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Pediatric surgery: Past, present, and future

2001; Elsevier BV; Volume: 36; Issue: 1 Linguagem: Inglês

10.1053/jpsu.2001.20065

1531-5037

Kathryn D. Anderson,

Medical History and Innovations

LADIES AND GENTLEMEN, Members of APSA and guests and especially my own guests, my family: I would like to thank the Association for the honor of serving as your President; this has been one of the most important years of my life, and I feel particularly privileged to serve as the last President of the 20th century and the first of the 21st. I am immensely grateful to my many mentors and teachers. I can only name a few: Dr Dorothy Heard at Girton College, in Cambridge, that stellar triumvirate who taught me Pediatric Surgery; Jud Randolph, Peter Altman, and the late John Lilly; Hardy Hendren, a beloved supporter, and also the best of my teachers—my residents past and present. But I particularly want to thank French, my best friend for the past 39 years. The saying goes, “Behind every successful man is a woman of great forbearance.” The converse is true for me. French has been behind and in front of me, pushing and pulling, cajoling and encouraging and making me believe in myself—even when I wake him up at 2 AM with my worries and doubts. As I reflected on a topic for this address it occurred to me that we are always stalled in the present. The President of the American College of Surgeons spoke of the present age of medicine in his address to the new Fellows of the College last October: “you have been subjected for the last several years to one of the greatest rearrangements of priorities that has ever occurred as control of medicine has been ceded to business. The moneychangers are ruling the temple...” In this address I have tried to put the achievements of pediatric surgery into the context of the social, medical, and surgical milieux of the day in 4 time periods: around 1900, 1950, the current year, and 2050, hoping by a short journey into the past and a glimpse at the future to put the present into a more comfortable perspective. The world was not at peace in 1900. Winston Churchill had just escaped from prison in South Africa, during the Boer War; the United States was engaged in guerilla warfare in the Philippines, and The Boxer uprising had just begun in China. The telephone was available, and the occasional automobile chugged down city streets with extreme care and at a glacial pace. Citizens who needed to know the time would consult their pocket watches. No wrist watches yet existed. The light bulb had been invented, but homes and streets were still largely lit by gaslight. The main fuel was coal, which polluted the air and often made for dense smog. No airplanes polluted the air with fuel or sound, as Kitty Hawk did not occur until 1903. Most citizens had their photographs taken, but few went to the movies. Queen Victoria was in the last year of her reign, and President McKinley was still alive. Millions of people were not content in the land of their birth and sought their fortunes in the land where the streets were paved with gold. Segregation was absolute. African-Americans could theoretically vote but did not because of required literacy testing. Women could not vote at all, literate or not. Life was short, an average of 45 years, and hard, and homelessness was a problem. Child labor was still common, and infectious diseases were a scourge. The mosquito began a malaria epidemic in San Francisco in 1900, and some years later yellow fever brought construction of the Panama Canal to a halt. Thanks to Walter Reed's discovery that yellow fever was also carried by the mosquito, the canal was completed with much reduced loss of life. X-rays had been discovered in 1895, and Roentgen received the first Nobel Prize ever given in 1901. Nothing more than curiosities at first, x-rays began to be used to compare findings at operation and at autopsy. It may interest you to know that the first malpractice lawsuit was filed in 1899 for a missed fracture! Radium was yet to be discovered by the Curies. Aspirin was newly identified from an infusion of willow leaves, and bloodletting for fever was permanently discontinued. Though the mortality rate of mothers during childbirth was decreasing, the infant mortality rate still was extremely high. There were a few scattered children's hospitals, but, in general, the care of children was not regarded as a separate specialty. Many children died of diptheria, and a tracheostomy, if it was performed, was done in bed at home by the local doctor. House calls were the norm but the doctor carried in his bag little besides Calomel, opium, quinine, and Ipecac. The sphygmomanometer and the EKG were new inventions but no normal values for blood pressure or heart rhythm were known. Landsteiner discovered blood groups in the same year, but blood transfusion was not widespread for several decades. California started its practice of leading the nation in “firsts” and elected a woman to be the President of the Los Angeles County Medical Society