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Presidential address: The evolution of pediatric surgery
Journal of Pediatric Surgery VOL. XV, NO. 6
DECEMBER 1980
P r e s i d e n t i a l A d d r e s s : T h e E v o l u t i o n of P e d i a t r i c S u r g e r y By Robert Allen Memphis, Tennessee
q R S T , I would like to welcome all our guests today and I especially want to welcome our wives and families. Most importantly, I want to thank you the members of APSA for having bestowed on me this unique and special honor, that of being your President. This address is a tribute, a few words of love, admiration, respect, and sincere thanks to Robert Edward Gross, APSA's first President. Pediatric surgeons the world over owe him a debt of gratitude for making our specialty what it is today. There is no question that William E . Ladd envisioned, pioneered, and was the founder of pediatric surgery in this country. Dr. Gross, to this day, refers to Ladd affectionately as "the Chief," praising his surgical skill and contributions related to esophageal and biliary atresia, Wilms' tumor and malrotation, to name a few. It was Gross, however, who through his technical advancements, his remarkable quality and quantity (250) of publications and his unique residency training program, broadened, popularized and finally, solidified pediatric surgery as an accepted specialty in this country. Many of you know him personally, some far better than I, but for those of you who don't, perhaps I can conjure up for you a visual image. Picture if you can, an ever youthful, vibrant individual who literally charges the air and stimulates the people about him (Fig. 1). He had the capacity to command enormous respect and inspire intense loyalty from those who worked with him. No matter how long or how well you have known him, you continue to stand in awe and feel a little fearful in his presence. Many consider him aloof, not understanding that he is basically quite shy and a private person. He is meticulous, actually compulsive, when it comes to personal neatness and attire. His coal-black hair was trimmed every Friday afternoon and
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Journal of Pediatric Surgery, Vol. 15, No. 6 (December), 1980
there was never a strand out of place. His trademark was a heavily starched white shirt, red bow tie, and a conservative suit. His compulsion for neatness, however, was only a part of an overall drive for perfection which he demanded from both his house staff and himself. There are many stories related to his demands for neatness, amusing to us now but not so laughable at the time they occurred. Most everyone who passed through his training program at one time or another received a cryptic note from the desk of " R E G , " in some way related to improper attire, much like the one sent to Jud Randolph in 1958. From Gross to Randolph: "In the dining room coats should be worn, signed R E G ; " or like this one to Eraklis: "Sin all you want, but don't smoke at the nursing station." George Holcomb received 50r for a haircut on more than one occasion and innumerable people, many who are now professors of pediatric surgery, received bottles of white Shinola when they failed to keep their shoes properly white. He also evaluated patients' families for propriety. On an office chart of a child with an undescended testicle, he added at the end of his evaluation: "Father did not wear tie. Mother a gum chewer."
From the Departments o f Surgery and Pediatrics, University o f Tennessee Center for the Health Sciences and LeBonheur Children's Medical Center, Memphis, Tenn. Presented before the l I th Annual Meeting o f the American Pediatric Surgical Association, Marco Island, Florida, May 7-10, 1980. Address reprint requests to Robert Allen, M.D., Departments o f Surgery and Pediatrics, Univesity o f Tennessee Center f o r the Health Sciences and LeBonheur Children's Medical Center, Memphis, Tenn. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1506M)001 $01.00/0 711
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ROBERT ALLEN
Fig. 1.
Dr. Robert Edward Gross.
One of the most famous stories handed down from year to year, one which ! was privileged to witness, concerned Walter Ellerbeck, a young rotating resident from the Brigham. In the locker room one morning, Walter appeared in white shoes that were both dirty and bloody, and the blood was old, not fresh. Dr. Gross didn't choose to chew Walter out verbally, something he rarely did to his resident staff. He didn't need to. He had a way of giving a very cold, icy stare, one that could freeze salt water. He didn't have to say much, you usually knew what was wrong and how to solve the problem. He took Walter's
shoes back to the bathroom. He unlaced one shoe, scrubbed it with soap and water and got his white Shinola and shined the shoe to perfection. He relaced it and then washed the excess polish from the red sole. Without smiling and not joking he handed the shoe back and said: "Walt, they had better stay this way," turned and walked out. I asked: "Walter, what did you do back there while Gross was shining your shoes?" He said: " W h a t could I do? I couldn't offer to help shine the shoe and I couldn't leave. I just had to stand there, watch, and suffer." Gross was born in July 1905. He was the son
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of a piano maker and the seventh of eight children. Of his 5 sisters, 1 died in her early 20s, 2 became housewives, 1 became a college president, and 1 a physician. His two brothers attended M.1.T., one continued on as an engineer and the other brother also became a college president. Although Gross did not attend M.I.T., he was an engineer at heart with a mechanistic bent, a characteristic that surfaced throughout his career. As a youth he was mischievous, inquisitive, industrious, and creative. At age 12, when his father was expected to be out of town for about a week, young Robert took the engine of the family car completely apart to see what made it run. His father returned 3 days early, and possibly the icy stare that Dr. Gross later used so effectively was learned at that time. On seeing the dismantled engine, his father didn't rant and rave, he simply told Robert to put the engine back together before morning and not to leave out a single piece, a job he accomplished. At a little later age, Robert had a beautiful, brown woollen suit of which he was very proud and wore frequently, so frequently that it became quite shiny, but not worn out. Rather than discard this suit, he took it completely apart, reversed it, relined it, restitched it, and wore it for many years thereafter. He attended Baltimore Polytechnic High School and from there went to Carleton College in Minnesota, a very competitive but small college, then as it is now. At Carleton he majored in chemistry. In the early part of his senior year he won a scholarship to attend the University of Wisconsin for three years of doctoral training in chemistry. A major turning point in his life occurred during Christmas vacation of his senior college year when he was given the magnificent twovolume set entitled, The Life of Sir William Osler, written by Harvey Cushing, then the Chief of Surgery at the Peter Bent Brigham Hospital. Gross became totally absorbed in these books, read and restudied them that spring, deciding then to enter medicine, a thought which had not occurred previously. Cushing became his idol and stimulation to apply to Harvard Medical School where he was accepted, much to his surprise. Early in his first year of medical school, the
