyperchlorhidria and hyperacidity. The authors illustrated the gross and microscopic appearance of the pyloric muscle and the infolded mucosa. They advocated reduced feedings, gastric lavage, and atropine, but if there was not a prompt response, surgery was indicated. Fredet again reviewed the various operations including his own extramucosal pyloroplasty. He mentioned Weber of Germany who had independently performed the same operation in 1908. Weber [8] gave Fredet credit for the operation, but the German literature gave priority to Weber. In 1912, Fredet and Guillemot [9] brought the literature review up-to-date, and Dr Fredet reported that the extra mucosal pyloroplasty could not be done if the pyloric muscle was too large. He said, “La gastroenterostomie a le grand avantage d'etre applicable a tous les cas, indistinctement.” This may have been because, in one case, he was unable to suture the muscle horizontally and performed a gastroenterostomy. The baby died. He evidently was still concerned about leaving the muscle open. During the First World War, Dr Fredet was a military surgeon and did not address pyloric stenosis again until 1921, when he reported 11 cases, 9 of which had gastroenterostomies [10]. In this article, he referred to the success of Ramstedt with a
1843 pyloromyotomy. Although Dr Fredet expressed confidence in his extramucosal pyloroplasty, he did not think it could be done when the pyloric mass was large, and he would not leave the mucosa exposed. In 1927, Dr Fredet [11] made another major contribution to the treatment of infants with pyloric stenosis. His opening sentence indicated his preference for pyloromyotomy. “La stenose hypertrophique est facilement curable par une operation simple. In la section du sphincter musculaire ou pylorotomie longitudinale extramuqeuse.” He had abandoned horizontal suturing of the muscle and left the mucosa exposed. In this article, he points out, possibly for the first time in the surgical literature, how to avoid perforation of the duodenal mucosa while at the same time sectioning all the muscular fibers. He illustrated the protrusion of the pyloric muscle beneath the duodenal mucosa and pointed out the inevitability of death after an unrecognized duodenal perforation. He used subcutaneous fluids (clysis), preoperative gastric lavage, and emphasized the importance of keeping the infant warm during surgery. Although many surgeons used a local anesthetic, Fredet preferred chloroform in “infinite doses” while incising the skin, replacing the stomach within the abdomen and closing the incision. The anesthetic was “suspended” at other times. After surgery, the infant was placed in a warm chamber, given more subcutaneous saline injections, and 2 hours after surgery, oral glucose was started. In this series of 25 pyloromyotomies, one baby with extreme cachexia died immediately after surgery. Another died with an intercurrent infection at 8 days. Dr Fredet demonstrated radiographs showing normal gastric emptying in his patients years after surgery. He also demonstrated, microscopically, how the pyloric muscle is reconstituted to normal after pyloromyotomy [12]. He also reported on the perfectly normal function of his first 2 patients operated upon in 1907, 32 years later [13]. The life of Pierre Fredet from 1870 to 1946 is all the more remarkable because it spanned periods of political unrest and 3 terrible wars between France and Germany. He was born in Clermont-Ferrand, where his father was a professor of medicine. At medical school in Paris, he won competitive examinations to become an extern and then an intern. After a year of military service, he returned to Paris to pursue a career in surgery as an intern to Felix Terrier. He learned asepsis with “inflexible rigor” and became a prosector in anatomy in 1898. His doctoral thesis was on the anatomy and surgical approaches to the uterine artery. These studies led to ligation of the uterine artery in cases of inoperable uterine cancer [14,15]. He did original anatomical and embryological research on the prepancreatic and mesocolic fascias, the formation of the renal capsules, and the terminal segment of the Wolffian duct in women. Dr Fredet also published on the pathologic anatomy of hernias and thyroglossal duct cysts. In the years following school and before the war, Fredet worked with Joseph Arrou, “an impeccable clinician and scrupulous operator.” It was
