History Of Pediatric Surgery
With Dr. Don Nakayama · hosted by Dr. Todd Ponsky
Part of
Pyloric Stenosis 10 items
Chapter 1 of 6 · Fundamentals
Halifax explosion
Introduction and the Halifax Explosion
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The Halifax explosion on December 6, 1917, marks the unofficial 100-year anniversary of pediatric surgery.
The Halifax explosion was the most powerful man-made blast until the Trinity atomic bomb test in 1945.
William Ladd organized a convoy of 40 physicians and nurses that reached Halifax 2 days after the blast and stayed for a month treating hundreds of children.
Ladd had already committed to pediatric surgery before the Halifax explosion, so the myth that Halifax inspired his career is not true.
The first smallpox vaccination in 1796 was given to an 8-year-old by Edward Jenner, a surgeon trained by John Hunter.
One of Crawford Long's first patients to receive ether anesthesia was a teenager with a finger amputation, at least a year before William Morton's demonstration.
Joseph Lister's first patient to receive carbolic acid in 1865 was a 7-year-old with a compound fracture; 4 of his first 11 patients reported in 1867 were children.
The first splenectomy for blunt trauma was performed on a 14-year-old laborer who had fallen from a scaffold and ruptured his spleen.
Pyloric stenosis was first described by Hezekiah Beardsley in 1788 and later by Harald Hirschsprung in Denmark in 1888.
Hirschsprung's first two pyloric stenosis cases were female infants, though the disease predominates in males.
Early physicians thought pyloric stenosis was due to pyloric spasm and treated it with belladonna and bicarbonate gastric lavage.
Early treatment included refeeding infants with their own vomited material.
Pierre Fredet in Paris was the first to describe projectile vomiting and visible peristalsis in pyloric stenosis.
The first operations for pyloric stenosis were gastroenterostomy and Heineke-Mikulicz pyloroplasty, adapted from adult operations for obstructing gastric cancer and peptic strictures.
Early pyloric stenosis operations had high mortality due to aspiration from open-drop ether in infants with full stomachs and gastric contents flooding the abdomen when the stomach was opened.
Pierre Fredet's innovation was the extramucosal pyloroplasty, staying outside the mucosa to avoid entering the stomach.
Fredet attempted to close the pyloromyotomy transversely in a Heineke-Mikulicz fashion and continued adding gastroenterostomy to most cases even 10 years after Ramstedt's operation.
Fredet achieved 17% mortality through preoperative gastric decompression, keeping babies warm, and giving fluids by clysis, compared to 50-60% mortality before.
Conrad Ramstedt in Munster, Germany, performed the first modern pyloromyotomy in 1911, four years after Fredet's operation.
Ramstedt's insight was to leave the pyloromyotomy open when he saw the channel gape after attempting transverse closure—'then the thought shot through my head.'
Pyloromyotomy has been described as the most consistently successful operation ever described.
Ramstedt's operation was slow to be adopted in England, only gaining acceptance in 1918 due to World War I.
In Hirschsprung disease, the megacolon is obvious but is not the cause—the cause is aganglionosis of the distal colon and anorectum.
Hirschsprung disease was described as early as the late 17th century; Harald Hirschsprung described it in 1886.
Aganglionosis in the myenteric plexus was first described in 1901, but its significance wasn't fully realized until the 1940s.
Between Hirschsprung's description and the 1940s, surgeons performed operations based on wrong pathophysiology, including colectomy, sigmoid straightening, and sympathectomy.
The first edition of Ladd and Gross's Abdominal Surgery of Infancy and Childhood included operative diagrams for left sympathectomy in children with impressive before-and-after pictures.
Mary Elizabeth Tiffin, a pathologist at Stanford, rediscovered the lack of ganglion cells in the myenteric plexus in 1940 in a patient with short-segment disease.
Orvar Swenson was hired by William Ladd to set up a research lab at Children's Hospital Boston and became interested in patients with megacolon who were dying.
Swenson performed a diverting colostomy on a patient he thought had inflammatory bowel disease; when the colostomy was closed, the child became obstructed again.
Swenson borrowed equipment from Sydney Farber to measure intestinal peristalsis and found active peristalsis above the colostomy but no contraction below it.