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ever inquisitive student found his way to the surgical research lab, the old dog lab in Building C and volunteered his services for various research projects. Here his interest in both surgery and research blossomed and he continued to work in the lab on a volunteer basis throughout his entire medical school days, kindling an enthusiasm for personal involvement in research which persisted throughout his academic life. During the last months of medical school, Gross first came in contact with Dr. William Ladd and solidly decided to follow the master into pediatric surgery. After medical school graduation in 1931, his formal training included 2 years of pathology, 3 years of general surgery (which included 6 months as traveling fellow to European surgical centers), and 3 years in pediatric surgery under Dr. Ladd. Following this he became a junior on Dr. Ladd's staff. He rotated through various jobs as openings became available. In the 1930s this was a strong background for general and pediatric surgery. His training began in pathology under Dr. Burt Wolbach, a scientist of broad scope and understanding. Wolbach devoted much time on a one to one basis with his house staff, and unquestionably played a major role in directing Gross' career. Wolbach insisted on careful and detailed autopsy reports and that each report be ended with recommendations as to how that patient might have fared better or have been treated more appropriately during his lifetime. I uncovered an autopsy report that Gross filed in 1931, his first year out of medical school. The post was on a 4-month-old baby admitted to the hospital with severe wheezing, diffieulaty in swallowing, followed by pneumonia and death. The clinical diagnosis had been mediastinal cyst. I would like to make a few excerpts from that autopsy summary: "The arch of the aorta is in an abnormal position, extending to the right and then up and posteriorly to go behind the esophagus and then down to the left along its normal course. A ductus arteriosus runs from the pulmonary artery back to the arch. There is then a vascular constricting circle around the esophagus and trachea. This is composed of the arch of the aorta, the pulmonary artery and an open ductus arteriosus." He concluded that "division
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of this vascular circle might have relieved the patient's symptoms." Another pathology resident involved in the same autopsy (in his summary which Wolbach required) stated: "It is quite doubtful whether any aid could have come from local surgical interference." This fatal case, long remembered, was the basis for subsequently leading Dr. Gross into performance of over 200 operations on babies and children who were suffering from various sorts of intrathoracic vascular anomalies giving rise to troublesome obstruction of the esophagus or trachea, or both, many of them life-threatening. As a surgery resident under Elliott Cutler, two of his running mates were Robert Zollinger and Bert Dunphy. I wonder if Cutler had any idea that these three young men, Gross, Zollinger and Dunphy, all under his tutelage at one time, would each make a significant mark on American surgery. Gross' fame came early when at the age of 33, in 1938, while he was still serving as chief resident, he literally opened the field of cardiac surgery by successfully ligating a patent ductus arteriosus. Sporadic attempts at cardiac surgery had been made unsuccessfully in various centers but the closure of a ductus in 1938, followed by other subsequent successes, was the explosion that opened the field of cardiac surgery. What led up to that event? Gross gives his classmate, Dr. John Hubbard, a great deal of credit. After graduation, Hubbard entered pediatrics and used to encourage and needle Gross to work on operations to help some of the children who had congenital heart problems. Eventually these two residents went to Dr. Blackfan, who was the Chief of Pediatrics at the time, a man for whom Dr. Gross had great respect and told him that of all the various congenital defects, they felt that an open ductus was the most amenable to surgical correction. Blackfan, to their surprise, agreed and encouraged the young men, but he insisted that they take their efforts first to the dog lab, create ductuses in dogs and then reoperate and close the shunts for practice. This is exactly what was done in 1936 and 1937. Gross, in 1938, sensed that Ladd would not sanction a proposal to attempt surgical closure of an open ductus in a human patient. Blackfan and
ROBERT ALLEN
Cutler, however, both encouraged him; in fact, Cutler said: "You'd better get on with it or somebody is going to beat you to it." Not only did Dr. Gross not consult Ladd, but while Ladd was away on vacation, he admitted 7-year-old Lorraine Sweeney to the Children's Hospital and successfully closed her ductus on August 26, 1938. Bessie Lank, nurse anesthetist at the Children's Hospital for over 30 years was at the head of the table and had only a tight-fitting mask and no endotracheal tube. No chest tube was required postop and there were no complications; the child was out of bed the next day. Word spread rapidly about this success. Ladd's only comment, that we know of, when he returned to town, was that he felt the undertaking was probably a bit premature. He may have had a few other remarks that we don't know about. The second ligation of a ductus took place three weeks later and this attracted the dean of the medical school to observe this new miracle. As luck would have it, while dissecting around the back side of a huge ductus, a large hole was made in the ductus itself. An enormous amount of blood filled the entire operative field. This being only the second major vascular case that Gross had ever done, you can be sure that he had never seen that much blood lost that quickly. It is a credit to his dexterity that somehow he got heavy ligatures around that ductus and tied the whole thing down tightly, stopping the hemorrhage. The boy rapidly recovered. Over the next decade he performed many firsts in surgery. In every instance, an enormous amount of careful lab work was undertaken and accomplished before a clinical case was undertaken. Studying the possibility and practicality of surgically correcting aortic coarctations of humans, extensive work was carried on in the research animal laboratory. Aortas were severed and resutured by various techniques; clamps were applied to the aorta and timed carefully to determine the safe interval before hind leg paralysis occurred. Aortic autografts, homografts, and heterografts were collected, preserved in various types of solutions and transplanted from dog to dog. The extensive research work in 1938 and 1939 with Dr. Charles Hufnagel showed
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that it was going to be possible to resect a coarctation of the aorta in humans and reconstruct an aortic pathway (either by direct suture of aortic ends, or in other instances by insertion of a graft whenever necessary). I uncovered a letter written by Dr. Gross in 1941 to Dr. Eugene Eppinger, who was a valued medical colleague, cooperating in studies and management of patients with congenital cardiovascular anomalies: Dear Gene: Last Saturday, April 5, after having had a thoroughly discouraging day, I went late in the afternoon and did unrewarding posts on those puppies (on which he had attempted making aortic valve stenoses). Each of them had died of left ventricular failure. We will have to create valvular stenosis more slowly, so the ventricle can progressively build up to an increasing strength. And then there was that 15-year-old girl I had operated upon a month ago for ligation of her patent ductus. At home, the ligatures suddenly cut through and she died instantly of hemorrhage. Sorry to send all the bad news to you. Bob
It was only a short time after this that he completely abandoned ligation of a patent ductus and used ductal division and individual suture closures of the aorta and pulmonary artery. This became the standard operation in nearly 1600 patients on the service. The summer of 1945 was noteworthy. On June 9th, he divided the first vascular ring, a double aortic arch. Quoting from his op note: "During the first part of the operation, the respiratory distress caused extreme anxiety. There was a pronounced shift in the mediastinum with each respiratory movement, making the dissection quite difficult. First, I divided the ligamentum arteriosum. This had some slight beneficial effect, but it was not marked. I then decided it necessary to divide some portion of the arterial ring that encircled the esophagus and trachea. The anterior arch was severed." Three weeks later on June 28th, he repaired his first human coarctation. Two more firsts were accomplished in May, 1948. On the 22nd, he successfully closed the first aortico-pulmonary window. Two days later he inserted the first arterial homograft to replace a coarcted segment of aorta. In the lab he had
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Fig. 2. Handwritten records like the above were kept by Dr. Gross on each category of surgery cases. The above are the first homografts ever inserted in humans. Note the first eight were used as aorticopulmonary shunts. After these proved successful, aortic replacement for coarctation was performed in case 9.