1844 during this period that Dr Fredet did his early work on pyloric stenosis. For 25 years, he was an associate or head of a department of surgery at the Charite and the Pitie hospitals. Dr Fredet was a true general surgeon who performed abdominal surgery, treated thoracic empyema, and developed new techniques for treating tuberculosis of the knee and fractures of the patella. He also published on the treatment of Dupuytren's contracture, articular foreign bodies, and missile injuries of the mediastinum. He was a precise surgeon and an exacting educator who said, “There are 2 categories of interns, the pests and the useless. Try to be only useless help.” When an intern demonstrated improvement, he would smile and say, “Well! Not bad progress!” [16]. At a meeting of the Society of Surgery in 1926, a fellow surgeon Victor Veau said, “In pediatric surgery, Fredet is the greatest benefactor of our generation” [17]. This remarkable man also adapted sterilizers to electric power, invented an inhalation device for chloroform, and anticipated modern anesthesia technique with a combination of preoperative sedation, intravenous barbiturates, and nitrous oxide. In addition to his hospital and surgical work, he labored to improve the health of railway workers. In 1929, he visited the United States to study industrial medicine. Pierre Fredet earned many rewards and honors, including the Legion of Honor for his surgical work during World War I and was elected to many professional societies. He was elected president of the National Society of Surgery, and in 1936 as the first president of the Academy of Surgery, he presided over the reestablishment of the Academy in the grand amphitheater of the Sorbonne. Even after his retirement from hospital practice, Dr Fredet made many contributions to surgery, anesthesia, and sterilization. He gave most of his presentations before the Academy of Surgery. In 1940, Dr Fredet moved to his property in the country where he remained with his family until the end of the War. He returned to Paris, became active in the Academies, and was elected president of the Society of Anesthesia. Sadly, he became ill and died on May 29, 1946. Wilhelm Weber of Dresden gave Fredet credit when he reported 2 babies operated upon with the extramucosal pyloroplasty in 1910. In 1911, Conrad Ramstedt [18] set out to do a “Fredet-Weber” partial pyloroplasty but was unable to suture the muscle. He left the mucosa exposed. This patient, and another operated upon with the same technique, survived. When he reported his operation in 1912, he did not mention the work of Fredet but attributed the operation to Weber. There were no references to the work of Fredet in the United States until Langley Porter and Lawson Tait gave him credit for his operation at a meeting of the American Medical Association in 1919 [19]. The “Ramstedt” operation, as it was known, was quickly adopted, especially in the United States. The operation was
Historical review introduced to the Babies Hospital in New York in 1914 and from then until 1920, 165 operations were performed with a 7.1% mortality. In infants operated upon within 4 weeks of the onset of symptoms, the mortality was less than 8%. Dr Downes gave Pierre Fredet credit for the essential features of the operation [20]. This delay in recognizing the work of Dr Fredet was likely due to Franco-German antagonism in the years leading up to World War I, and for Americans, German was the language of science and medicine at that time. Many American doctors took postgraduate courses in Germany, and as late as the 1940s, premedical students were advised to study German to read the medical literature. Thus, the work of Ramstedt became well-known in the United States. After the article by Dr Downes and with an increased understanding of the disturbances in fluid and electrolytes, the mortality rate for infants with pyloric stenosis decreased for the next 30 years to less than 1% in centers devoted to the care of children [21,22]. Today, the diagnosis is often made by ultrasonography within a day or two of the onset of symptoms and surgery performed by video-assisted laparoscopy. The essential step in the procedure, extramucosal separation of the pyloric muscle, is the same as that described by Pierre Fredet. We should now salute him for the extramucosal pyloromyotomy, his insistence on early operation, and his advice on avoiding duodenal perforation. He exhibited flexibility in his choice of operation and his advice on preoperative and postoperative care is as cogent today as a hundred years ago. The writings of Dr Fredet reflect rigorous honesty, and long before the days of computer searches, he meticulously researched and analyzed the surgical literature in 3 languages. With no more guidance than his writings, a few drops of chloroform, a scalpel, and a few hemostats, today's surgeons can successfully treat babies with pyloric stenosis—even when the electricity fails.
