Timelines in the history of pediatric surgery

Timelines

in the History ByJack

of Pediatric

Surgery

H.T. Chang

Denver, Colorado

P

EDIATRIC SURGERY is a recently developed subspecialty. It is of interest to examine its historic progress relative to social events, medical and scientific developments, and its parent specialty of general surgery (Table 1). From a historic standpoint, one may gain a perspective as to the future of pediatric surgery.

surgical procedures were contained in the Cerrahiyei Zlhaniye, a handwritten Turkish manuscript by Sabuncuoglu illustrating probing for imperforate anus, treatment for perineal fistula, repair of inguinal hernia, correction of hypospadias, circumcision, and treatment for fused vaginal labia.

1450 TO 1600

1600 TO 1700

The period after the fall of Constantinople to the Ottoman Turks is known as the Renaissance. This period produced a revival of learning due to the exodus of Byzantine men of science, arts, and letters from Asia Minor and the spread of printing from Mainz, Germany, throughout Europe. Art and literature flourished under the hands of Michelangelo, Leonardo da Vinci, and Shakespeare. Exploration extended to the New World; the Magellan expedition circumnavigated the globe, and Vasco de Gama found the long-awaited sea route to India. Religious unrest resulted in the Reformation of Martin Luther and the rise of Protestantism and other sects. Science and medicine were at best primitive. The heliocentric astronomy of Copernicus was considered heresy, and Galileo had just begun his studies of falling bodies. The study of human anatomy was initiated by Leonardo da Vinci and the publication of Vesalius’s De Fabrica Corporis. The world was intermittently ravaged by the plague, influenza, dysentery, and syphilhs; isolationism was the only (unsuccessful) remedy. Infant mortality was extremely high due to poor hygiene. Notable pediatric publications were that of Bagellardo, Metlinger (who first mentioned the nippled nursing can), and Phaer (who wrote the first English work on the diseases of children.) Ambrose Pare, the greatest French surgeon of the time, gained prominence by discarding the use of hot oil to cauterize wounds. Surgery in children was limited to trephining, removal of bladder stones, and surface procedures. The most extensive pediatric

The 17th century was the “Age of Kings,” when monarchs held absolute power over the people, and alliances and borders changed with the tides of war. Art, philosophy, and literature continue to thrive through people including Milton, Shakespeare, Moliere, Spinoza, Bacon, Locke, Descartes, and Rembrandt. In America, the Pilgrims arrived at New Plymouth, Mass; the Dutch founded New Amsterdam; and Jamestown, Va, established its Parliament and imported slaves for the fields. In the sciences, Galileo constructed an astronomical telescope to explore the macrocosm while Hooke and Leeuwenhoek used the microscope to examine the microcosm. Medicine advanced from static anatomical descriptions to a consideration of function as reflected by Harvey’s description of the circulation of blood and Malpighi’s De Pulmonibus detailing the capillary system. This was a particularly cruel period for children with infanticide and abandonment common even though laws were passed in England, Europe, Japan, and China against such practices. Those unfortunates relegated to charitable institutions were neglected and not uncommonly drugged. Children were used as beggars and purposefully malformed to further their sympathetic appeal (a treatise on how to deform children was even quoted in Victor Hugo’s L ‘Homme qui Rit). Saint Vincent de Paul was said to have saved a child whose limbs were being deformed; he organized “dames de charite” to care for these unfortunate waifs and founded the Hospice des Enfans Trouves. Surgery remained primitive with speed the keynote; rare survivors were reported after celiotomy. Blood, recognized as an important determinant of health, was withdrawn or occasionally transfused (from both animals and humans) with equally unpredictable results. In 1612, Felix Wurtz, a Swiss surgeon, appended The Children’s Book to his Practica der Wundartzney. Cited by Garrison as the first treatise on infantile surgery, it was little more than common sense advice in the care and feeding of infants with particular emphasis to prevent orthopedic deformities.