operated on nearly 100 dogs, the last 25 with only 3 failures, testing homografts. When he finally felt confident that a homograft would work, he elected to insert subclavian homografts between the aorta and the pulmonary artery in infants with tetralogy of Fallot in need of a systemic-pulmonary shunt. After using eight such homografts in the spring of 1948, in May, he replaced a section of the aorta in a child who had a long coarctation (Fig. 2). When you consider the number of vessel grafts and replacements of various sorts used in this country today, this is probably the single most important contribution he made to surgery. I must mention an encounter with Dr. Helen Taussig, the remarkable cardiologist at Johns Hopkins. She knew that tetralogy patients, who were fortunate enough to have a persistent ductus, fared better than those in whom the ductus had closely spontaneously. She had approached Blalock in hopes that he might create an iatrogenic ductus and thus increase the blood flow to the lungs, thus benefiting the cyanotic patient. It is ironic that Blalock, in an effort to create and study pulmonary hypertension, had actually done this operation in dogs in 1938 at Vanderbilt, before he moved to Hopkins. Blalock was unsure that a shunt would benefit a blue baby and at least temporarily refused a trial without further research. Taussig, discouraged at Blalock's attitude, went to Boston. She outlined her proposal to Dr. Gross and after consideration he remembers saying: "Dr. Taussig, I feel that the good Lord has spoken, and that these young patients with tetralogy simply
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don't represent a surgical problem," a statement he regretted thoroughly later on. Later Taussig convinced Blalock to try the shunt, with the brilliant results with which we are all familiar. He often said that episode taught him a lesson about listening to suggestions made by people around him. This was certainly evident in later years when at the operating table he was willing to listen to any suggestions made by the resident, the medical student, or the scrub nurse. Without a lot of discussion, he would quietly evaluate the suggestion and then either use or discard it, but he would listen, because often a very helpful thought had been brought out. After Ladd retired in 1945, Frank Ingram acted as temporary Chief of the surgical service until 1947 when Gross was elevated to professorship at Harvard, Chief of Surgery at the Children's and named the second William E. Ladd Professor of Surgery at the Children's Hospital. In that same year, the Children's Hospital purchased the nearby old Carnegie building for sixty thousand dollars and converted it into research laboratories. Gross, who had been instrumental in that purchase, asked for and received the top (third) floor as a surgical lab which is still active today under the guidance of Bill Bernhard. It was of tremendous importance to the advancement of pediatric surgery to have an experimental facility to devise methods for cure of a wide variety of baffling clinical problems. In a letter I recently received from Orvar Swenson, he stated: "Bob set me up in the laboratory where I could work. All we had to do was present a project to Bob and he always approved. No time was wasted writing for grants. Where he got the money was unknown to me." From this work by Swenson came his monumental contribution to the surgical treatment of Hirschsprung's disease. Early on, the money for that lab came from Gross' pocket and from families of grateful patients. Soon support from foundations and federal grants began to pour in and several million dollars have flowed through that laboratory to date and have had a most stimulating effect on the field of children's surgery. After becoming Chief he reorganized and established a four year pediatric surgery training
ROBERT ALLEN
program. The first year was spent learning about babies, fluids and starting i.v.'s, but you did spend several months assisting the Chief and learning how easy it seemed to perform pediatric surgery. Then, later as a senior resident you learned just how hard it was to perform pediatric surgery. In the third year, 6 months were spent assisting Gross as his senior resident and first assistant. At that time hopefully you learned all the tricks of the trade that he used which made it seem so easy in the first place. Assisting Dr. Gross, doing it yourself, and then assisting him again was an excellent method for training the young surgeon. Until his retirement, almost 200 men spent at least some part of their time in his residency training program. Eleven of the 19 approved pediatric surgery training programs today headed by, or have been headed by, his former residents. There are approximately 50 others who hold academic university pediatric surgery appointments and approximately 80 of his residents are members of APSA. There is a certain magic and prestige to be able to say that you were trained by Dr. Gross. It was during the 1940s and 1950s that he so greatly improved the techniques and results for almost every pediatric surgical procedure. He repaired the first congenital diaphragmatic hernia in an infant under 48 hours of age, developed the skin coverage method for repair of large omphaloceles, performed the first successful pneumonectomy in an infant, resected the first labor emphysema. He was particularly proud of the part he played in lowering the mortality in premature infants undergoing major surgery. A paper entitled, "Surgery In Premature Babies, Observations From 159 Cases," published in 1952 with Colin Ferguson, details with great clarity the best methods of management from the time the baby is transferred and throughout its entire hospital stay. Each of the babies was under 5 lb, 87 of them survived. Even today, in spite of the many recent advances in the field of neonatology, that paper is still filled with common sense and useful information. All of these achievements culminated in what I consider to be the zenith of his career when in 1953 he published his remarkable text, The Surgery of Infancy and Childhood. No surgical text, before or after, has met with such success.