Acknowledgments Constance Smith, administrative secretary; Pr Michel Lacombe, librarian; Pr Bernard Launois, president; and Jacques Poilleux, editor-in-chief of the Academie Nationale De Chirugie, Paris, France, provided invaluable assistance with translation and biographic material about Pierre Fredet. Ronald Sims, Special Collections Librarian, Galter Health Sciences Library, Northwestern University, Chicago, IL, discovered many helpful articles in the literature.
John Raffensperger Northwestern University (emeritus) Children's Memorial Hospital Chicago, IL, USA (emeritus) E-mail address: [email protected]
Historical review
References [1] Mack C. A history of hypertrophic pyloric stenosis and its treatment. Bull Hist Med 1942;XII:465-485, 595-615, 666-689. [2] Hirschprung H. Falle Von Angeborener Pylorustenose, Beobachtet bei Sauglingen. Jahrb D Kindeh 1885;27:61-8. [3] Mack, p. 602. [4] Nicoll JH. Several patients from a further series of cases of congenital obstruction of the pylorus treated by operation. Glasgow MedicoChirurgical Journal 1906;2:65:253. [5] Dufour H, Fredet P. La Stenose Hypertrophique Du Pylore Chez le Nourrison Et Son Traitement Chirurgical. Bulletin et Memoires. Societe de Medecine De Paris 1907;24, 1221, 208-217. [6] DuFour H, Fredet P. La Stenose Hypertrophique Du Pylore Chez Le Nourrisson et son traitment chiruggical. Rev Chir 1908;37:208-53. [7] Fredet P, Guillemot L. La Stenose du Pylore par Hypertrophic musculaire Chez les Nourrissons. Ann Gynecol Obstet 1910;67: 604-29. [8] Weber W. Ueber einen Technische Neuerung bei der Operation der Pylorus Stenoses des Sauglings. Berlin Klin Wehschr 1910;47:763. [9] Fredet P, Guillemot L. La Stenose Du Pylore Par Hypertrophie Musculaire Chez Les Nourrissons. Congres National Periodique de Gynecologie, D'Obstetrique et De Pediatrie VI me Session. Toulouse, Septembre 1910 Memoires and Discussions: Publies Par J. Audebert.: Toulouse Imprimerie ed Librairie Edouard Privat 1912:242-323. [10] Fredet P, Pironneau P. La Stenose Hypertrophique du Pylore. Bull Mem Soc Natl Chir de Paris 1921;47:1021.
1845 [11] Fredet P. La Cure de la Stenose Hypertrophique du Pylore Chez les Nourrissons par la Pylorotomie—extra Muqueuse. J Chir 1927;T. XXIX(4):385-408. [12] Fredet P, Lesne E. Stenose Hypertrophique du Pylore chez les Nourrissons. Resultat anatomique de la Pylorotomie sur un Sujet Traite Gueri Depuis Trois Mois. Bull Mem Soc Chir 1928;32: 1050-60. [13] Mack, loc cit Page 673, Personal communication with Dr Pierre Fredet on Dec. 3, 1939. [14] Fredet P. Recherches sur les Arteres de l'uterus. Journal d'anatomie et de Physiologie 1898;34:79-122. [15] Fredet P, Hartman H. Resultats Eloignes des Ligatures Atrophiantes Faites dans deux cases de Cancer Inoperable de l'uterus. Societe de Chir Paris 1898;24:130-3. [16] Cerbonnet G. Pierre Fredet, 1870-1946. Dernier President de la Societe Nationale et Premier President de l'Academie de Chirurgie,. Chirugie [Memoires de l'Academi] 1986;112(1):13-26. [17] Cerbonnet, 24. [18] Ramstedt C. Zur Operation der Angeborenen Pylorusstenose. Med Klin 1912;1702. [19] Mack 668. [20] Downes WA. Congenital hypertrophic pyloric stenosis, review of one hundred and seventy five cases in which the Fredet-Ramstedt operation was performed. JAMA 1928;75:228-32. [21] Gross RE. The surgery of infancy and childhood. Philadelphia: W.B. Saunders; 1953. p. 143. [22] Potts WJ. The surgeon and the child. Philadelphia: W.B. Saunders Co.; 1958. p. 57.