From
StayCurrentMD
History of Pediatric Surgery
hosted by Dr. Em Gootee & Dr. Todd Ponsky
Part of
Pyloric Stenosis 6 items
Chapter 1 of 12 · Fundamentals
Halifax explosion
Introduction and the Halifax Explosion
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What the experts said
Pierre Fredet in Paris was the first to describe projectile vomiting and visible peristalsis in pyloric stenosis.
Pierre Fredet's innovation was the extramucosal pyloromyotomy, staying outside the mucosa to avoid entering the stomach.
Fredet attempted to close the longitudinal pyloromyotomy incision transversely in a Heineke-Mikulicz fashion, but most of his cases still required gastroenterostomy.
Conrad Ramstedt performed the first modern pyloromyotomy in 1911 in Münster, Germany, on a nobleman's son.
During Ramstedt's first pyloromyotomy, he attempted to close the incision transversely but found the pylorus too stiff; when he saw the channel gape open, he realized the operation should be left open.
Hirschsprung described megacolon in 1886, but aganglionosis of the distal colon was not described until 1901, and its significance was not fully realized until the 1940s.
Helen Tausig, a diagnostician, first approached Robert Gross about performing a Blalock-Taussig shunt, demonstrating the diagnostic skills of early pediatricians and cardiologists.
Everts Graham, Chair of Surgery at Washington University in St. Louis, was offered a 50-year-old man in cardiac failure as a candidate for PDA ligation, reflecting how little pediatricians valued surgery at the time.
Robert Gross and pediatric cardiologist John Hubbard, who were fellows together, agreed that PDA ligation was a solution and identified a suitable infant patient who was healthy enough to withstand the operation.
William Ladd forbade Gross from performing PDA ligation; Gross waited until Ladd went on vacation in August and obtained permission from acting chief Thomas Lanman.
Esophageal atresia with distal tracheoesophageal fistula has been known since the late 17th century, along with associated cardiac, renal, and intestinal anomalies.
The first attempt to repair esophageal atresia was through an upper midline laparotomy in 1888, which was unsuccessful.
Joseph Brennemann in Chicago attempted gastrostomy for esophageal atresia, but this flooded the lungs and caused aspiration; jejunostomy had the same result.
Harry Richter, working with Brennemann in Chicago, addressed the tracheoesophageal fistula through a right chest via a vertical paravertebral incision through the sixth interspace with posterior rib resection.
Richter's operation in 1913 used open-drop ether, held the lung over with an assistant's finger, and employed a homemade pump to maintain positive pressure; patients died at 2 and 22 hours.
William Ladd and Logan Leven divided the tracheoesophageal fistula, performed cutaneous esophagostomy, fed via gastrostomy, and constructed skin-lined tubes over the anterior chest through multiple staged operations.
Thomas Lanman's 1940 review of 32 cases of esophageal atresia from Boston Children's Hospital—all fatalities—established that surgeons must operate early (within days of birth), that aspiration is always a threat, and that delay causes malnourishment, dehydration, and pneumonia.
Lanman's review established that esophageal atresia can be diagnosed without oral contrast by inability to pass a nasogastric tube into the stomach, and that air in the GI tract establishes the presence of a distal tracheoesophageal fistula.
Early deaths from esophageal atresia were attributed to fluid overload and injudicious fluid administration because surgeons had no concept of maintenance or resuscitation volumes.
Cameron Haight at the University of Michigan achieved the first long-term survivor of esophageal atresia repair in 1941—case number 10 in a series of 15.
Haight's successful patient was a 12-day-old infant who was well-hydrated, had received IV fluids from a pediatrician, and survived aspiration from a barium swallow without developing pneumonia.
Haight performed the operation under local anesthesia supplemented with open-drop ether, using a left chest via a vertical paravertebral incision with removal of posterior segments of ribs 2 through 6.
Haight included a photograph of his first esophageal atresia survivor in his 1957 presidential address to the American Association of Thoracic Surgery when she was a young teenager, and she was the last patient he saw before his death in 1970.
December 6, 1917, marks the unofficial birth of pediatric surgery due to the Halifax explosion, when William Ladd organized a convoy of 40 physicians and nurses to treat hundreds of injured children.
The Halifax explosion was the most powerful man-made blast until the Trinity atomic bomb test in 1945.
The first smallpox vaccination in 1796 was given to an 8-year-old by Edward Jenner, who was a surgeon trained by John Hunter.
One of the first patients to receive ether anesthesia by Crawford Long was a teenager undergoing finger amputation.
Joseph Lister's first patient to receive carbolic acid in 1865 was a 7-year-old with a compound fracture, and 4 of his first 11 patients reported in 1867 were children.
The first splenectomy for blunt trauma was performed on a 14-year-old laborer who had fallen from a scaffold and ruptured his spleen.