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It was translated into several foreign languages, read by both pediatricians and surgeons throughout the world, was truly authoritative and sold 39,000 copies. It was beautifully organized, well illustrated, written in a simple, concise fashion which was both easy to read and to remember. This text encompassed the entire gamut of pediatric surgery including abdominal, neck, thoracic, cardiac and urological problems, and had much to do with defining and solidifying the field of pediatric surgery as we know it today. He was one of the unique chiefs who could direct productive research, organize a department, teach and write with great clarity and at the same time become one of the great surgical technicians of his era. He had the knack of taking any operative procedure and reducing it to its most simple form. For 25 years this sign hung over the door of his operating room: I f an Operation is Difficult, You are not Doing it Properly. In this statement he was emphasizing that a vast number of operations can be handled best by thinking ahead of time and practicing in one's mind the various and most desirable steps to attain repair or correction of an existing situation. This approach makes it possible to proceed at operation with confidence, skill, and minimal difficulty and perspiration. He was at his very best when there was a major challenge. When he encountered something in an operation that was completely unknown or unseen before, he could assess this situation quickly and move forward just as if it had been done a hundred times previously. Bill Clatworthy remembers an episode when Dr. Gross eased into the operating room and stood behind him watching him operate, something he did to his resident staff quite frequently. Clatworthy was working hard on a hernia sac without really making any headway. Finally Gross said: "Bill, you can go up or you can go down, but for God's sake, go." When things were going badly at an operation, he used to perform what ! called the "Gross shuffle." First, he would begin to moan slightly under his breath, then shake his head back and forth. Next came a slight shuffle of the feet back and forth. If things didn't improve quickly, he would step back from the table, shuffle his feet and finally look at the assistants and give then an
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icy cold stare. I think he gained his composure during this maneuver, but as an assistant you knew to keep your mouth shut, hold still and give him room to work. Not only was he a great surgeon, he was a superb assistant. He had the knack of getting good exposure, letting you perform the operation as long as things were going right. Even if you got into trouble, as long as you made the right moves to get out of trouble, he remained patient and acted only as an excellent assistant. By 1955 he had already made an unbelievable number of outstanding contributions to surgery, but he was still compelled to push back other surgical frontiers. John Gibbon and his wife had been working for many years to unravel the mysteries of cardiopulmonary bypass. Dr. Gross visited Gibbon, picked his brain and studied his enormous, complicated pump oxygenator. Returning to Boston, his comment was that the Philadelphia couple had made enormous strides in physiologic studies (fully worthy of Nobel recognition), but that it would be important to devise a less complicated machine. It was this latter objective which for several years occupied most of Dr. Gross' time, with the help of Lester Sauvage, Bill Bernhard and others in the experimental lab of the Children's and a superb machinist in the basement, a reliable p u m p oxygenator was built and was used very satisfactorily on more than 2,000 patients. This involved an extensive and extremely active research and surgical therapy program, too broad to summarize here. The Chief stepped down as Chief of Pediatric Surgery at the Children's Hospital in 1967, but continued on as Chief of the cardiovascular program until his retirement in 1972. By then he had repaired 1600 ductus' and 800 coarctations. That golden time at the Children's Hospital, roughly from 1940 to 1970, has become known as the Gross era. He did not accomplish all of these things alone and I know he would be unhappy if I did not give credit to many who aided in his accomplishments. It was a wonderful institution to work in and to perform one's labors, and to have so readily available outstanding and helpful colleagues in other departments. Here are the various directors of other hospital departments at the Children's Hospital in 1950: Frank lngram,
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Fig. 3. Department heads at the Children's Hospital in 1950: Front row: Frank Ingram, Sidney Farber, William Green; Back row: Charles Janeway, Guy Brugler (Administrator), Ed Neuhauser, and Robert Gross. (Courtesy of the Children's Hospital. Boston, Mass.).
Neurosurgery; Sidney Farber, Pathology; Willie Green, Orthopedics; Charles Janeway, Pediatrics; Guy Brugler, the Administrator; Ed Neuhauser, Radiology; Lou Diamond, Hematology; Don MacCollum, plastic surgery; Don Matson, Neurosurgery; and finally Bob Smith, Anesthesiology (Fig. 3). Special recognition must be given to Bob Smith and Ed Neuhauser. Surgeons and surgery departments cannot function properly without the aid of an excellent radiologist and anesthesiologist. Neuhauser and Smith pioneered their fields much as Ladd and Gross pioneered pediatric surgery and both are still active at the Children's Hospital today. When you got a consult at the Children's, you got the best. Luther Longino was his right hand man for 20-odd years. Also a superb surgical technician, the residents who trained at the Children's are indebted to hims for the part he played in their surgery training. When you made rounds with Luther, you had to understand that he had a certain type of grunt that meant "yes" and another type grunt that meant "no." However, the decisions that emerged from Luther Longino concerning clinical management of patients were absolutely uncanny. Many tributes have been paid to Dr. Gross.
ROBERT ALLEN
He was the President of the American Association for Thoracic Surgery and the first President of APSA. He received 5 honorary doctorate degrees and was honored with 26 different medals. He was amazed at receiving the Albert Lasker award on two different occasions. Receipt of the Bigelow medal was a distinct and just tribute but at the same time it was a humbling experience to be placed in the company of previous assignments to William Mayo, Matas, J.M.T. Finney, Cushing, Whipple, Lahey, Cutler, Churchell, Dragstedt and Huggins. The Medallion he received for Scientific Achievement from the American Surgical Association and finally his election as a member of The National Academy of Sciences, he gratefully regards as recognition that pediatric surgery has arisen and entered into a permanent place in surgery in this country. I have had two delightful visits to Brattleboro recently and I am happy to report that the Chief is in better physical condition now than in the past several years. He had a difficult problem with a lumbar disc requiring several operations, but at the present time is recovered and full of his usual vim and vigor. We browsed through old records, took long walks in the countryside, reminisced about the good old days, and discussed what needs to be done in the future. During my last visit with Dr. Gross in Brattleboro, he told me that he attributed any success to the fact that he happened to be in the right place at the right time. Aren't we all at the right place at the right time. Very few of us are smart enough or willing to work hard enough to make the best of our situation. As he told Bill Clatworthy when he finished his training program: "Bill, we are all willing to work until midnight, but in order to achieve greatness, you have got to be willing to work past midnight." Genius is a gift. Dr. Gross was given that gift. Greatness, however, had to be achieved by hard work. Through his surgical technical advancements, his publications, his residency training program, the genius and greatness of Dr. Robert Gross contributed more to pediatric surgery than any other surgeon in the first half of this century.
