TO SAY THAT CHILD SURGERY WAS AN UNPOPULAR

DEVELOPMENT IN THE FIELD OF SURGERY IN 1946 IS A GROSS
UNDERSTATEMENT. GENERAL SURGEONS FELT THAT THE LOG OF
SURGERY HAD BEEN SPLINTERED ENOUGH; THERE WERE
ENOUGH SUB-SPECIALTIES WITHOUT CONTEMPLATING A NEW

ONE.

26
BUT THE INSULT ADDED TO THAT POTENTIAL INJURY WAS THAT
CHILD SURGEONS SAID THEY COULD DO ANY SURGERY IN
CHILDREN BETTER THAN ANATOMICAL SPECIALISTS BECAUSE OF
THEIR UNDERSTANDING OF THE PATHOLOGICAL PHYSIOLOGY OF
INFANTS UNDER STRESS AND UNDERSTOOD BETTER THE
MANAGEMENT OF THEIR VERY LIMITED RESERVE. IT MAY SOUND

BRASH AT THIS LATE DATE, BUT IT REALLY WAS TRUE IN 1946.

27
IN SPITE OF THE VERY SINCERE AND STRONG SUPPORT OF LS.
RAVDIN AND JONATHAN E. RHOADS, EVEN THE UNIVERISTY OF
PENNSYLVANIA WAS HOSTILE TO RAVDIN'S NEW PLANS FOR
CHILD SURGERY. SO WAS THE HOSPITAL WHERE | WAS TO
BECOME CHIEF, AND THE SURGEONS IN THE FOUR OTHER
MEDICAL SCHOOLS IN PHILADELPHIA DID NOT WELCOME A 29-
YEAR-OLD UPSTART AS THE CHIEF OF SURGERY IN THE OLDEST
CHILDREN'S HOSPITAL IN AMERICA--INTENT ON MAKING IT THE

CENTER OF A NEW SPECIALTY.

28
LAMENTABLY, AT FIRST, THERE WASNT MUCH TO DO IN
SURGERY. PEDIATRICIANS HAD BECOME SO DISCOURAGED WITH
THE OUTCOME OF ATTEMPTED SURGERY ON THE NEWBORN THAT
INFANTS DIED ON THE MEDICAL WARDS OF THE CHILDREN'S
HOSPITAL IN 1947 WITH ATRESIA OF THE SMALL BOWEL WITHOUT

EVEN THE BENEFIT OF A SURGICAL CONSULTATION.

29
THIS RELATIVE INACTIVITY PERMITTED ME TO SPEND HOURS IN |
THE RECORD ROOM. ONE OF THE FIRST PROJECTS | UNDERTOOK
WAS TO TRY TO REVIEW THE RECORDS OF PATIENTS WHO HAD A
DISCHARGE DIAGNOSIS OF A MALIGNANT TUMOR. IN
RETROSPECT, SOME VERY INTERESTING ANECDOTES SURFACED.
ONE | REMEMBER WELL WAS FINDING THE RECORD OF A CHILD
WHO HAD BEEN TREATED, BY SURGICAL EXCISION, FOR A

MALIGNANT TUMOR OF THE PAROTID.

30
THE SURGERY HAD BEEN DONE 60 YEARS BEFORE. TO MY UTTER
AMAZEMENT, | FOUND THE PATIENT STILL LIVED AT HER
CHILDHOOD ADDRESS--WITH NO EVIDENCE OF CANCER. SHE
WAS THEN, AND MAY REMAIN NOW, THE LONGEST FOLLOW-UP
ON A MALIGNANT TUMOR OF THE PAROTID ENCOUNTERED IN

CHILDHOOD.

OF THE FIRST 100 RECORDS I STUDIED RETROSPECTIVELY, 25%
HAD A DISCHARGE DIAGNOSIS OF NEUROBLASTOMA. THIRTEEN
OF THESE PATIENTS HAD BEEN ADMITTED TO THE HOSPITAL BYA
REFERRING PHYSICIAN OR HAD BEEN ADMITTED AFTER
EXAMINATION IN THE EMERGENCY ROOM WITH A DIAGNOSIS OF
RHEUMATIC FEVER,--A DIAGNOSIS MUCH MORE COMMONLY

ENTERTAINED AND FEARED IN THOSE DAYS THAN NOW.

31
WHY WOULD SO MANY NEUROBLASTOMAS BE MISDIAGNOSED AS
RHEUMATIC FEVER? MANY OF THESE YOUNGSTERS HAD BONE
METASTASES WHEN THEY WERE FIRST SEEN AND THE LEG PAIN
SO COMMON WITH THAT COMPLICATION WAS INTERPRETED AS

THE JOINT PAIN OF RHEUMATIC FEVER.

