One hundred years ago surgery at Children's Hospital was most often involved in the care of bone and joint tuberculosis. Appendicitis, which later became so common, was rare, having been only recently described by Reginald Fitz at the Massachusetts General Hospital. Almost none of the pediatric surgical problems that we see today were a part of the program at Children's Hospital.
From its early beginnings on Rutland Street (1869–1870) and Washington Street (1870–1882) Children's was a hospital of about 100 beds on Huntington Avenue from 1882 to 1914, near the present location of Symphony Hall. The hospital then moved in 1914 to its present location on Longwood Avenue, next to the Harvard Medical School. Cows were pastured across the street to provide bovine-tuberculosis free milk to the children in the hospital. Surgery as we know it today really began with Dr William E. Ladd, who joined the staff as a volunteer surgeon in 1910. Originally he also practiced gynecology. During World War I, an enormous explosion of an ammunition ship occurred in Halifax Harbor. Many children were injured. He was among the volunteer surgeons who went to Halifax. He then made the decision to practice only pediatric surgery, having been involved in the care of many of those injured children.
Dr Ladd studied the various surgical problems of infants and children and meticulously analyzed the results of their treatment. He was the first to save a child with esophageal atresia. In 1941 he emphasized that children should not be treated as little adults, that their problems are different and that the best care for children is given by those who make it their life's work. He recommended to the newly organized American Board of Surgery that there be established a means for certifying those surgeons with special interest in children. That recommendation did not come to fruition for 33 years!
A genealogy of pediatric surgery in North America was compiled recently by our colleagues, Dr Philip Click and Dr Richard Azizkhan at Children's Hospital in Buffalo, New York. This will be published in the near future. They noted that 85% of pediatric surgeons in North America and 68% of the training directors in pediatric surgery have a direct line of decent from Dr Ladd. On a personal note, when I started the Division of Pediatric Surgery at the Massachusetts General Hospital in 1960, it was a great honor to have Dr Ladd come to grand rounds as the discusser of my first infant with esophageal atresia. In 1967, the year that Dr Ladd died, I was walking through the operating room at Massachusetts General Hospital one evening and happened to glance into an induction room. There was Dr Ladd about to be anesthetized for drainage of an abscess that had formed after a hip fracture. It was a great honor to hold his hand while he was being anesthetized. He gave us many advances in pediatric surgery. The treatment of malrotation with midgut volvulus is still termed “the Ladd procedure.” He was a founding member of the Society of Plastic Surgery, and wrote many articles describing his work with cleft lip and palate. He pioneered the surgery for Wilms' tumor. He was a pioneer in the field of exstrophy of the bladder, treated by ureterosigmoidostomy diversion of the urine in those days. Truly, Dr Ladd was the father of pediatric surgery in this hemisphere.
Dr Ladd was succeeded by Dr Robert E. Gross. I have a letter written by Dr Charles McKhann to Dr Ladd recommending Dr Gross as “an interested, eager, and accurate medical student, somewhat above the average with a pleasant personality and a good appearance.” He concluded that he should make a satisfactory house officer. It was just 7 years later that Gross opened the entire field of congenital heart surgery by being the first to successfully divide a patent ductus arteriosus. He did the operation during August 1938, when he was the chief surgical resident at Children's Hospital. Dr Ladd was on vacation. Dr Ladd never forgave him for doing the operation when he was out of town: Dr Gross related that he did not believe that Dr Ladd would have allowed the operation to be done if he had been in Boston. This created a permanent rift between these two great surgeons.
