History of Pediatric Surgery

Today we're going to try something different. For the past couple of years we've been putting out these audio chapters on high yield topics in pediatric surgery, but today I was in the mood for story time. I wanted to understand more about the history of pediatric surgery. This is the field that we do every day, and a lot of us don't know enough about what our origins were. So today we're going to hear about the history of pediatric surgery from Doctor Don Nakayama. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Ian Glenn, and Sophia Abdulhai and is recorded and produced at Akron Children's Hospital in Akron, Ohio. This is Todd Ponsky from Akron Children's Hospital, and today with state currents and pediatric surgery, we're going to be doing something a little different. Instead of focusing on disease processes, we're going to actually go into a little bit of history. And with us we have Dr. Don Nakayama, who is the adjunct professor of the Department of Surgery at the Herbert Wertheim School of Medicine at the Florida International University. Don, thanks for joining us. No problem, Todd. Glad to join you. This is going to be an interesting discussion. Yeah, I think so. I actually saw some of your posts on the ACS communities and I saw how much you knew about history and pediatric surgery, and I thought a lot of people would love to hear some of this. So, well, above all, it's fun. I think pediatric surgery's got a very rich history and it's, it's very entertaining. It's got a lot to say about the history of medicine in general. Yeah, absolutely, and unfortunately most of us practice every day without knowing that. So let's get into it. Don, talk to me about how did this field start. What was the origin of pediatric surgery? Actually it's interesting because 2017 it marks a 100 year anniversary of pediatric surgery. It's the unofficial birth of pediatric surgery because 1917 on December 6th, that was the year of the Halifax explosion. There was a massive blast in the Halifax Harbor that came about because of a collision between a French munition ship that was called the Mont Blanc. With a relief vessel that was called the Emo, and the sparks from the collision caused the fire to ignite on the deck of the of the Mont Blanc, which was the munition ship, and the fire on the deck attracted the attention of the people of Halifax, and all the windows in the house of Halifax faced the harbor, and all the windows were of plate glass. And so it was a it was a bright December morning and everyone was getting ready for work or going to school and they couldn't help but be drawn by the conflagration that was going on. And not being able to control the fire and knowing what the cargo was, the crew of the of the ship just abandoned ship. And they couldn't warn the people of Halifax because they were all French. They only spoke only French. When the inevitable happened and the and the munitions exploded, the explosion was so, so powerful that it leveled all the buildings in in a 2 square mile area, and it drained the harbor, and the, the water rushing back in caused a tsunami so large that it washed, washed away a good part of the city. It was so powerful that the 6 ton anchor of the Emo was found in a ruined building nearly 3 miles from the harbor. And so historians estimate that the blast was the most powerful man-made blast until the Trinity atomic bomb test explosion in 1945. So when that blast happened and all the people were at the windows, it killed thousands and it maimed thousands of others, including horrendous facial and eye injuries from the shards of glass going through the faces and eyes of the kids that were watching and utterly devastated the medical community there. And so a call came out almost immediately for relief, and one of the calls made it to Boston. And It was a 37-year-old surgeon named William Ladd who responded. Now Ladd had already found an interest in pediatric surgery some years before, after he had trained at Harvard, and he organized a convoy of 40 physicians and nurses to go through the winter. They had had a snowstorm at that time, and so they had to go by train, and they reached there only 2 days after the blast itself. And they set up shop at a ruined church that was still serviceable. They took care of the injured and took care of hundreds of kids. They stayed for a month during the December and January of the holiday season of the 1917 and 1918. So that was a kind of unofficial start and it as a myth grew because people started to say that that's where Ladd got his inspiration to go to pediatric surgery. And although that's a great story, it wasn't true. Ladd had already made the commitment to go into pediatric surgery before then, but it just shows the level of his commitment and that was something that Mary Fallon as president of the Of Absa last year talked about the need for Pediatric surgeons to be committed to the care of care of kids, particularly kids who have been injured, and it's a powerful message that continues today. It's a good story whether or not it's the truth, like you said, but I like it so. You know, you had mentioned to me and that children really have been a part of the history of surgery for a long time. Can you go through some examples that you were mentioning? Yeah, kids have always been part of the most famous events in medicine. Children happen to have been the first patients in a number of signal achievements, such as the first smallpox vaccination in 1796. That was an 8 year old that was immunized by Edward Jenner. Who was a surgeon who had been trained by John Hunter, I think that gets lost sometimes. One of the first patients to get anesthesia by Crawford Long was a was a teenager who had a finger amputation, and he was one of the first to get ether for anesthesia. Some years after James Venable received it by Crawford Long, but certainly at least a year before William Morton demonstrated ether at the ether dorm. The first patients to get carbolic acid from Joseph Lister in 1865 was a 7-year-old with a compound fracture, and 4 of his 1st 11 patients that was reported in 1867 were kids. Famously, the patient in the Eakins, the Gross clinic, showing Samuel Gross during an operation was probably a teenager with osteonecrosis after osteomyelitis. And then finally the first splenectomy for blunt trauma was a 14-year-old who had fallen from a scaffold. He was a laborer, interestingly enough. He was a kid who was working on a scaffold, and he ruptured his spleen and he got his spleen out, but