THEN THESE YOUNGSTERS, BY THE TIME THEY WERE SEEN, WERE
OFTEN ANEMIC AND FRAIL AND PRESENTED WITHA
TACHYCARDIA. AND FINALLY, THE SEDIMENTATION RATE, ON
WHICH PEDIATRICIANS RELIED SO HEAVILY IN THE DIAGNOSIS OF
RHEUMATIC FEVER, WAS ALWAYS ELEVATED IN |

NEUROBLASTOMA.

32
EXCEPT FOR LEUKEMIA, CANCER WAS NOT A DIAGNOSIS
FREQUENTLY ENTERTAINED BY PEDIATRICIANS, NO MATTER HOW

OBVIOUS THE SIGNS AND SYMPTOMS MIGHT BE TO US TODAY.

| THINK | KNOW PEDIATRIC PRACTITIONERS AS WELL AS I KNOW
ANY GROUP OF MY COLLEAGUES, THEY ARE KIND, GENTLE, AND
THEY DONT LIKE TROUBLE. MALIGNANT TUMORS IN CHILDREN
ARE BIG TROUBLE. NOT ONLY TROUBLE WITH THE LOSS OF A
PATIENT, BUT CANCER IN CHILDHOOD HAS FAR-REACHING
EFFECTS. SOCIETY DOES NOT EXPECT CHILDREN TO DIE OF A
DISEASE THAT THEY ASSOCIATE WITH OLDER AGE. THEY ALSO
EXPECT MORE FROM MEDICINE AND HEALTH CARE THAN WE ARE
SOMETIMES ABLE TO DELIVER. THE MAGIC OF MEDICINE DOES
NOT ALWAYS EXTEND TO THE CURE OF MALIGNANT TUMORS IN

CHILDREN.

33
TWO ANECDOTES FROM THE EARLY 50S WILL SERVE TO
ILLUSTRATE THE ATTITUDE OF SOCIETY AND PEDIATRICIANS

TOWARD THIS DIAGNOSIS.

THE POPULARITY OF AFTERNOON SOAP OPERAS OF TODAY WAS
ASSUMED IN THE ERA OF WHICH I AM SPEAKING BY
AFTERNOOON RADIO TALK SHOWS. | WAS INVITED BYA
POPULAR PHILADELPHIA TALK SHOW HOSTESS TO COME AND
DISCUSS ”THE NEW AND WONDERFUL THINGS” | WAS DOING AT

CHILDREN'S HOSPITAL.

34
| ARRIVED AT THE STUDIO WITH THE USUAL LEAD TIME AND WE
HAD A CONVERSATION SO THAT SHE COULD PREPARE HERSELF
FOR THE QUESTIONS SHE WOULD ASK. WHEN ! TOLD HER |
WOULD BE DISCUSSING CHILDHOOD CANCER, SHE BRISTLED:

*DONT YOU DARE USE THAT HORRID WORD ON MY PROGRAM.”

35
*WHAT WORD?” I REPLIED.

*THAT HORRIBLE WORD, CANCER.”

”WHAT DO YOU WANT ME TO CALL IT?”

*CALL IT THAT DREAD DISEASE.”

BY THIS TIME WE WERE READY TO GO ON THE AIR. | COVERED
PROBLEMS ABOUT CONGENITAL DEFECTS AND SO ON, AND
EVENTUALLY GOT OFF INTO THE FIELD OF CANCER. | DID REFER

TO IT AS TUMOR, AND LATER AS MALIGNANT TUMOR, AND THEN |

DID USE THE WORDS ”DREAD DISEASE.”

36
BY THIS TIME THE SECOND HAND ON THE CLOCK WAS
APPROACHING THE TIME | HAD BEEN TOLD WE HAD TO QUIT,
WITH ABOUT 10 SECONDS LEFT, MY PARTING SHOT WAS: ”OF
COURSE, THE DREAD DISEASE IM TALKING ABOUT IS CANCER.” |

WAS NEVER INVITED BACK.

PERMANENTLY ATTACHED TO MY SURGICAL SERVICE AT THE
CHILDRENS HOSPITAL WAS A FINE OLD GENTLEMAN, EDWARD J.
RILEY. DR. RILEY WAS AN EXCELLENT PEDIATRICIAN WHO USED
MORE GOOD SENSE THAN SCIENCE, AT TIMES, BUT HIS
NOSTRUMS FOR TREATING PATIENTS WERE LEGENDARY AND HIS

DIAGNOSTIC ABILITY WAS PRODIGIOUS.