in 1902! The new century was a great time for surgeons. Since the advent of anesthesia and the increasing safety of this mode of pain relief operations were routinely performed in most areas of the body. Thyroidectomies, cholecystectomies, and herniorrhaphies were fairly routine, and even cerebral tumors yielded to the knife. The Halstead mastectomy was common, and surgeons had learned to do gastrointestinal anastomoses with relative safety. Appendicitis had gone from being a disease with many names to having a standardized surgical approach devised by MacBurney. The importance of actually removing the appendix was recognized universally, and surgical mortality rate was down to 4% by the dawn of the 20th century. Indeed, appendectomy became a designer operation when the coronation of Edward VII in 1902 was delayed while his appendix was removed. The “golden hour” of trauma care was recognized and put to good use in the Russo-Japanese War, this by a Russian surgeon, a princess, trained in Germany. Vascular surgery consisted of the ligation of injured blood vessels. Anastomoses were not performed for another 10 years. The only cavity that was still off limits to most surgeons was the chest cavity. The most that could be done was thoracic drainage or thoracoplasty. Sauerbruch in Germany was working on this and by 1903 was able to perform intrathoracic operations rather awkwardly in a box under negative pressure. Open thoracotomy awaited the routine use of the endotracheal tube and positive pressure ventilation. Surgery was still performed routinely under a Listerian mist of carbolic acid. Some surgeons wore gloves devised by Halstead for his scrub nurse who developed dermatitis from the acid spray. Masks were not routinely used. Surgical education was for the most part by apprenticeship, though Johns Hopkins Hospital had an established formal surgical residency. And what of pediatric surgery? In 1852 Dr Charles West who inspired the building of the Hospital for Sick Children in Great Ormond Street had said, “There are no surgical problems in childhood which demand a special skill or study.” By 1900, however, it was recognized that special skills were required, though there was no one in the United States who devoted his entire time to the surgical care of children. Intussusception was described probably centuries before. Malrotation, Hirschsprung's disease, esophageal and other intestinal atresias, Wilms tumor, diaphragmatic hernia, prune-belly syndrome, and imperforate anus were all known entities. Successful treatment lagged behind the pathologic description and often also clinical diagnosis so that death from these maladies was common, and in many cases inevitable. Let me give you a few examples to illustrate the state-of-the-art in 1900. The first attempt at primary repair of esophageal atresia was by Steele in 1888 without success. If children survived the newborn period they could have an antethoracic skin tube developed by Bircher in 1894. Intestinal transpositions were performed by 1907 when Roux swung the jejunum up to replace the esophagus, again subcutaneously. Though Chevalier Jackson introduced a lighted esophagoscope in 1902, esophageal strictures were dilated blindly with hard rubber tubes. Pyloric stenosis was treated surgically by gastroenterostomy until 1912 when Ramstedt performed the first successful pyloromyotomy. Mortality rate was 24% undoubtedly from the metabolic abnormalities. Duodenal and intestinal atresias were uniformly fatal until 1914, and although diaphragmatic hernia had been described in the mid-17th century, the first survival of a repair was not reported until 1920 of a child operated on in 1901. That patient survived to fight in the First World War. Intussusception was diagnosed clinically and sometimes could be reduced by water, saline, or air enemas, but mortality rate was still 50%. The neurogenic origin of Hirschsprung's disease was suggested in that same year, but this condition was treated by forceful enemas and dilatations of the rectum. No one tackled exstrophy of the bladder or cloaca. The anatomy of imperforate anus and the levator and external sphincter muscles had been described in the middle of the 18th century. The significance of the musculature was missed. In the mid-19th century a French surgeon described passing a probe through the distal end of a colostomy to the perineum and cutting through onto the probe. However, high mortality rate associated with performing colostomies in 1900 presumably led to an extreme reluctance to perform this procedure. My second cousin was born with a high imperforate anus with a urethral fistula. At birth a perineal procedure was performed without anesthesia. The surgeon sutured the rectum to the skin but was not aware of, or ignored, the rectourethral fistula. My cousin was then subjected all his life to rectal dilatations, simultaneous passage of stool and urine by urethra and by rectum, and the personal and social humiliation associated with total incontinence. Let me turn now to the years around 1950. World War II was