that was the first time that someone recognized that that someone was about to die from a ruptured spleen, and they did an operation that saved his life. So the history of surgery is rich. With patients of childhood age, tell me how you became interested in surgical history, pediatric surgical history, because your wealth of knowledge is pretty impressive. How did I get interested in surgical history? I think it comes from just the fascination of how we got here. I think that there's a tremendous respect that you have for the pioneers and the dedication of people who who saw that kids were suffering and they needed to have some sort of surgical operation. And so they went ahead and just did it. They were, they were presented with a problem and it was obvious that they had. That the child or their patient had a surgical problem and needed a surgical operation and not knowing the stuff that we take for granted, such as endotracheal anesthesia, fluid resuscitation, antibiotics, a knowledge of anatomy, they just went ahead and did it and gradually by fits and starts. The discipline grew to where it is today, which is truly impressive, and I think that that says a lot about the dedication of the surgeons, the trust that parents had in the surgeons and the resilience of kids, and I think all those things are things that that attract us as pediatric surgeon to the field today. Yep, I agree. You know, we're, we're a small knit group. It's a very special feeling to feel part of it. And so we particularly should know about our history. It's a, it's a real, real fun thing to do and it's, and it's, and you have such a respect for a lot of the people who were true pioneers and some of them. Still go to the meetings and you could, you can, you can talk to them today and and and it's, it's a lot of fun just to, just to talk about how things were. Yep, absolutely. Well, let's, let's go into dive deep into a couple of disease processes that are particularly notable. Tell me about the history of pyloric stenosis. Well, pyloic stenosis is a good example of a pediatric operation that arose from modifications of adult surgery. It was first described of all places by an American named Hezekiah Beardsley in 1788, and then later by the almost ubiquitous Harald Hirschprung in Denmark in 1888. And it's interesting that his report is interesting because the first two cases were of female infants and everyone knows, of course, that the disease predominates in males. At first there was nothing they could do, right? They just, you know, you describe a kid because he dies and you dissect them out and you see that he's got pylaric stenosis, right? And so what they tried to do, of course, was just to sustain the infant over the 1st 6 months or so it took to resolve and, and, and most of them, of course, died long before. Their understanding about physiology was very rudimentary, and, and they thought that pyloric stenosis was due to pyloric spasm. And so they gave Belladonna. And they knew that the gastric secretions were acid, and so they tried to lavage the stomach with with bicarbonate. They understood that the kids were not going to survive unless they got nourishment. And so their solution was, of course, to refeed the kid with whatever the child had vomited. That was not a very appetizing task, but what else were we going to do? So this was, this was in the 1800s. So at this time, I mean, what diagnostic. Tests did they even have? Did they, what was the status of X-rays? X-rays hadn't been discovered until the 1870s, and even the first operations for oesophageal resia, which we can discuss later, they didn't have the benefit of X-rays. And so it was just kind of someone who had, who had a lot of experience and, and it was up to someone like who really had a knowledge and really was alert to the possibility of pylo stenosis was present. And we'll talk about Pierre Fride from Paris. He was a guy who just said, OK, this is what you see when you've got pyloric stenosis, because he had amassed enough experience with the, with the, with the condition that he recognized it as a disease of early infancy. That the kids had vomiting that was non bilious. He's he's the one that described projectile vomiting, the first person to use that term. He also said that you can see peristalsis, and he described that also. And so he had a good idea and good understanding, but that that only came after being first very interested in the topic and then actually kind of treating it, being the first to try to treat this thing and have the kids survive. So back in when this was first starting to get diagnosed. Talk to me about how they first started operating on these. The first surgeons who went in a serious way onto the GI tract were the surgeons of Billroth school in Vienna and other surgeons in Germany, and they were bold enough to go inside the abdomen and start operating on the intestinal tract, and that came about because of anesthesia, obviously, but also asepsis. They were confident enough that they weren't going to cause what they called surgical sepsis or hospitalism or just cause. You know, infection and death because that's what, that's what Lister was trying to combat in the 1860s. But as he got more experience with, with, with asepsis and success with asepsis, then they started to explore intra cavitary operations such as operation on the GI tract. And so they had to deal with adult conditions such as obstructing cancer of the pyloris and stomach and also peptic strictures of the pylorus. And so they devised operations in the late 1880s and 1890s for those for those conditions. And that's how you got gastroenterostomy and a pyloroplasty, particularly the Heineke-Miklitz pyloroplasty. And so it follows that the first operations for parlor stenosis would be those two operations, gastroenterostomy and the Heineke-Micowitz pyloroplasty. But there was a problem with that because, you know, kids just, they're babies, for one thing, they weren't resuscitated for another thing. They had a full stomach and you're trying to give them open drop ether and so aspiration was, I can't imagine a kid not aspirating under those sorts, those sorts of circumstances. And once they got into the abdomen, they had to open the stomach for either a gastroenterostomy or a pyloroplasty, and that caused all the contents of the stomach to flood the abdomen and that was of course was a disaster. And so it's it's impressive that they persisted despite the high mortality, but that's kind of the story of pediatric surgery. In pediatric surgical conditions