Dr Gross accomplished many things during his brilliant career. The bookAbdominal Surgery of Infancy and Childhood, co-authored with Dr Ladd and published in 1941, was a classic. He became the William E. Ladd Professor in 1947. In 1953, his 1000-page book calledSurgery of Infancy and Childhood was published. Although Dr Clarence Craaford in Stockholm did the first successful coarctation of the aorta in 1944, Gross soon followed with great contributions to that pioneering effort. With the late Dr Charles Hufnagle, he introduced the use of human aortic homografts, which were freeze-dried and radiated for sterilization to replace the narrow aortic segment in coarctation cases that were too long for excision and primary anastomosis of the aorta. This was a major contribution to the field of vascular surgery. Some believe for that contribution alone he deserved the Nobel Prize. He was awarded the Lasker Award twice. His description of malformations of the aorta and great vessels, including vascular ring, and method of repair of those malformations were classic. Today, 50 years later, little of importance has been added. He continued as surgeon-in-chief until 1967, when he was succeeded by Dr Judah Folkman. Until 1972, he concentrated on cardiac surgery, as cardiovascular surgeon-in-chief, retiring in 1972. A chair was named in his honor in 1985 on his 80th birthday. His first patent ductus patient, Lorraine Sweeney, attended that dinner. She is alive and well today, 59 years later. I feel very privileged to have the honor of being the first incumbent of the Robert E. Gross Professorship in Surgery at Harvard.
A contemporary of Dr Gross' was Dr Ovar Swenson, who unlocked the mystery of Hirschprung's disease. Together with the late Dr Alexander Bill, he described the pathology of Hirschsprung's disease, namely the aganglionic distal colon and described an effective surgical correction. This consisted of removal of the aganglionic segment, and pull-through of normally innervated colon to just above the anal opening. Although other operations were described subsequently by Duhamel and Soave; this seminal contribution remains one of the most important in pediatric surgery. Hirschsprung's disease represents about one-third of all neonatal intestinal obstructions.
Dr C. Everett Koop, our recent Surgeon General of the United States, is also the part of the legacy of surgery at Children's. When he finished his residency at the Hospital of the University of Pennsylvania, his chief, Dr Isidore Ravdin, announced to him, “Chick, you are now going to become a pediatric surgeon and take over the Department at Children's Hospital of Philadelphia.” Koop came to Boston, spent several months observing Dr Gross and others at Children's, and returned to Philadelphia to establish a brilliant career in pediatric surgery. As we all know, he continues to make great contributions to mankind, 15 years after his retirement from Children's Hospital of Philadelphia, first as US Surgeon General, and now as the inspiration for the Koop Institute at Dartmouth College and Medical School.
Dr Willis Potts of Chicago and Northwestern University was another who came to Boston in preparation for a career in pediatric surgery. As a general surgeon, after World War II, he came to Boston for an extended visit and returned to become surgeon-in-chief at Children's Memorial Hospital in Chicago. He pioneered the Potts shunt, a direct connection of the aorta with the right pulmonary artery for palliation for blue babies before total correction of cyanotic congenital heart disease became possible. In his book, The Surgeon and The Child, he emphasized how well children fare if they are treated expertly and the operation is performed correctly the first time.
Today pediatric surgeons represent 1% of all of the surgeons in the American College of Surgeons. When I trained at Children's in the mid-1950s, the surgical staff consisted of Dr Robert Gross, Dr Luther Longino, Dr Donald MacCullum, and Dr Samuel Schuster. They were responsible for all of general surgery, including the heart, thorax, belly, and urology and plastic surgery. The Department of Anesthesia under Dr Robert Smith included two superb nurse anesthetists, one of whom was Betty Lank who did the first patent ductus arteriosus with Gross, and a few fellows and residents rotating through from other departments in Boston. Our current Department of Surgery has chief residents in general surgery, urology, gynecology and plastic surgery. There are 10 general full-time surgeons, 5 full-time urologists, 5 plastic surgeons, and 3 gynecologists. The number of cases have tripled in the past three decades, and the complexity of the surgery is far beyond what might have been imagined 40 years ago.
The Department of Anesthesia is large, with 28 full-time staff members who make possible long operations not even dreamed of just 30 to 40 years ago. From my perspective they represent one of the greatest advances in the field of pediatric surgery.
There are now 31 training programs in pediatric surgery in the United States and 6 in Canada. In fact, we are at a point where there is concern that we may be training too many pediatric surgeons.