From the Department of Pediatric Surgery, The Children’s Hospital in Denver. Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto, Ontario, May 14-17. 1986. Address reprint requests to Jack H.T. Chang, MD, Suite 501, 1056 East Nineteenth Avenue, Denver, CO 80218 0 I986 by Grune & Stratton, Inc. 0022-3468/86/2112-0010$03.00/0 1068

Journal of Pediatric Surgery, Vol2 1, No 12 (December), 1986: pp 1068- 1072

THE HISTORY OF PEDIATRIC SURGERY

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Table 1. Pediatric Surgery Timeline World Events

Years 1450 to 1599

1453

Fall of Constantinople

1453

Beginning of the Re-

1517

1454

1584

1472

printing

Surgeryand PediatricSurgery

Bagellardo, Pediatric

with pediatric surgery

1473

Metlinger’s Regiment

1544

Miro coined Pedene-

Indies

16001 1512

Circumnavigation

Heliocentric astronVesalius’s De fabrica

Paris decree for indigent care

omy of Copernicus 1543

1564

Raleigh annexes Vir-

procedures 1540

meci 1547

Cerrahivei Ilhanive Turkish manuscnpt

Pandemic and epi-

Luther begins the Re-

1465

lncunabula

demic plagues (to

1478

formation 1522

Gutenberg Invents

Pediatricsand Nursing

Columbus discovers

naissance 1492

Scienceand Medicine

English barbers and surgeons united

575

Pare, Les Oeuvres

Aranzi De Human0 Foetu

ginia

1573

Pare introduced version

1600 to 1699

1607

Jamestown, Virginia,

1608

1619

First black slave in

1628

Pilgrims at New Ply-

1662

mouth, Mass 1626 1651

Dutch found New

1665

1 733

755

Industrial Revolution

1733 1735

dependence French Revolution

1797

U.S. opens trade with

Beginning of Industrial Linnaeus’s Systema

1761

Morgagni’s De Sedi-

1730

Lavoisier respiratory

1761

Eli Whitney’s cotton

1777

1799

Davy, anesthetic ni-

1784

1803

Louisiana Purchase

1816

1796

1812

War Between Britain

1842

Marx and Engels’s

1843

1861

American Civil War Alaska sold by Russia to U.S.

1884

1858 1859

1821

Virchow, Cellular PaDarwin’s Origin of

1865

Mendel’s Laws of

1836

Lister’s antiseptic

1852

1877

Koch stains bacteria

1880

Edison invents electric lights

1885 1888

1860 1865 1875

Rontgen discovers Curies discover ra-

1783

Duboise used Littre colost for imperforate

Underwood published

anus 1794

Jenner vaccination for

Hunter, experimental surgery

Seaman training

Hospital des Enfants

1835

1889

Meckel theory of re-

1846

English child labor

1852

Hospital for Sick Chil-

1868

1896

Nightingale nursing

1871

Banks, hernia repair

French Child Protec-

1884

tion Socrety

1886

Fitz, appendicitrs

Pediatrist recognized

1887

Olhausen omphaloc

Pediatric section

skin close AMA

Tarnier developed inRetch first milk laboStraus opened milk Retch percentage Holt published Therapeutics

1898

Hutchinson reduces tntussusception

feedings 1896

Holmes text on pediatric surgery

stations

dium

Pollock, surgeon Hospital for Sick Children

1889

Rubner and Heubner lnfan t Nutrition

Halsted residency program

1892

Bayer myelomeningoc flap closure

1898

ratory 1892

Coley? first pedratric surgeon

cubator 1891

Amussat, perineal anoplasty

formed

x-rays 1898

Frank initiated public

specialist 1880

era 1895

Oehme treatise on pediatric surgery

training

Benz builds motor car Eastman invents cam-

1773

dren

principles

tional disputes

Rousseau published

legislation

Heredity 1865

Barbers/surgeons separated

capitulation

Species

First Hague Conference to settle interna-

Holmes, Puerperal Fe-

1745

Malades

thology

Berlin Conference on the Partition of Africa

1899

1802

ver Cause

Manifesto 1867

Long uses ether anes-

tnfantile mor-

school for nurses

thetic

and U.S. 1848

Laennec invents

74.5%

smallpox 1798

stethosocpe

from France

Mayor, human transfusion

Needham placental

treatise

trous oxide 1800 to 1899

lamb blood 1668

health

gin

Japan

1667

Emile

gases 1792

Minnus, torticollis surgery Denis. transfused

tality, London

bus 1777

1651

nourishment

Na turae

War of American In-

1789

1667

Hildanus, trocar for hydrocephalus

Kircher found bacteria in mrlk

Revolution

Mason-Dixon Line established

775

Leeuwenhoek de-

1658

scribes bacteria

French and Indian War

1767

fans

Hooke publishes Mi-

Wurtz. The Children’s Book

1646

“dames de charite”