is that they kind of soldiered on despite these horrific mortality rates. So they weren't wrong. I mean they were finding a pretty aggressive way of dealing with it, but the kids were dying. So how did it progress from there? So enter Pierre Verde, and he was in Paris and around the turn of the 19th and 20th century. And he was really credited with the extra mucosal pyloroplasty. His innovation was to stay outside the mucosa and not into the stomach, and that was pretty impressive because he understood enough to know that, OK, we're going to, we're going to have problems here if we enter the stomach. And so what he did was a longitudinal incision in the pylorus staying outside the mucosa. What he tried to do though was to close it transversely. In a Heineke Mikowitz fashion, and so although he was able to do that in a couple of cases, most of his cases he added a gastroenterostomy, and he continued to do that long after Ramstead showed that all he had to do was just pyloyotomy, such that of his 11 1st 11 patients up to 1921, about 10 years after Ramstead described his operation, his patients still got gastroostomy. It's a Amazing that he persisted despite seeing good results from Ramstead. I'm assuming Ramstead had good results incredible. Yeah, but for Day though had had a good understanding of pediatric conditions and what she had to do to keep these kids alive. Remember we had about a 50 or 65% mortality with parlarmyotomy. He was In some ways, the first complete pediatric surgeon treating the whole patient because he knew that care before and during surgery was important. And so he knew that she had to have preoperative gastric decompression that he did with a catheter. He knew that she had to keep the baby warm during and after surgery, and then he knew that the baby was that dehydration was a problem. And so he, he gave the kids fluids by lysis. Now they had no idea how much fluid to give and lysis is always a problem. But the bottom line is that his mortality was 17%, which is much improved over the 50 to 60% that you saw before, right? And what's incredible was he wasn't really doing much of a different operation. He was still doing the gastroenterostomy but had a substantial. Yeah, so it shows the other stuff. So F, Fy's operation was, was reported in 1907, and some 4 years later, Conrad Ramstead did the first modern pylomyotomy, and he was in Munster in Westphalia in Germany, and it's interesting to hear to read these reports because his first patient was a nobleman's son, and so he was pretty nervous about what was going on. And like the commercial says, you know, he, he read about it and so he tried to do it and he tried to pyloroplasty, stayed extra mucosal and he tried to close it transversely, but everyone who does pyloyotomies know that most of the time that's not possible. And it was too stiff to do that. And, but then he saw that the channel gaped open and in one of the, one of the great quotes of pediatric surgery was, then the thought shot through my head. He had one of the great insights. And then he knew that that was the way to do the operation, just leave it open and not try to close it. And of course the baby did well. That's amazing. And so what had a uniform mortality got to be a tremendously popular operation and the surgeon in the US adopted very quickly. And got a series of 20-30 patients very quickly. It's interesting though that it was slow to catch on in England because that was the time of World War I and the operation only got adopted in Great Britain in 1918. But since then it's been described as the most consistently successful operation ever described, and I think, I think that's absolutely true. You know, this hits on an interesting point. So you can sure predict that when he told his partners, he left it open. They probably all thought he was crazy and that's probably a common theme that, you know, these guys who are the most innovative were also the ones who were the craziest. Yeah, Frida Ferday was very nervous about leaving the submucosa exposed, and that's the reason why he, he had to add a gastroenterostomy to it. Yeah, well, it's fascinating. So back then, It probably took quite a bit longer for innovations to make their way to the public. We didn't have social media back then, right, right. It took 4 years. It took 4 years for that to occur. And, and, and you'll see that in situations where X-ray would, would, would make sense. It took decades. For radiology to mature such that X-rays could be used for diagnostic purposes to advantage in pediatric surgical conditions. It's incredible. All right, well, let's go to another one. Talk to me about Hirschprung's disease. OK, Hirschsprung's disease is interesting because the lesion in polar stenosis is obvious, OK, and the operation is apparent. In Hirschprung's disease, the lesion seems obvious, the megacolon, but it really isn't the cause of the disease. Which is a ganginosis of the distal colon and anal rectum. It was an impressive disease, I guess, back in the day when, when, when kids died of it because the morbid anatomy is easy to recognize. It was described as early as the late 17th century, and Harold Hirschprungs only described it much later in 1886, but he had, he had, you know, he had branding, I guess we could say today. And he had the disease named after him. A gangnosis itself, the property of not having ganglion cells in myenteric plexus, wasn't described until 1901, but its significance wasn't fully realized until the 1940s, and that's, that's the error that we find over Swenson. So yeah, it's really, it really isn't when you think about things. So in the time between Hirschprung's description and the 1940s. OK, there are no lack of operations, but the surgeons were just plain wrong about the pathophysiology. And so the first operations, of course, is to remove the colon. Some people thought that was kinking of the sigmoid, that was the culprit, and so they tried to straighten out the sigmoid. And then one of the more enduring operations up to the point of Swenson was sympathectomy, and people understood that the autonomic nervous system might be somehow involved. And so they advocated sympathectomy. And then if you take a look at the first edition of Ladd and Gross's book Abdominal Surgery of Infancy and Childhood, they've got great operative diagrams on how to do a left sympathectomy in kids, and they have a very impressive before and after. Pictures of a child who's distended before the operation and whose abdomen is scaphoid after the operation, and the implication