DECEMBER 1980
P r e s i d e n t i a l A d d r e s s : T h e E v o l u t i o n of P e d i a t r i c S u r g e r y By Robert Allen Memphis, Tennessee
q R S T , I would like to welcome all our guests today and I especially want to welcome our wives and families. Most importantly, I want to thank you the members of APSA for having bestowed on me this unique and special honor, that of being your President. This address is a tribute, a few words of love, admiration, respect, and sincere thanks to Robert Edward Gross, APSA's first President. Pediatric surgeons the world over owe him a debt of gratitude for making our specialty what it is today. There is no question that William E . Ladd envisioned, pioneered, and was the founder of pediatric surgery in this country. Dr. Gross, to this day, refers to Ladd affectionately as "the Chief," praising his surgical skill and contributions related to esophageal and biliary atresia, Wilms' tumor and malrotation, to name a few. It was Gross, however, who through his technical advancements, his remarkable quality and quantity (250) of publications and his unique residency training program, broadened, popularized and finally, solidified pediatric surgery as an accepted specialty in this country. Many of you know him personally, some far better than I, but for those of you who don't, perhaps I can conjure up for you a visual image. Picture if you can, an ever youthful, vibrant individual who literally charges the air and stimulates the people about him (Fig. 1). He had the capacity to command enormous respect and inspire intense loyalty from those who worked with him. No matter how long or how well you have known him, you continue to stand in awe and feel a little fearful in his presence. Many consider him aloof, not understanding that he is basically quite shy and a private person. He is meticulous, actually compulsive, when it comes to personal neatness and attire. His coal-black hair was trimmed every Friday afternoon and
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Journal of Pediatric Surgery, Vol. 15, No. 6 (December), 1980
there was never a strand out of place. His trademark was a heavily starched white shirt, red bow tie, and a conservative suit. His compulsion for neatness, however, was only a part of an overall drive for perfection which he demanded from both his house staff and himself. There are many stories related to his demands for neatness, amusing to us now but not so laughable at the time they occurred. Most everyone who passed through his training program at one time or another received a cryptic note from the desk of " R E G , " in some way related to improper attire, much like the one sent to Jud Randolph in 1958. From Gross to Randolph: "In the dining room coats should be worn, signed R E G ; " or like this one to Eraklis: "Sin all you want, but don't smoke at the nursing station." George Holcomb received 50r for a haircut on more than one occasion and innumerable people, many who are now professors of pediatric surgery, received bottles of white Shinola when they failed to keep their shoes properly white. He also evaluated patients' families for propriety. On an office chart of a child with an undescended testicle, he added at the end of his evaluation: "Father did not wear tie. Mother a gum chewer."
From the Departments o f Surgery and Pediatrics, University o f Tennessee Center for the Health Sciences and LeBonheur Children's Medical Center, Memphis, Tenn. Presented before the l I th Annual Meeting o f the American Pediatric Surgical Association, Marco Island, Florida, May 7-10, 1980. Address reprint requests to Robert Allen, M.D., Departments o f Surgery and Pediatrics, Univesity o f Tennessee Center f o r the Health Sciences and LeBonheur Children's Medical Center, Memphis, Tenn. 9 1980 by Grune & Stratton, Inc. 0022-3468/80/1506M)001 $01.00/0 711
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ROBERT ALLEN
Fig. 1.
Dr. Robert Edward Gross.
One of the most famous stories handed down from year to year, one which ! was privileged to witness, concerned Walter Ellerbeck, a young rotating resident from the Brigham. In the locker room one morning, Walter appeared in white shoes that were both dirty and bloody, and the blood was old, not fresh. Dr. Gross didn't choose to chew Walter out verbally, something he rarely did to his resident staff. He didn't need to. He had a way of giving a very cold, icy stare, one that could freeze salt water. He didn't have to say much, you usually knew what was wrong and how to solve the problem. He took Walter's
shoes back to the bathroom. He unlaced one shoe, scrubbed it with soap and water and got his white Shinola and shined the shoe to perfection. He relaced it and then washed the excess polish from the red sole. Without smiling and not joking he handed the shoe back and said: "Walt, they had better stay this way," turned and walked out. I asked: "Walter, what did you do back there while Gross was shining your shoes?" He said: " W h a t could I do? I couldn't offer to help shine the shoe and I couldn't leave. I just had to stand there, watch, and suffer." Gross was born in July 1905. He was the son
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of a piano maker and the seventh of eight children. Of his 5 sisters, 1 died in her early 20s, 2 became housewives, 1 became a college president, and 1 a physician. His two brothers attended M.1.T., one continued on as an engineer and the other brother also became a college president. Although Gross did not attend M.I.T., he was an engineer at heart with a mechanistic bent, a characteristic that surfaced throughout his career. As a youth he was mischievous, inquisitive, industrious, and creative. At age 12, when his father was expected to be out of town for about a week, young Robert took the engine of the family car completely apart to see what made it run. His father returned 3 days early, and possibly the icy stare that Dr. Gross later used so effectively was learned at that time. On seeing the dismantled engine, his father didn't rant and rave, he simply told Robert to put the engine back together before morning and not to leave out a single piece, a job he accomplished. At a little later age, Robert had a beautiful, brown woollen suit of which he was very proud and wore frequently, so frequently that it became quite shiny, but not worn out. Rather than discard this suit, he took it completely apart, reversed it, relined it, restitched it, and wore it for many years thereafter. He attended Baltimore Polytechnic High School and from there went to Carleton College in Minnesota, a very competitive but small college, then as it is now. At Carleton he majored in chemistry. In the early part of his senior year he won a scholarship to attend the University of Wisconsin for three years of doctoral training in chemistry. A major turning point in his life occurred during Christmas vacation of his senior college year when he was given the magnificent twovolume set entitled, The Life of Sir William Osler, written by Harvey Cushing, then the Chief of Surgery at the Peter Bent Brigham Hospital. Gross became totally absorbed in these books, read and restudied them that spring, deciding then to enter medicine, a thought which had not occurred previously. Cushing became his idol and stimulation to apply to Harvard Medical School where he was accepted, much to his surprise. Early in his first year of medical school, the