croscope

1612

St. Vincent de Paul and Hospice de En-

Hobbes publishes Leabsolute monarchy

1700 to 1799

dren 1617

Royal Society char-

crographia on the mi1683

English Poor Law, apprenticeship of chil-

tered

Amsterdam viathan in defense of

1602

Harvey. Circulation of Blood

Virginia 1620

Galileo makes telescope

founded

Kirmisson embryology and surgical defects

1899

Ahlfeld alcohol dress ings for omphaloceles

JACK H.T. CHANG

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Table 1. Pediatric Years

1900 to present

World Events

I

1914

World War

1929

U.S. stock market collapses

1935

1945

Scienceand Medicine 1901 1903 1909

1948

U.N. Charter signed

1915

1963

1910

Einstein’s theory of

1911

Banting and Best iso-

1912

1943

1919

1962

1929

First automatic com-

1923

White House confer-

1941

Haight, EA/TEF repair

ence on child welfare

1944

Blalock. Taussig shunt Swenson procedure

American Nurses As-

1948

sociation founded

1948

Surgical section AAP

Kiebel and Mall, em-

1953

Gibbon heart/lung machine

Marriott, fluid acid

1953

1948

Fiickham, neonatal surgery unit

Garrod inborn errors

1954

of metabolism

Kolff devised artificial

Forssmann. cardiac catheterization

and base

kidney 1957

English notification of

Rammstedt, pyloromyotomy

bryology

Fleming discovers

puter (U.S.)

Peace treaty between Israel and Egypt

Ehrlich prepared Sal-

penicillin 1942

1912

birth

lated insulin 1928

U.S. lands on the moon

1979

1921

Nuclear test ban treaty signed

1969

1907

relativity

State of Israel declared

Wright bros. flying

Surgeryand PediatricSurgery

Czerny interm metabolism and nutrition

varsan for syphilis

against Japan 1945

Pediatricsand Nursing 1906

machine

World War II Atomic bomb used

Landsteiner discovered blood groupings

Roosevelt signs Social Security Act

1939

Surgery Timeline (Cont’d)

Merrill, kidney transplant

Farber cancer chemo-

1962

Benson et al, textbook

therapy

1970

APSA formed

1975

Russian sputnik I

1954

Salk polio vaccine

launched

1970

Intensive care of new-

cial competency in pe-

borns

diatric surgery

Watson and Crick win Nobel Prize for DNA

1978 1979

Examination for spe-

“Test tube” baby UN.

International

Year of the Child

1700

TO 1800

Politically, the 18th century was one of revolutions, notably that of the American colonies and by the French. Understandably, the literature reflected the times, particularly in the works of Voltaire and Rousseau. The development of the “flying shuttle,” a machine to speed weaving, by the Englishman John Kay in 1733 heralded the Industrial Revolution. Steam was used as a source of energy and, by the end of the century, Eli Whitney had invented the cotton gin. In science, Linnaeus had established his method of classification of animals and plants. Black, Priestley, and Lavoisier advanced the knowledge of gases and respiration. This was a century of rich clinical and pathologic descriptions. The most important works were De Sebibus, et Causis Morborum per Anatomen Indagatis Libri Quinque, by Morgagni, a classic in clinical pathology, and Avenbrugger’s Inventum Novum

describing the use of chest percussion for diagnosis. The pediatric literature was replete with case descriptions of gastrointestinal (esophageal atresia, pyloric stenosis, duplication, intestinal atresia, and intussusception) and neurologic anomalies as well as infectious diseases. Unfortunately, morbid anatomy rather than therapeutic success was the usual report. Mortality of infants and children varied from 74.5% in London to 80% in Paris to 99.6% in Dublin. By the end of this century, Edward Jenner had introduced the use of vaccination against smallpox. John Hunter, the greatest surgeon of his day, began experimental surgery including transplantation. Pediatric surgical

works were sparse, and Oehme’s treatise was very limited in scope. As early as 17 10, Littre suggested the use of colostomy for the relief of imperforate anus. Unfortunately, it took nearly 75 years before Duboise used Littre’s technique. 1800