over, and the initial euphoria associated with the end of hostilities was wearing off. The population of the world had risen to over 2.5 billion, over half of these living in Asia. Several events were transforming the old order of colonial power. Ceylon and India had become independent, and the British Empire was breaking up. Israel became a state in 1948, the year that Ghandi was assassinated by a disgruntled follower angered by his pacifism. The People's Republic of China was declared in Tienamen Square by Mao in 1949 after the civil war ended in a communist victory. The Soviet Union began to make its own ambitions for empire obvious to the western world. Although the Berlin Wall was not physically built for more than a decade, access to West Berlin was denied by the Russians to Western powers. My uncle took part in the Berlin airlift in which daily supply planes kept West Berliners alive for the duration of the embargo. Churchill coined the term “The Iron Curtain” and George Orwell wrote his famous book, “1984.” America, magnanimous after winning the war, began the Marshall plan to rebuild Europe. At home in the United States the Armed Forces and baseball were integrated, and Jackie Robinson joined the big leagues. The good life that followed the war was in full swing. The parents of the future baby-boomers were moving out of urban areas, and in 1950 alone 2 million tract houses were built. Some of you may remember the folk singer Pete Seeger describing the “houses made of ticky-tacky which all looked just the same.” Every home had the latest in appliances, washing machines, dryers, refrigerators, vacuum cleaners, and food mixers. The family began to congregate not around the table but around the television set, which was emerging as a significant leisure time occupier. Lucy Ricardo and Ed Sullivan became household words. The transistor was invented by Shockley in 1947, the forerunner of the chip technology, which would make complicated gadgetry available to the average citizen and which now totally run our lives. ENIAC, the first computer, had been built at the University of Pennsylvania in the final war years taking up a whole room, and in 1952 the second-generation computer UNIVAC was used to predict accurately Eisenhower's Presidential victory. While surface life was wonderful, there were some gathering storm clouds. South Korea was invaded by the North Koreans, bringing with it the first full-scale involvement of Americans in a foreign war. Atomic bomb testing became commonplace, and the mushroom cloud became a relatively common sight in cities bordering on the Arizona desert and the atolls of the South Pacific. The Russians detonated their own atomic bomb. The Arms Race began leading to great unease among the United States population who scurried to build and stock bomb shelters in their gardens. Senator Joe McCarthy took advantage of this siege mentality and notified the American public that there were “205 known Communists working in the State Department.” The frenzy he produced pitted Americans against each other, and mass paranoia ruled. And what of the medical environment in 1950? Harvard had just graduated its first “girl” doctors! Penicillin and streptomycin were both available, though still in very short supply, and the first randomized clinical trial was performed using streptomycin against tuberculosis. Elucidation of the structure and function of adrenocortical hormones led to a Nobel Prize for 2 US and 1 Swiss physician. The first iteration of the Krebs cycle was published. Research suggested a link between smoking and cancer. Linus Pauling showed the difference between the structure of normal and sickle cell hemoglobin. The extra chromosome of Down's syndrome was described. The science of immunology was founded following the discovery by McFarland Burnet that the animal body had a mechanism for distinguishing self from nonself. The discovery of the structure of DNA also led to the Nobel Prize for Watson and Crick in 1953. Children examined their own feet fluoroscopically in shoe stores in spite of the fact that x-ray technicians and radiologists were known to have a high incidence of leukemia. The study of ultrasound was returning to civilian research after delays caused by the World War II military use of sonar, and the first brain scanner was tested at MIT though not successfully. EMI, an English music company developed the first CT scanner in 1951, but medical diagnostics would not have useful ultrasound, isotope scans, or computerized scans for 20 more years. Nuclear magnetic resonance also remained in the province of the physicists for 25 more years. Lessons learned from the effects of mustard gas in World War I were used in the development of methotrexate for the treatment of leukemia at The Children's Hospital in Boston by Sidney Farber. Alfred Blalock described his operation for transposition of the great vessels at the American Surgical Association. At that same meeting it was noted that there were “too few surgical teachers and budgets of surgery departments needed support.” How