is, OK, you do a sympathectomy and you see reports of kids undergoing emergency sympathectomies because of colonic obstruction. And so that to me is interesting that you know the authorities are so confident that sympathectomy works, but obviously it was, it was, it was, it was just plain wrong, right? I'm surprised they got a scaphoid abdomen after doing it. Yeah, I wonder what they're operating. They got a worm leg, but now you still can't poop, so. That's amazing. So the role of the myenteric plexus just took time, and it was the first description was 1901, but people said that's that's that's not right because here's here's another kid who's got the same phenotype that is constipation and he's got ganglion cells, but of course that child didn't have Hirschmann's disease at all or had short segment Hirschmann's disease and just didn't sample the right right segment for your for your biopsy. And so there's a lot of confusion about what was, what was going on until it was rediscovered in 1940 by a pathologist named Mary Elizabeth Tiffin, and up to now we're all just talking about Vienna and and and and and Germany and Boston and Hopkins. But now we go to the left coast and to an institution that is a little closer to my heart, Stanford. And she described the lack of gangon cells in the myoteric plexus in a patient with short segment disease. And so they correctly surmised that a functional obstruction was the cause and and that set the stage for Ovo Swenson and Swenson's story is very interesting because he had been hired by William Ladd to set up a research lab at the Children's Hospital in Boston and one of the first things he became interested in was patients with megacolon who are dying with no effective treatment. And so he was puzzling about that and what to do about those patients. He actually had a patient who he thought had inflammatory bowel disease did a did a diverting colostomy for for Bega colon, and the kid did so well that they thought that the inflammatory bowel disease had resolved. And so they closed the stone and the kid became obstructed again. And so Swenson is a real hero and pediatric surgeon in many respects, but mostly because of his great insight into this disease, obviously. He borrowed equipment to measure intestinal peristalsis from Sydney Farber. And Farber's name is famous, of course, for his research in cancer chemotherapy as a pathologist at the Children's Hospital, but he had this equipment and he loaned it to Swenson, and Swenson found that when he tested the colon above the colostomy, he had active peristalsis, and when he did the same thing to the colon below the colostomy, it didn't contract. And so he concluded. That the obstruction was functional and not mechanical, and he showed the physiological consequences of not having ganglion cells in the distal colon. In other words, he showed the physiological consequences of what Mary Elizabeth Tiffin found pathologically. Is there really a peristalsis issue, or is it, well, you know, it's just, it just doesn't, doesn't move, doesn't work. So it's the distal part, yeah, so that's the pure genius of it. The pure genius to Swenson was a clear what had to be done. He had to, he had to address the distal colon. And the therapeutic key was to get the colon that has peristalsis to the anus. And the next great innovation is the Swenson procedure, and it was a pull-through operation and what he said was it's basically it's a low anterior section, a very, very, very low anterior section. And in order to get low enough in his mind, and this is really outstanding. He decided to avert the rectum out the anus and then complete the anastomosis outside the anus. Yeah. And that was, that was, that was a technical tour de force, but that's exactly what the kid needed and, and his first patients did fine. So the other things that he had, he had two other major contributions to the disease. The first was making a diagnosis on barium enema. OK, but what he recognized is that the standard AP projection. Projected the sigmoid right on top of the rectum and that was useless. What he asked Edwin. Neuhauser, who's a radiologist at the Children's Hospital, who by the way, was a guy who worked on radiotherapy with gross on Wilm's tumor, what he wanted, what Swenson prevailed on him to do was do a lateral X-ray, and that showed the transition zone, and that's how they made a diagnosis. The other, the third major, or probably innumerable, but the 3rd major contribution that Swenson had was the biopsy because of his 1st 6 patients, 5 of them did fine. But the 6th 1 was still obstructed, and he wanted to know why and he said, Well, let's do a biopsy. OK, let's do a biopsy. And I think another great quote in pediatric surgery was, I think, was with Swenson's he says, Well, hell, let's do a biopsy. And that's what he did. So he found out that there are no gangon cells, and then he resolved that not only was it useful there, but it's useful in terms of verifying that you're going to have a functioning stoma and that you're going to have a functioning pull through. And that could be used for for diagnosis as well. Unbelievable. Yeah, it's crazy. The guy is, if you, if you read about there's an oral history on the American Academy of Pediatrics website. It's very entertaining because it's just it's very, very chatty and and he's a, he's, he was a raconteur. So what happened then? So after he made these innovative discoveries, how was he perceived or how was it received by his colleagues? Well, REG, or what the children's called gross REG, he had, he had a strained relationship with this very, very innovative young surgeon, and Swenson was one. Hardy Hendris another, and that's, that's another story that's separately told. But, but he just couldn't stand a young surgeon being famous, even though it reflect greatly on on the Children's Hospital. He developed a feud with REG and The ladd had retired soon after he had recruited Swenson and so Swenson was really unprotected. And so Gross opposed the pull through operation to try to take over his first patient because he was afraid that the operation itself was unsound because of all the dissection around the pull through rectum. And so he was worried that the patients were going to have urinary incontinence and sexual dysfunction and the mother. Of the child who Swenson was going to operate on refused to have Gross take over the care. And so Swenson went ahead and did the operation. The kid did well. When Swenson wanted to do a rectal biopsy, REG was, was opposed to that too, and he