37
HE HAD NEVER TAKEN HIS BOARDS AND WAS UNORTHODOX
ENOUGH NOT TO BE ACCEPTED IN THE HIGHER SCIENTIFIC
ECHELONS OF THE DEPARTMENT OF PEDIATRICS AT THE
UNIVERSITY OF PENNSYLVANIA, HENCE HIS ASSIGNMENT AS A
SORT OF PERMANENT ”*CONSULTANT” TO THE SURGICAL
SERVICE. HE MADE ROUNDS WITH US DAILY; WE ALL PROFITED
BY HIS WISDOM. ABOUT TUMORS, HE UNDERSTOOD WILMS'
TUMORS AND NEUROBLASTOMAS AND HE CERTAINLY KNEW

ABOUT LEUKEMIA, BUT THAT'S WHERE IT ENDED.

38
ONE AFTERNOON AS I WAS LEAVING THE HOSPITAL, HE WAS
COMING IN. | STOPPED HIM IN THE LOBBY, TO TELL HIM
ENTHUSIASTICALLY ABOUT A PATIENT | HAD ADMITTED THAT
AFTERNOON. WHEN ! TOLD HIM THAT | FELT QUITE CERTAIN |
HAD A 13-YEAR-OLD GIRL WITH A CANCER OF THE THYROID, HE
JUST LAUGHED. THEN HE DID MORE THAN THAT. HE SLAPPED
HIS THIGH, AND LAUGHED AGAIN. IT WAS OBVIOUS THAT | HAD

MADE THE GREATEST DIAGNOSTIC ERROR.

39
| TOOK HIM TO THE WARD, INTRODUCED HIM TO THE YOUNG
LADY, AND DEMONSTRATED THE FIRM NODULE IN THE THYROID.
HE WAS STILL SO AMUSED THAT, ONCE AGAIN, | GAVE HIM MY
LITTLE LECTURE ON ”ALL LUMPS AND BUMPS IN CHILDREN ARE
MALIGNANT UNTIL PROVEN OTHERWISE.” | TOLD HIM THE ONLY
WAY YOU COULD PROVE THIS ONE TO BE OTHERWISE WAS TO DO
A BIOPSY. AND THAT'S WHAT | INTENDED TO DO THE NEXT

MORNING, BY FROZEN SECTION.

40
IN THE OPERATING ROOM AT 8:00 A.M., POP RILEY WAS PRESENT.
ITS THE FIRST TIME | EVER HAD SEEN HIM PUT ON A SCRUB SUIT,
CAP, AND MASK TO GET CLOSE TO THE OPERATING TABLE. |
BIOPSIED THE MASS AND WHEN IT CAME BACK AS A FOLLICULAR
CARCINOMA OF THE THYROID | PERFORMED A TOTAL
THYROIDECTOMY. THE CHILD RECOVERED, GREW UP, MARRIED,

AND HAD THREE CHILDREN.

41
THREE WEEKS AFTER THAT SURGERY, POP RILEY BROUGHT A
BEAUTIFUL 4-YEAR-OLD GIRL INTO MY OFFICE. HE STOOD HER
DIRECTLY IN FRONT OF ME AND SAID ”WHAT DO YOU THINK OF
THIS BIRD?”, USING THE AFFECTIONATE TERM BY WHICH HE
CALLED HIS PATIENTS.

”*WHAT AM I SUPPOSED TO SEE?”

”*SMILE!” HE SAID TO THE CHILD.

42
SHE DID, AND IT WAS OBVIOUS THAT SHE HAD TWO DIMPLES ON
ONE OF THE CHEEKS AND ONLY ONE ON THE OTHER.

”*PUT YOUR FINGER ON THAT UPPER DIMPLE.” SAID RILEY.

1 DID AND WHILE | HELD MY FINGER THERE, HE SAID TO HER:
*STOP SMILING.” AND TO ME ”WHAT DO YOU FEEL?”

"A TINY NODULE.”

"WELL, WHAT ARE YOU GOING TO DO ABOUT IT?” THEN WITHA
SMIRK ON HIS FACE HE SAID ”ALL LUMPS IN CHILDREN ARE

MALIGNANT UNTIL PROVEN OTHERWISE.”

43
”IM GOING TO ADMIT HER AND DO AN EXCISIONAL BIOPSY.”
RILEY WENT ALONG WITH IT BUT VERY SKEPTICALLY. HIS
CONVERSION TO MY THESIS WAS COMPLETE WHEN THE
DIAGNOSIS CAME BACK ”RHABDOMYOSARCOMA, COMPLETELY
EXCISED.” COULD BE THE EARLIEST DIAGNOSIS OF A FACIAL
RHABDO EVER MADE--AND BY A NON-BELIEVER--AT LEAST UP

TO THEN.