This leads me to speculate about the future. I have never been very good about predicting what the future holds, but I am confident that it will be bright. Dr Judah Folkman succeeded Dr Gross, but after 15 years he decided to devote himself full-time to the surgical laboratory. He founded the field of angiogenesis research, starting with the astute observation that tumors grow by attracting new blood vessels. He reasoned that control of angiogenesis could control growth of tumors and other nonmalignant pathology, which depends on vascular ingrowth. There are many examples, such as diabetic retinopathy and life-threatening hemangiomas that can kill a child by vascular shunting. α-interferon, a potent angiogenesis inhibitor, has proven effective in greatly reducing the mortality of some of these hemangiomas. There are clinical trials in progress for treating a variety of conditions with antiangiogenic agents.
Another seminal contribution is extracorporeal membrane oxygenation, developed by Dr Robert Bartlett, formerly a student of Dr Gross, and currently professor of surgery at the University of Michigan in Ann Arbor. Use of this modality has greatly advanced the care of infants with congenital diaphragmatic hernia, and other problems that require temporary cardiopulmonary support for survival. Currently, the collaborative work of Dr Ronald Hirschl in Ann Arbor, Michigan and Dr Jay Wilson in own department has proven that the hypoplastic lung on the side of a congenital diaphragmatic hernia can be made to grow postnatally by perfusion of the lung with perfluorocarbon.
Dr Michael Harrison in San Francisco in collaboration with Dr Alfred deLorimier has pioneered the field of fetal surgery. In this month's 30th anniversary volume of the Journal of Pediatric Surgeryis an article by Harrison and co-workers1 on the response of the hypoplastic lung to tracheal occlusion in utero. Another of Dr Harrison's trainees, Dr Allen Flake, has just moved to Children's Hospital of Philadelphia. With Dr Scott Adzick, he has just reported successful treatment of a fetus destined to have combined immunodeficiency syndrome with prenatal stem cell therapy using enhanced stem cells from the father, injected at 14 weeks of gestation intraperitoneally into the infant. The infant is now 1½ years old with no evidence of disease. This raises the possibility for gene therapy with the stem cell as the target for cellular deficiency diseases. It raises also the possibility of inducing tolerance for transplantation in a fetus about to be born with a problem needing transplantation, possibly using a xenograft.
Dr Joseph E. Murray of the Peter Bent Brigham Hospital and the Children's Hospital received the Nobel Prize for renal transplantation. Today the 3-year survival rate after organ transplantation is amazing. For the kidney it is 87%, the pancreas, 83%; the heart, 74%; the liver, 73%; the lung, 56%; and combined heart and lung, 49%. Lack of organ availability has been a major problem in transplantation. Dr Joseph Vacanti in our department, in collaboration with Dr Robert Langer at Massachusetts Institute of Technology, has pioneered the field of tissue engineering. Human cells are grown in three dimensions on a biodegradable matrix. To date, this has produced cartilage grown from the patient's own cells for replacement of chest wall defects. A trial is underway by Atala and others using autologous cartilage cells in a homogenate that can be injected beneath a ureter as a possible means for treating vesicoureteral reflux, where the ureter lacks bladder muscle behind it.
Dr Patricia Donahoe at the Massachusetts General Hospital has spent 25 years in the pursuit of the müllerian-inhibiting substance, which is so important in fetal sexual differentiation. She has discovered that this is a tumor growth factor β group compound that suppresses ovarian cancer. Soon a trial will be underway using müllerian-inhibiting substance at the National Cancer Institute for treatment of ovarian cancer.
Finally, I would like to mention the work of Dr Scott Adzick who graduated from our training program in pediatric surgery in 1988 and who then worked with Dr Harrison. He has demonstrated that a fetus heals without scar during the first two trimesters. This has enormous possible implication for modification of scar formation in many postnatal diseases, such as diabetic retinopathy, intestinal adhesions, and other conditions where scar formation thwarts the physician.
In 1935, Dr William E. Ladd wrote, “Undoubtedly great strides have been made in this field of surgery in the last few years and I have confidence that greater advances are soon to follow.” Events that have taken place since then have proven that he was correct. I think the same statement is valid today, and that the best is yet to come!
- Copyright © 1998 American Academy of Pediatrics