Swenson concluded the obstruction was functional, not mechanical, showing the physiological consequences of aganglionosis that Tiffin found pathologically.
Swenson's therapeutic key was to get the colon with peristalsis to the anus through a pull-through operation—essentially a very low anterior resection.
Swenson everted the rectum out the anus to complete the anastomosis outside the anus—a technical tour de force.
Swenson's second major contribution was making the diagnosis on barium enema using a lateral X-ray projection to show the transition zone, working with radiologist Edwin Neuhauser.
Swenson's third major contribution was the rectal biopsy—when his 6th patient remained obstructed, he said 'Well, hell, let's do a biopsy' and found no ganglion cells.
Robert E. Gross (REG) had a strained relationship with innovative young surgeons including Swenson and Hardy Hendren.
Gross opposed Swenson's pull-through operation, fearing urinary incontinence and sexual dysfunction from dissection around the rectum, and tried to take over Swenson's first patient.
Gross prohibited Swenson from doing rectal biopsies due to fear of pelvic infections; when Swenson did them anyway, he was out of a job within months.
Gross himself waited until Ladd was on vacation to perform his first PDA ligation, with Thomas Landman as acting surgeon-in-chief.
The Soave procedure (endorectal pull-through) was actually preceded by Sabiston and Ravitch's 1947 report of mucosal proctectomy in dogs for ulcerative colitis and familial polyposis.
Asa Yancey, an African American surgeon in Tuskegee, Alabama, performed an endorectal pull-through in an adult with Hirschsprung disease in 1952—11 years before Franco Soave's infant operation in Genoa, Italy.
The Duhamel procedure came in 1956, Keith Georgeson performed the first laparoscopic pull-through in 1995, and de la Torre in Mexico City did the first completely transanal pull-through in 1998.
Helen Tausig first approached Gross about doing a Blalock-Taussig shunt for tetralogy of Fallot.
Gross's PDA ligation took one hour in complete silence; the murmur was so loud it could almost be heard in the room, and it stopped after ligation.
The PDA operation was performed under open-drop ether by anesthetist Betty Lenk.
When Ladd asked Gross how things were at the hospital, Gross said 'nothing special'—he had only invented cardiac surgery during Ladd's absence.
Gross was briefly fired for insubordination and lying to Ladd; he was reinstated only after intercession by the hospital board.
Gross had already performed the Blalock-Taussig shunt operation in dogs as preparation for PDA ligation—anastomosing the left pulmonary artery to the aorta, letting it heal, then practicing ligating that fistula.
When Tausig proposed creating a shunt for blue babies, Gross refused, saying 'I'm in the business of ligating PDAs, not creating them'—one of the great 'what ifs' in surgical history.
Esophageal atresia with distal tracheoesophageal fistula has been known since the late 17th century, including associated cardiac, renal, and intestinal anomalies.
The first attempt to repair esophageal atresia was through upper midline laparotomy in 1888.
Joseph Brennemann in Chicago tried gastrostomy for esophageal atresia, but it flooded the lungs; jejunostomy had the same result.
Harry Richter, working with Brennemann, addressed the fistula through a right chest vertical paravertebral incision through the 6th interspace, resecting posterior ribs, using open-drop ether and a homemade pump for positive pressure—both patients died at 2 and 22 hours.
Richter freely admitted he didn't know the anatomy or what he was looking at during the 1913 operation.
A child with isolated esophageal atresia reported in 1935 had esophagostomy and gastrostomy and lived into late teens before being lost to follow-up.
William Ladd and Logan Leven divided the tracheoesophageal fistula, performed cutaneous esophagostomy, fed via gastrostomy, and constructed skin-lined tubes over the anterior chest through multiple staged operations.
Thomas Landman's 1940 review of 32 esophageal atresia cases from Children's Hospital—all fatalities—established that operation must be early (within days of birth), aspiration is always a threat, diagnosis can be made without oral contrast (by inability to pass a tube to the stomach), and air in the GI tract establishes distal fistula.
Many early esophageal atresia deaths were attributed to 'fluid overload' or 'injudicious fluid administration' because surgeons had no concept of maintenance fluids or resuscitation volumes for infants.
Landman's approach resected the 4th rib and posterior aspects of ribs above and below, staying extrapleural to confine leaks outside the pleural cavity—principles still used in open operations today.