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ever inquisitive student found his way to the surgical research lab, the old dog lab in Building C and volunteered his services for various research projects. Here his interest in both surgery and research blossomed and he continued to work in the lab on a volunteer basis throughout his entire medical school days, kindling an enthusiasm for personal involvement in research which persisted throughout his academic life. During the last months of medical school, Gross first came in contact with Dr. William Ladd and solidly decided to follow the master into pediatric surgery. After medical school graduation in 1931, his formal training included 2 years of pathology, 3 years of general surgery (which included 6 months as traveling fellow to European surgical centers), and 3 years in pediatric surgery under Dr. Ladd. Following this he became a junior on Dr. Ladd's staff. He rotated through various jobs as openings became available. In the 1930s this was a strong background for general and pediatric surgery. His training began in pathology under Dr. Burt Wolbach, a scientist of broad scope and understanding. Wolbach devoted much time on a one to one basis with his house staff, and unquestionably played a major role in directing Gross' career. Wolbach insisted on careful and detailed autopsy reports and that each report be ended with recommendations as to how that patient might have fared better or have been treated more appropriately during his lifetime. I uncovered an autopsy report that Gross filed in 1931, his first year out of medical school. The post was on a 4-month-old baby admitted to the hospital with severe wheezing, diffieulaty in swallowing, followed by pneumonia and death. The clinical diagnosis had been mediastinal cyst. I would like to make a few excerpts from that autopsy summary: "The arch of the aorta is in an abnormal position, extending to the right and then up and posteriorly to go behind the esophagus and then down to the left along its normal course. A ductus arteriosus runs from the pulmonary artery back to the arch. There is then a vascular constricting circle around the esophagus and trachea. This is composed of the arch of the aorta, the pulmonary artery and an open ductus arteriosus." He concluded that "division
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of this vascular circle might have relieved the patient's symptoms." Another pathology resident involved in the same autopsy (in his summary which Wolbach required) stated: "It is quite doubtful whether any aid could have come from local surgical interference." This fatal case, long remembered, was the basis for subsequently leading Dr. Gross into performance of over 200 operations on babies and children who were suffering from various sorts of intrathoracic vascular anomalies giving rise to troublesome obstruction of the esophagus or trachea, or both, many of them life-threatening. As a surgery resident under Elliott Cutler, two of his running mates were Robert Zollinger and Bert Dunphy. I wonder if Cutler had any idea that these three young men, Gross, Zollinger and Dunphy, all under his tutelage at one time, would each make a significant mark on American surgery. Gross' fame came early when at the age of 33, in 1938, while he was still serving as chief resident, he literally opened the field of cardiac surgery by successfully ligating a patent ductus arteriosus. Sporadic attempts at cardiac surgery had been made unsuccessfully in various centers but the closure of a ductus in 1938, followed by other subsequent successes, was the explosion that opened the field of cardiac surgery. What led up to that event? Gross gives his classmate, Dr. John Hubbard, a great deal of credit. After graduation, Hubbard entered pediatrics and used to encourage and needle Gross to work on operations to help some of the children who had congenital heart problems. Eventually these two residents went to Dr. Blackfan, who was the Chief of Pediatrics at the time, a man for whom Dr. Gross had great respect and told him that of all the various congenital defects, they felt that an open ductus was the most amenable to surgical correction. Blackfan, to their surprise, agreed and encouraged the young men, but he insisted that they take their efforts first to the dog lab, create ductuses in dogs and then reoperate and close the shunts for practice. This is exactly what was done in 1936 and 1937. Gross, in 1938, sensed that Ladd would not sanction a proposal to attempt surgical closure of an open ductus in a human patient. Blackfan and
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Cutler, however, both encouraged him; in fact, Cutler said: "You'd better get on with it or somebody is going to beat you to it." Not only did Dr. Gross not consult Ladd, but while Ladd was away on vacation, he admitted 7-year-old Lorraine Sweeney to the Children's Hospital and successfully closed her ductus on August 26, 1938. Bessie Lank, nurse anesthetist at the Children's Hospital for over 30 years was at the head of the table and had only a tight-fitting mask and no endotracheal tube. No chest tube was required postop and there were no complications; the child was out of bed the next day. Word spread rapidly about this success. Ladd's only comment, that we know of, when he returned to town, was that he felt the undertaking was probably a bit premature. He may have had a few other remarks that we don't know about. The second ligation of a ductus took place three weeks later and this attracted the dean of the medical school to observe this new miracle. As luck would have it, while dissecting around the back side of a huge ductus, a large hole was made in the ductus itself. An enormous amount of blood filled the entire operative field. This being only the second major vascular case that Gross had ever done, you can be sure that he had never seen that much blood lost that quickly. It is a credit to his dexterity that somehow he got heavy ligatures around that ductus and tied the whole thing down tightly, stopping the hemorrhage. The boy rapidly recovered. Over the next decade he performed many firsts in surgery. In every instance, an enormous amount of careful lab work was undertaken and accomplished before a clinical case was undertaken. Studying the possibility and practicality of surgically correcting aortic coarctations of humans, extensive work was carried on in the research animal laboratory. Aortas were severed and resutured by various techniques; clamps were applied to the aorta and timed carefully to determine the safe interval before hind leg paralysis occurred. Aortic autografts, homografts, and heterografts were collected, preserved in various types of solutions and transplanted from dog to dog. The extensive research work in 1938 and 1939 with Dr. Charles Hufnagel showed
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that it was going to be possible to resect a coarctation of the aorta in humans and reconstruct an aortic pathway (either by direct suture of aortic ends, or in other instances by insertion of a graft whenever necessary). I uncovered a letter written by Dr. Gross in 1941 to Dr. Eugene Eppinger, who was a valued medical colleague, cooperating in studies and management of patients with congenital cardiovascular anomalies: Dear Gene: Last Saturday, April 5, after having had a thoroughly discouraging day, I went late in the afternoon and did unrewarding posts on those puppies (on which he had attempted making aortic valve stenoses). Each of them had died of left ventricular failure. We will have to create valvular stenosis more slowly, so the ventricle can progressively build up to an increasing strength. And then there was that 15-year-old girl I had operated upon a month ago for ligation of her patent ductus. At home, the ligatures suddenly cut through and she died instantly of hemorrhage. Sorry to send all the bad news to you. Bob
It was only a short time after this that he completely abandoned ligation of a patent ductus and used ductal division and individual suture closures of the aorta and pulmonary artery. This became the standard operation in nearly 1600 patients on the service. The summer of 1945 was noteworthy. On June 9th, he divided the first vascular ring, a double aortic arch. Quoting from his op note: "During the first part of the operation, the respiratory distress caused extreme anxiety. There was a pronounced shift in the mediastinum with each respiratory movement, making the dissection quite difficult. First, I divided the ligamentum arteriosum. This had some slight beneficial effect, but it was not marked. I then decided it necessary to divide some portion of the arterial ring that encircled the esophagus and trachea. The anterior arch was severed." Three weeks later on June 28th, he repaired his first human coarctation. Two more firsts were accomplished in May, 1948. On the 22nd, he successfully closed the first aortico-pulmonary window. Two days later he inserted the first arterial homograft to replace a coarcted segment of aorta. In the lab he had
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Fig. 2. Handwritten records like the above were kept by Dr. Gross on each category of surgery cases. The above are the first homografts ever inserted in humans. Note the first eight were used as aorticopulmonary shunts. After these proved successful, aortic replacement for coarctation was performed in case 9.