history repeats itself! A motion was passed from the floor decrying “the formation of so many separate and independent boards as being contrary to the best interests of the community at large” suggesting that the fragmentation of surgery was beginning in these early days. The American College of Surgeons, now in its 37th year, created a full-time post of Director and spun off the Joint Commission in 1951. The ACS also developed the Residency Review Committee and approved a total of 482 programs in General Surgery. Plastic went into full-scale production in the late 1940s, and the first patient to receive an artificial hip had an acrylic one implanted in 1950. Dwight Harken went to work at the Brigham and with great ceremony cracked stenotic mitral valves with his serrated fingernail! Weinberg revascularized damaged myocardium using the internal mammary artery, at McGill, and Hufnagel inserted the first artificial valve in the descending aorta. Vascular surgery came into its own in the M.A.S.H. units in South Korea. Renal dialysis was already established as the treatment for end-stage renal disease. The Brigham team performed the first renal transplantation between identical twins in 1954, an achievement that earned Joe Murray the Nobel Prize in 1990. Although the heart-lung machine was known in concept in 1950, its first use was in 1953 to successfully close an ASD on an 18-year-old girl. By 1950, pioneers in pediatric Surgery such as Robert Gross, a pupil of Dr William Ladd, had long been devoting their lives to the care of children. The Potts shunt for Tetralogy, patent ductus ligation, reconstruction of coarctation of the aorta, primary repair of esophageal atresia, as well as repair of congenital diaphragmatic hernia were all established procedures. The definitive treatment of Hirschsprung's disease had been reported by Drs Swenson and Bill and hypospadias repair, omphalocele closure by skin flaps, and many other operations were now well done, and surgical mortality was dropping as the rough and ready techniques of adult surgeons gave way to delicate handling of fragile tissues by skilled pediatric surgeons. Ravitch described the reduction of intussusception using barium and established the guidelines for this highly successful mode of treatment. He also proposed rectal mucosectomy for ulcerative colitis and familial polyposis to avoid permanent ileostomies in these diseases. This latter proposal he did not carry to the next stage, and so this technique remained to be rediscovered by Soave 15 years later. Transposition of the colon became the standard esophageal replacement in children in this country in 1954. The specialty of pediatric radiology began with pioneers like Edward Neuhauser and Caffey describing among many other conditions the characteristic findings of multiple healed fractures of child abuse. Many general surgeons were threatened by the establishment of Pediatric Surgery as a distinct specialty. The American Academy of Pediatrics welcomed us, however, and the oldest of the pure pediatric surgical institutions was established in 1948 as the Surgical Section of the AAP. BAPS soon followed; CAPS and APSA were launched in the late 1960s. And now to the present day. The world has a population of more than 6 billion. In developed countries life expectancy is 75 years, and a number of people have lived in 3 centuries, attaining the age of 100. We are in the era of “fast, faster, fastest.” Fast food, fast planes, fast cars, instant communication by cellular phones, beepers, computers, laptops, World Wide Web and the information superhighway. Global communication has destroyed the Berlin Wall, and reduced the ideological isolation of people. The world is advancing toward a global economy. The price of all of the new technology, however, is very high. While travel to other planets is no longer beyond our dreams, space exploration has lost a lot of its glamour and is judged too costly. We are living in relative peace but still spending enormous amounts of money on developing smart bombs and curbing aggression in other countries that potentially could threaten our way of life. Huge migrations of people are still occurring, and the immigrant population of the United States increases exponentially each year. Although the mass rallies that characterized the 1960s and 1970s are now a rarity, and minorities have made great strides, prejudice continues in more subtle ways. Now everything is seen instantly through television cameras. All news is reported in sound bites, and we view domestic and international acts of terrorism, acts of war, sensational trials, the funeral of a princess and the peccadilloes of the President in color in our living rooms. Y2K and the “love bug” are history, and the information age is proceeding at a pace that makes us gasp. Instant fortunes are made; the proliferation of dot-com companies is staggering in its volume, and for the first time in history the loss of money is equated with success. Virtual reality is becoming more important than actual reality, and in an age where the