44
THE PROTOTYPE OF CHILDHOOD CANCER WAS THE WILMS'
TUMOR. REMOVING A WILMS' TUMOR CAN BE ONE OF THE MOST
SATISFACTORY ACCOMPLISHMENTS IN PEDIATRIC SURGERY. ON
THE OTHER HAND, IT CAN ALSO BE ONE OF THE MOST

TERRIFYING.

TO ENCOUNTER A WILMS' TUMOR OF PRODIGIOUS SIZE,
DISPLACING THE LIVER AND THE BOWEL, PUSHING THE VENA
CAVA AND THE AORTA TO THE OTHER SIDE OF THE SPINAL
COLUMN, WITH TUMOR EXTENSION EXTENDING INTO THE RENAL
VEIN AND UP THE VENA CAVA AND PERHAPS INTO THE LEFT

ATRIUM, CAN BE HUMBLING INDEED.

45
A KIND OF FOLKLORE DEVELOPED AROUND THE MANAGEMENT
OF WILMS' TUMOR. WE ALL KNEW THAT THESE TUMORS WERE

FRIABLE AND THAT THE CAPSULE COULD BE EASILY RUPTURED.

WE ALSO KNEW THAT A RUPTURED WILMS' TUMOR HAD A VERY
POOR PROGNOSIS. WE ALSO KNEW THAT WILMS' TUMORS GREW
RAPIDLY, AND WHO KNEW WHEN THE MOMENT OF METASTASIS
MIGHT BE? WE ALSO KNEW THAT WHEN A LARGE ABDOMINAL
TUMOR WAS ADMITTED TO THE WARDS OF A CHILDREN'S
HOSPITAL, MORE PEOPLE THAN NEEDED TO BE INVOLVED FELT

THEY HAD TO FEEL THE TUMOR WITHIN THE ABDOMEN.

46
MY RULES DEVELOPED RAPIDLY AND WERE FIRM. THE FIRST
PERSON ON THE SURGICAL SERVICE THAT ENCOUNTERED THE
CHILD PUT A SIGN ON THE ABDOMEN WHICH SAID ”DO NOT
PALPATE THIS ABDOMEN.” A SIMILAR SIGN WAS PUT ON THE
FOOT OF THE BED. NO ONE ELSE FELT THAT BELLY EXCEPT THE
SURGEON WHO WAS GOING TO PERFORM THE OPERATION AND
HIS SUPERVISOR. IF THEY WERE ONE AND THE SAME, ONLY ONE
PAIR OF HANDS, OTHER THAN THOSE OF THE ORIGINAL

DIAGNOSTICIAN WERE INTENDED TO FEEL THE ABDOMEN.

47
SECONDLY, EXCISION OF A WILMS' TUMOR WAS CONSIDERED TO
BE AN EMERGENCY; NO MORE THAN ONE COMPLETE HOSPITAL
DAY WAS PERMITTED TO ELAPSE BEFORE THE OPERATION WAS
PERFORMED. AT THE OPERATING TABLE THE TUMOR WAS
TREATED AS THOUGH IT WERE AN UNEXPLODED BOMB AND HAD
TO BE DEFUSED. IT WAS HANDLED WITH UTMOST CARE AND
BECAUSE MOST METASTASES WERE BLOOD BORNE, BY WAY OF

THE RENAL VEIN, THE VEINS WERE LIGATED BEFORE THE ARTERY.

48
THESE WERE NOT FOOLISH PRECAUTIONS AND IM SURE THEY
SAVED LIVES. MANY SURGEONS ARE UNAWARE OF THE DAMAGE
CAUSED BY PALPATING FINGERSON SMALL CHILDREN. | LEARNED
THIS FROM WILLIAM E. LADD, WHO TOLD ME NEVER TO OPERATE
ON A PYLORIC STENOSIS IF THE PEDIATRICIANS HAD A GO AT

FEELING THE ”OLIVE.”

HE SAID HE HAD LEARNED BY BITTER EXPERIENCE THAT SUCH
TRAUMA PRODUCED SO MUCH PYLORIC EDEMA THAT NO MATTER
HOW WELL THE OPERATION WAS PERFORMED, THE CHILD

VOMITED FOR DAYS THEREAFTER.

49
| HAVE OPENED THE ABDOMENS OF CHILDREN WITH PYLORIC
STENOSIS, UNAWARE OF THE FACT THAT MY RULES HAD BEEN
BROKEN ABOUT PREOPERATIVE PALPATION. IN ADDITION TO THE
EDEMA OF THE PYLORUS, ACTUAL HEMORRHAGES CAN BE SEEN
IN THE TRANSVERSE MESOCOLON FROM WHAT IM SURE THE

PERPETRATOR WOULD HAVE CALLED ”GENTLE” PALPATION.

50