operated on nearly 100 dogs, the last 25 with only 3 failures, testing homografts. When he finally felt confident that a homograft would work, he elected to insert subclavian homografts between the aorta and the pulmonary artery in infants with tetralogy of Fallot in need of a systemic-pulmonary shunt. After using eight such homografts in the spring of 1948, in May, he replaced a section of the aorta in a child who had a long coarctation (Fig. 2). When you consider the number of vessel grafts and replacements of various sorts used in this country today, this is probably the single most important contribution he made to surgery. I must mention an encounter with Dr. Helen Taussig, the remarkable cardiologist at Johns Hopkins. She knew that tetralogy patients, who were fortunate enough to have a persistent ductus, fared better than those in whom the ductus had closely spontaneously. She had approached Blalock in hopes that he might create an iatrogenic ductus and thus increase the blood flow to the lungs, thus benefiting the cyanotic patient. It is ironic that Blalock, in an effort to create and study pulmonary hypertension, had actually done this operation in dogs in 1938 at Vanderbilt, before he moved to Hopkins. Blalock was unsure that a shunt would benefit a blue baby and at least temporarily refused a trial without further research. Taussig, discouraged at Blalock's attitude, went to Boston. She outlined her proposal to Dr. Gross and after consideration he remembers saying: "Dr. Taussig, I feel that the good Lord has spoken, and that these young patients with tetralogy simply
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don't represent a surgical problem," a statement he regretted thoroughly later on. Later Taussig convinced Blalock to try the shunt, with the brilliant results with which we are all familiar. He often said that episode taught him a lesson about listening to suggestions made by people around him. This was certainly evident in later years when at the operating table he was willing to listen to any suggestions made by the resident, the medical student, or the scrub nurse. Without a lot of discussion, he would quietly evaluate the suggestion and then either use or discard it, but he would listen, because often a very helpful thought had been brought out. After Ladd retired in 1945, Frank Ingram acted as temporary Chief of the surgical service until 1947 when Gross was elevated to professorship at Harvard, Chief of Surgery at the Children's and named the second William E. Ladd Professor of Surgery at the Children's Hospital. In that same year, the Children's Hospital purchased the nearby old Carnegie building for sixty thousand dollars and converted it into research laboratories. Gross, who had been instrumental in that purchase, asked for and received the top (third) floor as a surgical lab which is still active today under the guidance of Bill Bernhard. It was of tremendous importance to the advancement of pediatric surgery to have an experimental facility to devise methods for cure of a wide variety of baffling clinical problems. In a letter I recently received from Orvar Swenson, he stated: "Bob set me up in the laboratory where I could work. All we had to do was present a project to Bob and he always approved. No time was wasted writing for grants. Where he got the money was unknown to me." From this work by Swenson came his monumental contribution to the surgical treatment of Hirschsprung's disease. Early on, the money for that lab came from Gross' pocket and from families of grateful patients. Soon support from foundations and federal grants began to pour in and several million dollars have flowed through that laboratory to date and have had a most stimulating effect on the field of children's surgery. After becoming Chief he reorganized and established a four year pediatric surgery training
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program. The first year was spent learning about babies, fluids and starting i.v.'s, but you did spend several months assisting the Chief and learning how easy it seemed to perform pediatric surgery. Then, later as a senior resident you learned just how hard it was to perform pediatric surgery. In the third year, 6 months were spent assisting Gross as his senior resident and first assistant. At that time hopefully you learned all the tricks of the trade that he used which made it seem so easy in the first place. Assisting Dr. Gross, doing it yourself, and then assisting him again was an excellent method for training the young surgeon. Until his retirement, almost 200 men spent at least some part of their time in his residency training program. Eleven of the 19 approved pediatric surgery training programs today headed by, or have been headed by, his former residents. There are approximately 50 others who hold academic university pediatric surgery appointments and approximately 80 of his residents are members of APSA. There is a certain magic and prestige to be able to say that you were trained by Dr. Gross. It was during the 1940s and 1950s that he so greatly improved the techniques and results for almost every pediatric surgical procedure. He repaired the first congenital diaphragmatic hernia in an infant under 48 hours of age, developed the skin coverage method for repair of large omphaloceles, performed the first successful pneumonectomy in an infant, resected the first labor emphysema. He was particularly proud of the part he played in lowering the mortality in premature infants undergoing major surgery. A paper entitled, "Surgery In Premature Babies, Observations From 159 Cases," published in 1952 with Colin Ferguson, details with great clarity the best methods of management from the time the baby is transferred and throughout its entire hospital stay. Each of the babies was under 5 lb, 87 of them survived. Even today, in spite of the many recent advances in the field of neonatology, that paper is still filled with common sense and useful information. All of these achievements culminated in what I consider to be the zenith of his career when in 1953 he published his remarkable text, The Surgery of Infancy and Childhood. No surgical text, before or after, has met with such success.