prohibited him from doing the operation because he was afraid of. Of infections and pelvic infections. And so when when Swenson went ahead and just did it, you know, which is, which is basically what what these great surgeons did. And interestingly enough, there's another side. That's what Gross himself did when he did his first PDA, right? He wait until Ladd was on vacation, then he did the PDA. Is that a true story, by the way? Oh yeah, it's absolutely true. Yeah, it's totally true. And the backstory of that that feud was that Gross waited until Ladd was on vacation. And the acting surgeon in chief was Thomas Landman, who was, who was at the Boston Children's Hospital surgeon who was so involved with esophageal ressure repair. At any rate, so what happened was Swenson went ahead and did his operations, did his biopsies, did his pull-throughs, and then within months was out of a job. And so that's why a lot of the early, well, most of the early reports from Swenson switches over abruptly from the Children's Hospital and Harvard Medical School to a floating hospital for children. And Tufts University Medical School unbelievable in Boston also. So the next edition of Surgery of Infancy and Childhood that was that was solely edited or solely written by Robert E. Gross, lad having been retired and them not being in speaking terms because of all the feud between them on the PDA ligation kind of story. Uh, he actually says that Swenson did outstanding work and the diagrams are of Swenson's procedure, but he, he, he gave attribution to the barium enema, the lateral view of barium enema to Neuhauser, and he doesn't mention that at all doing biopsies. So you know, a lot of people are now moving to or perform the suave procedure, and I think it was Keith Jorgeson where Swenson said to him, thank you for re refinding the Swenson procedure, because a lot of people are now going back to the Swenson procedure. So even today it's still becoming one of the preferred procedures. Yes, yes, as a matter of fact, in our own practice down here in Pensacola, Florida, we still do a swabbe procedure for the infant Hirschberg's disease, but We are gradually doing more of these, particularly for salvage operations for Hirschhorn's disease, and we find there's always something, some kid that will benefit from a Swenson procedure. But actually the history of the Swabee procedure actually predates Swenson's article because David Sabaston and Mark Ravich from Hopkins devised a pull-through operation where in dogs they they intended to take out the mucosa and pull through the ileum. During anastomosis and they reported that in 1947, and they intended that for ulcerative colitis and familial polyposis. And that was 2 years before Swenson's report. And then, and then 3 years after Swenson's article. The same operation, a mucosal procectomy, staying within the within the rectal tube and pulling through the ganglion segment of colon disease was actually done in an adult by Asa Yancey, who is an African American surgeon in Tuskegee, Alabama, and that was in a patient, adult patient who had Hirschbung's disease. And that was 11 years before Franco Suave did his infant epididymis operation of an endorectal pull-through. In Genoa, Italy, and so that's the story behind the Suave procedure. The Duomel procedure came sometime later in 1956. That's 4 years later, and then Keith Jorgeson did it laparoscopically, not surprisingly, in 1995 when he started to push the frontiers of laparoscopic surgery in infancy. And then redispense with the intraabdominal part entirely in 1998 when de la Torre in Mexico City did the first completely trans anal pull through in that year in 1998. So Hirschberg's disease is a great example of continuing improvement of procedures and techniques over time. It's incredible. That's another history, a great story. It's a wonderful story. Can you tell me in brief again the story of the PDA? Well, the PDA is interesting because people understood that kids were dying from a patent ductus arteriosis. They knew that, you know, and this is before they were able to make the diagnosis. This is just based on clinical diagnosis. And it was a machinery murmur, right, and the kids started to have gradual cardiac failure and, and people understood that there was going to be problems with cardiac failure early on and later on with endocarditis. And it was, you know, the great diagnostician Helen Tausig, who first approached Gross about doing a Blalock Tausig shunt. But that goes to show you, you know, the diagnostic skills of these of these early pediatricians and cardiologists. They knew that they had a problem with PDA, and surgeons knew from way back around the turn of the 19th century, then the early 1900s that the PDA was accessible. They knew that it was just, just, just a simple thoracotomy way and it's often isolated. And so people were all primed to do it and some of the great surgeons in history. were ready to do it. And that included Everts Graham, OK, Chair of Surgery at Washington University of St. Louis. And when he approached the Department of Pediatrics for getting a suitable candidate, what he got was like a 50 year old guy who was in cardiac failure. And so that's, that's how little they thought of surgery. That's how little the pediatricians thought the potential of surgery at the time. And so it really took a real good partner in pediatric cardiology. And Robert Gross found him and John Hubbard, who had trained with them. They're fellows together, John Hubbard in cardiology and Robert Gross in surgery. And so they, they had the kind of friendship that that you have when you're fellows together, right? And so they agreed that this was a solution for a patent duct seriosis, and you need to have someone who was healthy enough to withstand the operation because There had been previous attempts before, but all the patients that they had tried were adults who were in cardiac failure or had rip roaring endocarditis. And so they had people who were dying from the surgery, and people were afraid of the surgery. And as was William Ladd, who, when Gross proposed the operation that he do the operation, absolutely forbid him to do it. He said no. And so what they did was they wait until Ladd decided to go on his usual August holiday. And they waited and they and and he went on holiday and then he asked permission from Thomas Landman. A who was in charge during Ladd's absence and they got the go ahead to do the operation and so that was a that was a story on that and And if you've done the operation for