advance of technology is unprecedented, we have not caught up with the necessity of finding some way of paying for all our inventions without destroying our safety nets. And what of the medical achievements? In the year 2000 there is almost nothing in the human body that remains unseen whether by ultrasound, isotope scanning, computerized tomography, or magnetic resonance imaging, in real time with digitized pictures to enhance our view of the anatomic and physiological state of our patients. Radiologists, cardiologists, and gastroenterologists have changed the face of surgery as they invade the body with their peering, stenting, draining, opening, closing, and miscellaneous procedures. We can develop a baby to a fairly advanced stage in a test tube and then implant the embryo into the biological or a surrogate mother. We can clone whole animals from cells. The Human Genome Project is all but completed, identifying most of our 100,000 plus genes. The social implications of knowing one's future diseases have yet to be addressed. We know the structure and function of many oncogenes and tumor suppressor genes, though we are not yet successful in manipulating them at a molecular level. Gene therapy is proving successful, and new discoveries are almost a daily occurrence. Multidisciplinary approaches for cardiovascular disease, cancer, and neurologic problems, including research into spinal cord regeneration, have resulted in not only increased life expectancy but also increased health expectancy. Fetal diagnosis and treatment are merging medicine and surgery, and the widespread dissemination of medical information via the Internet has led to a vastly better-informed public. Telemedicine now enables specialty information, advice and even care to be practiced in remote areas of the world. As the public has become more aware of medical possibilities, do-it-yourself medicine has become more widespread, particularly in the area of so-called alternative medicine. This has become a multibillion dollar industry and has resulted in the value of alternative health care practitioners being raised while at the same time high technology has depersonalized traditional medicine. Minimally invasive techniques have taken the world by storm, and there is literally no area of the body that has failed to give up its secrets to smaller and smaller instruments aided by telescopes with advanced optics. Computerized images can be projected into the operative field within a microscope or a headpiece worn by the surgeon making surgery much safer and with less chance of destroying normal tissue. Microsurgery with replantation of severed fingers, limbs, and even misplaced testicles is routine. Robotics can scale down the movements of the human hand to perform even more delicate surgery with unprecedented precision. Operations can now be performed by surgeons remote from the operative field. There is even tactile feedback built into instruments so the surgeon really feels as if she is exploring with her finger. New parts for old are common from the expanded skin used to cover burn wounds to replacement for congenitally deformed or aging hips and knees. The deaf can hear with cochlear implants. Artificial hands and even coordinated stimulation of leg muscles after spinal cord injury have enabled disabled people to resume much more normal lives. Shock is beginning to yield its secrets with knowledge of cytokines and antioxidants, and growth factors can be used to augment wound healing so that diabetic and other ulcers can more speedily be healed. Tissue engineering is beginning to be incorporated into the surgical armamentarium, and biodegradable scaffolds are used to grow human tissues and organelles. Tissue and bone defects can be replaced with materials that support the ingrowth of blood vessels and tissue and bone expanders are in routine use for replacement, transfer, and lengthening of diseased or deficient tissues. Even diseases exclusive to women have recently been found worthy of study. And medications to alleviate prostatic hypertrophy, nerve-sparing surgery for prostatic carcinoma, not to mention Viagra, have extended the health and well being of men. Pediatric surgery sometimes has followed the technologies developed in the adult world and sometimes led them. Since Tessier's work, no longer are children born with complicated craniofacial abnormalities, doomed to lead a life of ugliness. More and more complex surgery can be done in small infants with heart disease with transplantation reaching high levels of success when surgical reconstruction is not possible or fails. Living donor kidney and liver transplants have greatly enhanced the life expectancy of patients with end-stage renal disease and infants for whom the Kasai operation is only a temporary prolonging of life. Research on the phenomenon of tolerance along with increasingly specific methods of immunotherapy suggest the possibility that xenotransplantation will become a reality in the not too distant future, while the development of animal and human chimeras is also proceeding. This