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It was translated into several foreign languages, read by both pediatricians and surgeons throughout the world, was truly authoritative and sold 39,000 copies. It was beautifully organized, well illustrated, written in a simple, concise fashion which was both easy to read and to remember. This text encompassed the entire gamut of pediatric surgery including abdominal, neck, thoracic, cardiac and urological problems, and had much to do with defining and solidifying the field of pediatric surgery as we know it today. He was one of the unique chiefs who could direct productive research, organize a department, teach and write with great clarity and at the same time become one of the great surgical technicians of his era. He had the knack of taking any operative procedure and reducing it to its most simple form. For 25 years this sign hung over the door of his operating room: I f an Operation is Difficult, You are not Doing it Properly. In this statement he was emphasizing that a vast number of operations can be handled best by thinking ahead of time and practicing in one's mind the various and most desirable steps to attain repair or correction of an existing situation. This approach makes it possible to proceed at operation with confidence, skill, and minimal difficulty and perspiration. He was at his very best when there was a major challenge. When he encountered something in an operation that was completely unknown or unseen before, he could assess this situation quickly and move forward just as if it had been done a hundred times previously. Bill Clatworthy remembers an episode when Dr. Gross eased into the operating room and stood behind him watching him operate, something he did to his resident staff quite frequently. Clatworthy was working hard on a hernia sac without really making any headway. Finally Gross said: "Bill, you can go up or you can go down, but for God's sake, go." When things were going badly at an operation, he used to perform what ! called the "Gross shuffle." First, he would begin to moan slightly under his breath, then shake his head back and forth. Next came a slight shuffle of the feet back and forth. If things didn't improve quickly, he would step back from the table, shuffle his feet and finally look at the assistants and give then an
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icy cold stare. I think he gained his composure during this maneuver, but as an assistant you knew to keep your mouth shut, hold still and give him room to work. Not only was he a great surgeon, he was a superb assistant. He had the knack of getting good exposure, letting you perform the operation as long as things were going right. Even if you got into trouble, as long as you made the right moves to get out of trouble, he remained patient and acted only as an excellent assistant. By 1955 he had already made an unbelievable number of outstanding contributions to surgery, but he was still compelled to push back other surgical frontiers. John Gibbon and his wife had been working for many years to unravel the mysteries of cardiopulmonary bypass. Dr. Gross visited Gibbon, picked his brain and studied his enormous, complicated pump oxygenator. Returning to Boston, his comment was that the Philadelphia couple had made enormous strides in physiologic studies (fully worthy of Nobel recognition), but that it would be important to devise a less complicated machine. It was this latter objective which for several years occupied most of Dr. Gross' time, with the help of Lester Sauvage, Bill Bernhard and others in the experimental lab of the Children's and a superb machinist in the basement, a reliable p u m p oxygenator was built and was used very satisfactorily on more than 2,000 patients. This involved an extensive and extremely active research and surgical therapy program, too broad to summarize here. The Chief stepped down as Chief of Pediatric Surgery at the Children's Hospital in 1967, but continued on as Chief of the cardiovascular program until his retirement in 1972. By then he had repaired 1600 ductus' and 800 coarctations. That golden time at the Children's Hospital, roughly from 1940 to 1970, has become known as the Gross era. He did not accomplish all of these things alone and I know he would be unhappy if I did not give credit to many who aided in his accomplishments. It was a wonderful institution to work in and to perform one's labors, and to have so readily available outstanding and helpful colleagues in other departments. Here are the various directors of other hospital departments at the Children's Hospital in 1950: Frank lngram,
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Fig. 3. Department heads at the Children's Hospital in 1950: Front row: Frank Ingram, Sidney Farber, William Green; Back row: Charles Janeway, Guy Brugler (Administrator), Ed Neuhauser, and Robert Gross. (Courtesy of the Children's Hospital. Boston, Mass.).
Neurosurgery; Sidney Farber, Pathology; Willie Green, Orthopedics; Charles Janeway, Pediatrics; Guy Brugler, the Administrator; Ed Neuhauser, Radiology; Lou Diamond, Hematology; Don MacCollum, plastic surgery; Don Matson, Neurosurgery; and finally Bob Smith, Anesthesiology (Fig. 3). Special recognition must be given to Bob Smith and Ed Neuhauser. Surgeons and surgery departments cannot function properly without the aid of an excellent radiologist and anesthesiologist. Neuhauser and Smith pioneered their fields much as Ladd and Gross pioneered pediatric surgery and both are still active at the Children's Hospital today. When you got a consult at the Children's, you got the best. Luther Longino was his right hand man for 20-odd years. Also a superb surgical technician, the residents who trained at the Children's are indebted to hims for the part he played in their surgery training. When you made rounds with Luther, you had to understand that he had a certain type of grunt that meant "yes" and another type grunt that meant "no." However, the decisions that emerged from Luther Longino concerning clinical management of patients were absolutely uncanny. Many tributes have been paid to Dr. Gross.
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He was the President of the American Association for Thoracic Surgery and the first President of APSA. He received 5 honorary doctorate degrees and was honored with 26 different medals. He was amazed at receiving the Albert Lasker award on two different occasions. Receipt of the Bigelow medal was a distinct and just tribute but at the same time it was a humbling experience to be placed in the company of previous assignments to William Mayo, Matas, J.M.T. Finney, Cushing, Whipple, Lahey, Cutler, Churchell, Dragstedt and Huggins. The Medallion he received for Scientific Achievement from the American Surgical Association and finally his election as a member of The National Academy of Sciences, he gratefully regards as recognition that pediatric surgery has arisen and entered into a permanent place in surgery in this country. I have had two delightful visits to Brattleboro recently and I am happy to report that the Chief is in better physical condition now than in the past several years. He had a difficult problem with a lumbar disc requiring several operations, but at the present time is recovered and full of his usual vim and vigor. We browsed through old records, took long walks in the countryside, reminisced about the good old days, and discussed what needs to be done in the future. During my last visit with Dr. Gross in Brattleboro, he told me that he attributed any success to the fact that he happened to be in the right place at the right time. Aren't we all at the right place at the right time. Very few of us are smart enough or willing to work hard enough to make the best of our situation. As he told Bill Clatworthy when he finished his training program: "Bill, we are all willing to work until midnight, but in order to achieve greatness, you have got to be willing to work past midnight." Genius is a gift. Dr. Gross was given that gift. Greatness, however, had to be achieved by hard work. Through his surgical technical advancements, his publications, his residency training program, the genius and greatness of Dr. Robert Gross contributed more to pediatric surgery than any other surgeon in the first half of this century.