PDA, you know how precious it is because a suture can easily cut through the PDA. And so it was, it was a great hazard to not only to the patient, of course, but the gross's career because that easily could have been a disaster, but it, but it worked. God, the courage of those guys is just unbelievable. And so what happened was this the operation itself took just just an hour and they said it was in complete silence. They said that you could almost hear the murmur. In the room because it was so loud and after he tied it off, then the murmur stopped, they had a special stethoscope that they, I guess, had sterilized or maybe in a baggie or something, so they confirmed that it was that that the fistula had been ligated. And they closed and that was that. And that was also under Open Drop ether too by anesthetist, Betty Lank, L E N K, and she, she was the expert anesthetist there. And, and that was, that was that. And, and it was a success. And so Gross happened to go to the, I think it was a cricket club or maybe, maybe the polo club, something very high tone in New England. And he happened to run into Ladd and Ladd said, how are things at the at the hospital? And then Gross said, well, nothing special. And Ladd I'm sure said, OK, fine. And then found out that Gross had been insubordinate during his absence and in fact had lied that he had that nothing much had happened. He'd only invented cardiac surgery during his absence. He, for a little while there, he was, he was, he was also fired, OK. And it was only after intercession by the hospital board that he was reinstated. And so that was one of the great things. It was groundbreaking and Gross became justifiedly famous for it, but Helen Tausig heard about it and she went to Boston and heard him speak on it. And then she said, you know, if we just created a a fistula. Wouldn't this be palliative for blue babies and tetrology below and would you, would you be willing to try it? And so Gross had actually done the operation, the blala tossic shunt in preparation for his PE ligation because in dogs he anastomos the pulmonary artery, left pulmonary artery to the aorta, let it heal, and then he practiced doing that operation of ligating that particular fistula. And so that operation, that, that experimental prepping the dog. was the same operation that Vivian Thomas had done for Alfred Blaylock in preparation for the Blue Baby operation. Unbelievable. That movie Something the Lord Made is probably one of my all-time favorite movies. It is me too. Me too. It's, it's, it's, it's a favorite. It never fails to choke me up. And, and what happens is that Helen Tausig goes up to Gross and says, can you do this operation? He says, well, yeah, actually I've done it many times in dogs. But I'm not, I'm not about to do it because I'm in the business of ligating PDAs. I'm not in the business of creating them. And it's one of the great what ifs in surgical history is that, you know, it grows, the psychological flaw that made him what he is, the great man that he is, made it impossible for him to see that this was going to be the next great cardiac operation and in fact it was. And that's what made Tausig propose it to. Vivian Thomas and Alfred Blaylock some years later in Hopkins. So unbelievable. That's a remarkable story. What was the relationship like between Gross and Ladd, especially after that whole episode? Oh, they didn't talk to each other. Gross became the William Ladd Professor of Surgery. But the next edition of Vlad and Gross was just plain gross, and it was, it was frosty to say the least. It was just, there's no repairing it. And it turned out that Gross was, you know, was, was not good to his, uh, it wasn't a mentee relationship. He was just subordinates and Swenson's one, Hardy, Hardy Hendris another. And really drove both those guys out of the Children's Hospital to different institutions in Boston. Unbelievable. Yeah, it is unbelievable. It's crazy. The last thing I want to talk about, at least today, because I could go on like this forever, is esophageal atresia, one of the real defining operations for a pediatric surgeon. How did all this get started? Well, the most common pattern, paroxyal esophageal atresia and distal tricusa fistula have been known since late 17th century. It was just, you know, it's the most common thing we encounter. And the ancients knew about it and they also knew about the associated cardiac and renal anomalies too and the various intestinal treatures that were associated, but it was a lethal combination, obviously, the esophageal trusion tris off your fistula, and it had to wait until, until the rest of the surgical, uh, the surgical disciplines caught up, such as anesthesia and then thoracic surgery, and then the, the willingness to operate aggressively in the immediate postnatal period, right, in the early newborn period. Also they had to realize. That the palliative operations weren't going to work. And so all those had to kind of come together and that's why it's it's late in our, in our timeline. The first attempt was through an upper midline laparotomy and that was done in 1888 and that just wasn't going to work. OK. But the doctors knew that somehow the kid had to be fed and so Joseph Brenham in Chicago. Tried a gastrostomy and that flooded the lungs and the kids aspirated and died. And then they tried a Janostomy and the same thing happened. And so Brennan's associate, a guy named Harry Richter, uh working with Brennaman in Chicago, addressed the fistul itself. And so his operation incorporated a lot of the elements that we use today. He, he went through a right chest, only he went through a vertical paravertebral incision. He went through the sixth inner space. He resected the posterior parts of the ribs. And then using again open drop ether, they held the lung over with an assistant's finger while they kind of probed around and tried to find the various ends of the esophagus and and the tracheoesophageal fistula, and they knew that somehow they had to keep the lungs inflated, so they had, they had a homemade pump to pump air into the lungs. It wasn't a ventilator at all, but it was just some homemade pump that just kind of held things in positive pressure. And so it wasn't surprising that kids died, OK, 2 and 22 hours later. Uh, the other thing was is that he freely admitted that he didn't know the anatomy or what he was looking at. And so there's a certain amount of expertise that had to be developed before anything was going to be successful. And so this is 1913. Now there are still long-term