is a time of decreasing reimbursement. So, although there is more money available for research, surgeons must increase their workload with less time for student and resident teaching as well as self-education and research. Are we reaching a point at which new technology applications must be slowed down not because of a plateau in knowledge but because of the inability to pay for these advances and adapt them into the clinical arena? Which brings me to the final part of my walk through pediatric surgery in the context of a whole century of achievement and change. What will the world be like in the year 2050? I submit that science and medicine will so far have outstripped our collective imagination that no one in 2050 will be interested in what we predict today. So it is without too much fear of looking ridiculous posthumously that I offer this speculative glimpse into our future. I believe among other things that: we will have smart cars that avoid collision; we will have dispensed with gasoline products or developed extraction systems for exhaust that is 100% efficient and whose products can be put to other use; whatever trash we cannot recycle will be reduced to microscopic proportions by bacteria as yet undiscovered, or by chemical processes as yet unknown. Radioactive waste materials will be rendered harmless by induced transmutation to inert substances, so that radioactive chemicals will be a safe energy source. We will also tap the molten core of the Earth for energy sources and for many other purposes. There will be few uninhabitable areas of the Earth's surface. Millions of people will live into their 100s. There will be a universal standard of living with universal food production and distribution. We will grow food under the sea and tap this wide resource for many of its hidden assets. Computers will be even more miniaturized to give instant information for physicians and lay alike, beamed from huge centralized information systems and in multiple languages. Artificial neural networks, currently in very primitive stages will have developed to perform most medical diagnoses and the majority of imaging. They will produce automatic readout of pathologic specimens, wave forms such as EEG, EKG, and Doppler ultrasounds, decreasing almost to zero the human element of error in diagnosis and outcome prediction. Will we then gently and humanely omit treatment for people for whom the treatment is worse than the disease and does not alter the outcome? Will this capacity be economically driven or by humanitarianism? And will we have the courage or the right to practice euthanasia? Every individual's genome will be known, and everyone will have the freedom to ignore the information about future diseases or adopt lifestyle changes most likely to prevent them. Vaccines made from naked DNA will be readily available for most bacterial, viral, and malignant diseases. Gene therapy will be targeted so that it will be as easy as reaching for an antibiotic off the shelf. Gene therapy for cancer will not kill tumor cells. Instead, we will restore the normal regulatory processes into each tumor cell either turning off oncogenes or turning on tumor suppressor genes. Although tolerance will be a reality, and xenografts will be possible, we will rarely need them because we will grow whole organs for replacement. We will have implantable devices for drug delivery and also for the measurement of bodily functions. Alternative medicine will be mainstream, and all drugs will be manufactured without side effects. Robotic surgery will be routine and will have overcome the limitations imposed by the time lapse that currently limits the distance between the transmitted computerized signals from operator to patient. Virtual reality will be so advanced that video-assisted surgery will be exactly equivalent to open surgery. Ablative surgery will be less needed, as unhealthy organs will be replaced by engineered tissue, organs, or genetic material. The genetic abnormalities of diseases such as cystic fibrosis, esophageal atresia, imperforate anus will be identified in the genetic profile of embryos early enough to substitute new or correct defective genes allowing normal development of the fetus. Trauma surgeons will still be needed to some extent, and correction of anomalies that slip through the genetic screen will still require skilled pediatric surgeons. Most surgical teaching will be on virtual patients. Will this be Utopia, or is Utopia always defined as something in the future rather than the present? I don't know, and I certainly will not be around to find out. Let me conclude by saying that there is surely no better career than that of restoring life and function to our children. It is a legacy that is not limited by time or dimension. There is no more important body than that devoted to the education and fellowship of those of us who have this privilege, and APSA will still exist in 2050. We can all be proud of what we have accomplished and with a renewed faith in what we do, look to the future with enthusiasm and with hope.