TO 1900

The 19th century was one of expansionism of Europeans in Africa and of Americans in the New World. By the end of the century, the United States had obtained, in order, the Louisiana Territory, Florida, Texas Territory, California, New Mexico, Alaska, Hawaii, Puerto Rico, Guam, and the Phillipines. The United States had suffered through 4 years of civil war and was undergoing reconstruction. Science and medicine were in ascendancy. In 100 short years, the telegraph, telephone, phonograph, electric light, camera, and car were invented. Dalton advanced his atomic theory, Helmholtz published the Conservation of Energy, and Darwin’s Origin of the Species came into print. Medicine advanced further in this century than in the previous 18. Medical schools were established, replacing apprenticeship in America. Beaumont, McLeod, Mueller, and Cannon instituted the study of physiology. Virchow published Cellular Pathology, Mendel enunciated the laws of heredity, and Rontgen discovered the x-ray, which, within 3 years, was used to study gastrointestinal motility and to treat cancer. In 1816, Laennec invented the stethoscope, which 3 years later he used to make the diagnosis of congenital diaphragmatic hernia, even

THE HISTORY OF PEDIATRIC SURGERY

suggesting surgical intervention. Ironically, Sir Astley Cooper, a prominent surgeon of the time, felt that congenital diaphragmatic hernias were inoperable and incurable. The two greatest medical advancements were in bacteriology and anesthesia. Oliver Wendell Holmes and, later, Ignais Semmelweis determined that the cause of puerperal fever was a contact contagion. Koch and Pasteur showed that bacteria were the cause of disease, and Lister introduced antisepsis in surgery. While Davey had described the anesthetic properties of nitrous oxide in 1799, it was not until the 1840s that Long and Morton used ether for dental extraction and surgical procedures. The Hopital des Enfant Malades in Paris was founded in 1802, and by the middle of the century, the Hospital for Sick Children, London; the Children’s Hospital and Nursery, New York; and the Children’s Hospital of Philadelphia were established. Bloodletting, swaddling, and mercenary wet-nursing, commonly practiced in the early 1800s all but vanished by the end of the century. New therapeutic modalities, such as incubators, umbilical vein transfusions for respiratory symptoms, artificial feeding, and fluid replacement, were tried. Classic texts were published by outstanding pediatrists including DeWees, West, Gerhardt, Keating, and Jacobi. Such concentrated interest naturally resulted in the publication of periodicals (Analekten Uber Kinderkrankheiten, 1834; Archives of Pediatrics, 1884) and the formation of societies (Societe Protectrice de L’Enfance, 1865; Society for the Prevention of Cruelty to Children, 1874; Pediatric Section of the American Medical Association, 1880; American Pediatric Society, 1888). These societies lobbied for the passage of many laws protecting children in school, at home, and in employment. By 1860, coincident with the development of pediatric hospitals, Florence Nightingale had returned from the Crimean War and established training schools for nurses. Most pediatric hospitals, however, had their own training programs for nurses. This was a golden era for surgery and particularly pediatric surgery. With the advent of anesthesia and antisepsis, surgical speed was not of prime importance, and daring operations were performed by Dupuytren, Roux, and Larrey of the French school and by Langenbeck, Billroth, Gurlt, Volkman, Esmarch, and Mikulicz of Germany. In America, William Halsted standardized operations such as inguinal hernia repair and mastectomy. He also organized the first formal surgical residency program at the Johns Hopkins Hospital. Pediatric surgery was primarily orthopedics, as practiced in France, Germany, Denmark, Sweden, and Switzerland. Interest in pediatric surgery was fostered by original clinical observations of nephroblastoma,

1071

annular pancreas, biliary atresia, Hodgkins’ disease, urethral valves, chylous cysts, Bochdalek hernia, hydrocolpos, congenital megacolon, necrotizing enterocolitis, and congenital deficiency of the abdominal wall. General pediatric surgery received a great impetus in the mid-1800’s in England. Great Ormond Street appointed G. D. Pollack as its first hospital surgeon. In 1846, James Milman Coley published his Practical Treatise on the Diseases of Children, which discoursed on both medical and surgical subjects. This was followed in 1860 by J. C. Forster’s The Surgical Diseases of Children, in which topics concerned anesthesia and nursing care were introduced. He described gastrostomy and tracheostomy and recommended the Littre operation for imperforate anus and multiple skin grafts for the treatment of burns. Following Forster, Timothy Holmes published Surgical Treatment of Children’s Diseases in 1868. Holmes’ text was much more detailed and included such topics as joined twins, innocent versus malignant tumors, and exstrophy of the bladder. This was the most systematic treatise on the practical surgery of children in its time. Many other textbooks were published including that of Guersant, Giraldes, Fumagalli, De Saint-Germain, Owen, Riberia Y Sans, Karewski, and Power. The majority of these texts dealt with orthopedics (which means literally “to straighten the child”), and in France, from Kirmisson to modern times, many French pediatric surgeons were orthopedists. This, of course, was due to the great number of spinal and limb deformities secondary to tuberculosis and other infectious diseases. 1900 TO PRESENT