survivors, OK, in the 1930s, and there was a kid with an isolated esophageal resia that was reported in 1935 that had esophagostomy and had a gastrostomy and lived into his teens, late teens, and then it was lost to follow up, obviously. And then William Ladd in Boston, Logan Levin in Minneapolis began to divide the trisos your fistula, OK, and then do a cutaneous esophagostomy. Makes sense. And then they fed the kid with a gastrostomy and then they construct these skin lined tubes over the kid's anterior chest. And through multiple staged operations created these tubes. Over the kid's anterior chest, and that's what you see in a lot of the textbooks is this is what you know people used to do for oesophagealresion when in point of fact, it was only in Levin's Levin's and Ladd's cases and it was just a handful of cases, but it's sufficiently frightening and hideous to see and, and, and, and remarkable insofar as that that's what people were kind of reduced to doing at the time. So it's obvious that that something had to be done that was more definitive and that was what they were doing at the children's hospital. And at the University of Michigan during the 1930s and 1940s. And I think one of the great papers of pediatric surgery was Thomas Landman's 1940 review of 32 cases from the Children's Hospital, and they're all fatalities, you know, and it takes, it says a lot, and it's kind of still in that chatty kind of case report style that typifies a lot of the early literature, you know, that that's the script of every detail, kind of like a bad Eminem conference. And he describes what they learned, OK, and they were all lots of deaths and a lot of screwy operations, but what they learned was that you had to operate early, certainly within days of birth, and and they grew to be very comfortable doing that. They knew that aspiration was always a threat and that delay only caused more malnourishment, dehydration, and pneumonia, and they had to do that before the kid got sicker. They understood that you could make the diagnosis without giving oral contrast. Giving oral contrast meant that You risked aspiration, but they said you didn't need to do that, and, and they, they knew that just putting a tube down, not being able to pass a nasogastric tube or an oral gastric tube all the way down into the stomach made the diagnosis of esophageal resia, and that if you had air in the GI tract, then that established the presence of a distal tracheoal fistula. In 2017 we're doing the same thing. That's great, isn't it? We're so we're so advanced. And then the thing that that that that you see a lot of is that kids died of what they called fluid overload, injudicious fluid administration. I'm sure that that probably happened because they had no concept of what maintenance was or what fluid resuscitation was. Something we take, take for granted, you know, the 150/20 formulas, the 421 formulas that we use routinely now is just back then they had kids who were always dehydrated for one thing. The second thing was that they had crisis for gosh sakes. And then the IV therapy was just starting and they didn't know, they had no idea what normal volumes were for infancy and so they had to kind of feel their way around that. So it was a it was a real pioneering experience. What they knew didn't work though was anything that was palliative wasn't going to work like gastroscopy and janoscopy. They knew that from before, but also very, very what we would think of as screwy operations, but kind of born out of desperation really. And associated with some of the great names of surgery like Alton Oxford advocated just a vision of the cardia. All right. What ladd did was they divided the te fish to the fine, but then they exteriorized the distal esophageal segment off the kid's back so they could feed it to the kid's back, and you're going, holy Moses, you know, that's that's, that's, that's the kind of stuff that they were trying to do, and you can only imagine, imagine what's going on. Finally though. Landman and colleagues decided that they should just go ahead and repair the thing, OK, early in the newborn period, and the approach that they came up with is, is again one of several of the concepts we still use today. Except that we don't resect the 4th rib, we go through the inner space, but they resect the 4th rib. And then they resected the ribs above and below the posterior aspects, and they tried to stay extra plural because this remembers the day before antibiotics. And so they want to confine any leaks outside the portal cavity and, and that's the certain principles that we continue today and open open operations. So he tried that and he actually had two kids survive for 8 and 9 days. OK. And to him that meant that, you know, at some point someone was going to succeed. It was just a question of who was going to succeed first. It's unbelievable. And so it was Cameron Hay. Talk about getting scooped. Cameron Hayton and Arbor. Had the first survivor and that was in 1941, 1 year after Landman's report, OK. And he had done 15 cases and this was his only survivor. It was number 10 in a series of 15. And she was a she was a survivor. You know, everything that you read about this girl shows that she was going to survive. She was 12 days old, but she was in decent shape. She had the good fortune to be taken care of by a pediatrician who actually gave her an IV and gave her enough fluids and that she was in good shape as far as hydration. And they hadn't read Landman's article, so they'd done a bear and swallow. And the baby aspirated, but she didn't get pneumonia. And so you kind of get the idea that this kid was going to be indestructible and indeed, as you hear later, the kid indeed was. And so they did the operation. They went ahead and did the operation and it's truly impressive how they did it. They did it under local anesthesia and it was supplemented with open drop either to allow mobilization of the esophagus and the trachea. So the kid was always breathing, the thing was always moving. And they did the operation with the baby prone, but they used the left chest. They did a vertical paravertebral incision, not intercostal. They removed the posterior segments of ribs 2 through 6 and went through that vertical exposure and then. The diagrams show that the entire field's in view. They didn't have the entire field. They had to shift the retraction here and there just so they could do the operation. And so it must have been maddening because they had to go around the aorta. They had to go around the subclavian