Pyloric stenosis was first described by Hezekiah Beardsley in 1788 and later by Harald Hirschsprung in Denmark in 1888.
Hirschsprung's first two reported cases of pyloric stenosis were female infants, though the disease predominates in males.
Early physicians believed pyloric stenosis was due to pyloric spasm and treated it with belladonna; they also attempted gastric lavage with bicarbonate and refeeding of vomitus.
The first operations for pyloric stenosis were gastroenterostomy and Heineke-Mikulicz pyloroplasty, adapted from adult operations for obstructing gastric cancer and peptic strictures.
Early pyloric stenosis operations had high mortality due to aspiration from open-drop ether in infants with full stomachs and peritoneal contamination when the stomach was opened.
Fredet understood the importance of preoperative gastric decompression, keeping the baby warm during and after surgery, and giving fluids by clysis.
Fredet's mortality rate for pyloric stenosis was 17%, a substantial improvement over the 50-60% mortality seen before.
Ramstedt's operation was rapidly adopted in the United States, with surgeons accumulating series of 20-30 patients quickly, but adoption in England was delayed until 1918 due to World War I.
Ramstedt's pyloromyotomy has been described as the most consistently successful operation ever described.
Early operations for Hirschsprung's disease included colectomy, sigmoid straightening, and sympathectomy, all based on incorrect understanding of pathophysiology.
The first edition of Ladd and Gross's textbook Abdominal Surgery of Infancy and Childhood included operative diagrams for left sympathectomy and impressive before-and-after photographs of a child with a distended abdomen before and scaphoid abdomen after sympathectomy.
Mary Elizabeth Tiffin, a pathologist at Stanford, rediscovered the lack of ganglion cells in the myenteric plexus in 1940 in a patient with short-segment Hirschsprung's disease.
Orvar Swenson was hired by William Ladd to set up a research lab at Boston Children's Hospital and became interested in patients with megacolon who were dying with no effective treatment.
Swenson borrowed equipment from Sidney Farber to measure intestinal peristalsis and found that colon above a diverting colostomy had active peristalsis, while colon below the colostomy did not contract.
Swenson concluded that the obstruction in Hirschsprung's disease was functional, not mechanical, demonstrating the physiological consequences of aganglionosis.
Swenson's pull-through operation was essentially a very low anterior resection, with the rectum everted out the anus to complete the anastomosis outside the anus.
Swenson introduced the lateral barium enema X-ray to visualize the transition zone in Hirschsprung's disease, working with radiologist Edwin Neuhauser.
Of Swenson's first 6 patients, 5 did well, but the 6th remained obstructed; Swenson performed a rectal biopsy and found no ganglion cells, establishing biopsy as a diagnostic and intraoperative tool.
Robert Gross opposed Swenson's pull-through operation, fearing urinary incontinence and sexual dysfunction from dissection around the rectum, and prohibited rectal biopsy due to fear of pelvic infection.
When Swenson proceeded with his operations despite Gross's opposition, he was out of a job within months and moved to the Floating Hospital for Children and Tufts University Medical School.
The Soave endorectal pull-through was preceded by David Sabiston and Mark Ravitch's 1947 report of mucosal proctectomy in dogs, intended for ulcerative colitis and familial polyposis.
Asa Yancey, an African American surgeon in Tuskegee, Alabama, performed an endorectal pull-through in an adult with Hirschsprung's disease in 1952, 11 years before Franco Soave's infant operation in Genoa, Italy.
The Duhamel procedure for Hirschsprung's disease was described in 1956, Keith Jorgenson performed the first laparoscopic pull-through in 1995, and de la Torre in Mexico City performed the first completely transanal pull-through in 1998.
Gross's first PDA ligation took one hour in complete silence under open-drop ether; the murmur was audible in the room and stopped after ligation.
When Ladd discovered Gross had performed the PDA ligation during his absence, he briefly fired Gross, who was reinstated after hospital board intervention.
Gross had performed systemic-to-pulmonary artery anastomosis in dogs as preparation for PDA ligation, the same operation Vivian Thomas performed for Alfred Blalock in preparation for the Blue Baby operation.
When Helen Tausig proposed creating a systemic-to-pulmonary artery shunt to palliate tetralogy of Fallot, Gross refused, stating he was in the business of ligating PDAs, not creating them.
Gross and Ladd did not speak to each other after the PDA incident; the next edition of Surgery of Infancy and Childhood was authored by Gross alone.
Lanman and colleagues decided to repair esophageal atresia early in the newborn period via resection of the 4th rib and posterior aspects of ribs above and below, staying extrapleural to confine leaks outside the pleural cavity.
Lanman had two patients survive 8 and 9 days after esophageal atresia repair, indicating that eventual success was possible.
Haight's patient developed an anastomotic leak with saliva in the drain, was treated with gastrostomy, then had feeding appear in the drain; a catheter passed through the mouth came out the wound, but the anastomosis eventually healed.