The present century has witnessed the development of rapid global communication, air transportation, nuclear power, and space exploration. It has also suffered two world wars, multiple limited conflicts. the destructive use of nuclear power, and the proliferation of political terrorism. Science and medicine have accelerated at a logarithmic pace. Planck’s quantum theory, Einstein’s theory of relativity, Lawrence’s development of the cyclotron, and Fermi’s splitting of the atom paced the physical sciences. The invention of transistors was followed by the microchip and the dissemination of the computer. Biochemicals such as epinephrine. insulin, and cortisone were isolated. Molecular structures were discerned, and the unit of heredity, the gene, was characterized and even synthetically replicated to serve humans. Antibiotics and vaccines nearly eliminated (in developed nations) the devastating scourges of mankind including polio, plague, diphtheria, and syphilis. In pediatrics. child advocacy reached national and

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international levels. Laws requiring the registration of births, deaths, and communicable diseases enabled the evaluation of the prevalence and geographic distribution of such diseases. Public health, particularly in the field of milk purification, saved a multitude of children. The development of biochemistry enabled the advancement of nutrition and metabolism in the study of growth and development. Specialties in pediatrics comparable with internal medicine blossomed. Neonatology and perinatology promoted the salvage of many low-birth-weight newborns but not without the creation of a significant percentage of neurologically damaged and ventilatory dependent infants. The development of intravenous nutrition by Dudrick sustained countless numbers of newborns with congenital gastrointestinal disorders and prematurity. Surgery continued to advance with the development of mechanical devices to aid in thoracic and in cardiovascular surgery. The development of renal dialysis salvaged many patients until renal transplantation could be performed. Transplantation survival of the heart, liver, kidney, and other organs have recently improved by the use of Cyclosporin. Pediatric surgery advanced, utilizing many of those techniques developed in general surgery. In 1909, S.E. Kelley of Cleveland published the first North American pediatric surgery textbook, a work of two volumes. By the 1920s and 193Os, Barrington-Ward of London, Fraser of Edinburgh, Ombredanne in France, Drachter and Grossmann in Germany, Grob of Switzerland, and Ladd, Gross, Swenson, and Coe of the United States devoted their entire practice to pediatric surgery. These men and their pupils developed modern pediatric surgery. Surgical techniques were developed for the cure of many diseases including congenital megacolon, imperforate anus, esophageal atresia, patent ductus arteriosus, coarctation of the aorta, and others. Ladd and

JACK H.T. CHANG

Gross’s textbook, Abdominal Surgery of Znfancy and Childhood, published in 194 1, established a norm for surgical technique and was the standard of care for many years. Gross, trained by Ladd, developed the field of pediatric cardiovascular surgery. In the past 30 years, pediatric surgery has thrived, largely supported by the pediatricians. Pediatrics and pediatric surgery have largely been responsible for the necessity of the development of pediatric anesthesia, radiology, and pathology. Textbooks in pediatric surgery have been published in nearly every language. The first journal of pediatric surgery, Rivista di Chirurgia Pediatrica, was published in Italy in 1959. This was followed by journals from France in 1960, Germany in 1964, and finally the international Journal of Pediatric Surgery in the United States in 1966. Societies developed in many countries to exchange information. The British Association of Pediatric Surgeons was founded in 1953 and the American Pediatric Surgical Association in 1970. Formal training programs were developed and, in 1975, competency examination in pediatric surgery was established by the American Board of Surgery. Modern pediatric surgery has begun to explore such new fields as fetal surgery, intraoperative radiation, mechanical pulmonary support, and organ transplantation. Pediatric surgery remains, however, an art rather than a science. The great clinical burden of the pediatric surgeon has limited his or her ability to extend the field in the basic laboratory. It is comparable with pediatrics of the 1950s and general surgery of the 1960s. The future of pediatric surgery lies in the laboratory. Its training programs are woefully deficient in training pediatric surgical scientists. This is a must for pediatric surgery to be elevated to the scientific standing of its sister field of pediatrics and its parent field of general surgery.