because they were on the left side and they did the operation. And then just to show that antibiotics cures everything they give the kid after the operation, rectal sulfathiazole. We kind of scoff at the antibiotics being given after the operation and not before the incision. They give a rectal sulfaiazole and say, OK, great, we gave you antibiotics. OK, fine. And so technically after they were done, they were satisfied. They said, well, you know, this thing might work. And, and as it turns out, the kids survived, but Cameron Hay, not only having done the first survival, long term survivor of esophageal seizure repair with distal strikes or fistula, uh, he got to experience all the complications first as well, right? So. So the saliva appeared in the drain, OK, a few days after the operation, and so he got to experience that, oh shit, there's saliva in my drain. And so they put a gastrostomy and then they fed the kids with a gastrostomy and then feeding started to come out from the gastrostomy out the drain itself. And so what they did is, cripes, what should we do? And so they tried to probe the anastomosis by passing a catheter in the kid's mouth and it comes out the kid's wound. And so you know you can say, OK, how much more can we foul this thing up? And so it's it's one of those things where you just got to shake your head and say, oh man, you guys are insane. So at 3 weeks, the baby burps some evaporated milk and so that tells them that the anasmosis is open and that like all things in surgery, sometimes it's better to be lucky than good. And they got a contrast study and showed that the anastomos was opened and the leak had sealed, and so they started oral feedings and so the only oesophageal complication that they had was a stricture at age 17 months, but aside from that, the kid did well. And so obviously he's got great attachment to the patient herself, this little girl, and he has a photo of her in his presidential address to the American Association of Thoracic Surgery that he gave in 1957 when she was, she was a young teenager. And then legend has it that she was the last patient that he saw before he died in 1970. And so it was, uh, it was one of those, you know, yet another one of those things that you get from pediatric surgery is that you get a patient for life, right? And that's one of the great satisfactions that we get in our field. What's incredible is a lot of people would stop after the first death. You know, they had 10, right? Case number 10. Well, case number 10, and they had 5 more deaths after that. And so of the first between Landman and Haight, they had 47 deaths and 1 survivor. And from that you go to, if you don't have, you know, extreme prematurity, you don't have cardiac disease, you don't have a major chromosomal problem, you're going to have close to 100%, 100% survival. And there's not a lot of things to thank for that. One is that you've got a tremendous maturation of the field itself, and you've got technically superb pediatric surgeons now who do amazing things with infant care, with infant surgery, with infant minimally invasive surgery, and then you've got the corresponding maturation of every one of the people that we depend on in neonatology and anesthesiology and pediatric critical care. And so it's a real testament to our field as a whole and where we are going with this. It's, it's absolutely incredible. I mean, Back then they used their postmortem to figure out what to do next time. Exactly right. And it may not happen in months, but it might, it might happen tomorrow. And so they're ready, and I think that says something about, you know, the faculty at places like University of Michigan and the Children's Hospital and now we have in dozens of centers across the country right now, you know, esophageal atresia has been called the epitome of modern surgery, and, and it shows why. The history of pediatric surgery is so important because it shows how the best motivations of medicine have evolved because you're dedicated to the craft, using the craft to save lives. Despite something that has 100% mortality and you've had 32 failures. You go ahead and keep on working on it until you figure it out and then you rely on on the expertise of people who who you regard as colleagues in all branches of medicine like anesthesia and neonatology and critical care and genetics and oncology now to really, you know, improve the entire field so that you've got kids that are surviving with cancer who never survived before, just not, not more than, you know, half a lifetime for most of us. And it shows you why pediatric surgery is such a wonderful discipline. I have to tell you, Don, this has been so fun for me. I love history, but especially knowing about my own field, and I think that the common theme here is you've got to push and not be complacent. You think about where we are now, we're going to look back and say, wow, can you believe how we used to treat appendicitis or pyelonidal disease? We're we're still bad at those pure aresia, pure esophageal atresia. And without someone being a little crazy and out there and being a cowboy, we're never going to advance. So it's a, it's a tough balance between doing what's safe and what you know, but also trying to push the envelope a little bit. And the great thing about ABSA is that all these guys, they're kind of dying out now, but, but some of these guys are still alive, and I think that in a lot of ways it's time to say thank you, you know, they were the forerunners, they're the guys who ran interference, and they're the ones, they're the ones who You know, to call for Cincinnati, you know what I mean, to call for Pittsburgh, to call for Baltimore, and without complaint really, and, and, and, well, I'm sure that they've had their dark moments, but had that kind of dedication to children's surgery that that it took to really get the field to mature and, and have the field come to full flower that we that we enjoy today. Yeah, absolutely. Well, I hope maybe periodically we can do this again. I know there are a lot of other stories I would love to hear and actually a lot of the senior surgeons at ABSA that you mentioned, I would love to hear more about their history. And so I have to tell you, thank you so much for for sharing this with us, and I'm sure this will be a nice treat, a little story time for everyone, and we really should know more of our history. So thank you again for spending the time. Todd, thanks for having me. I appreciate it very much. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.