MEREDITH CAMPBELL MEMORIAL LECTURE

AMERICAN UROLOGIC ASSOCIATION

  NEW ORLEANS, LOUISIANA

      MAY 13,199O


I FIRST HEARD THE NAME MEREDITH CAMPBELL WHEN I WENT TO

BOSTON IN THE SPRING OF 1946 TO LEARN SOMETHING ABOUT A

NEW FIELD THAT WAS DEVELOPING CALLED CHILD SURGERY.

MEREDITH CAMPBELL,, TO US ON THE HOUSE STAFF AT THE

BOSTON CHILDRENS HOSPITAL, WAS A NAME THAT CONJURED

UP THE MAGIC OF SURGERY,--RIGHT UP THERE WITH NAMES

LIKE WILLIAM E. LADD AND SIR DENNIS BROWN.


NOT EVEN THE MOST FANCIFUL FLIGHT OF IMAGINATION WOULD

HAVE LED ME TO DREAM OF GIVING THE MEREDITH CAMPBELL

MEMORIAL LECTURE ALMOST HALF A CENTURY LATER. BUT

HERE I AM, AND HONORED INDEED TO BE AMONG YOU AND TO

HONOR THE MEMORY OF THIS PIONEER IN UROLOGY AND

ESPECIALLY THAT OF CHILDREN.


IN 1946, WE WHO WERE ON THE CURING EDGE OF A NEW

DISCIPLINE, LATER TO BE KNOWN AS PEDIATRIC SURGERY,

CONSIDERED OURSELVES TO BE WORKING IN A FIELD OF

ULTIMATE SURGICAL SOPHISTICATION.

EVEN HAD THAT BEEN TRUE FOR DISCIPLINES IN ADULT

SURGERY, THE ATTENTION GIVEN TO CHILDREN WITH SURGICAL

PROBLEMS WAS A DISGRACE.


IN INSTITUTIONS WHICH HAD BEEN DEVOTED TO THE CARE OF

CHILDREN, WHERE PIONEERING ADVANCES WERE MADE IN

MEDICAL PEDIATRICS, THE SURGERY OF CHILDREN LAGGED FAR

BEHIND. PEDIATRIC ORTHOPEDICS WAS IN A WAY FAR

ADVANCED OVER OTHER PEDIATRIC SURGICAL SUB-SPECIALTIES.

EARLY GIANTS IN THAT FIELD, LIKE WILLARD AND NICHOLSON,

SPENT MOST OF THEIR TIME REPAIRING THE RAVAGES OF

CHILDHOOD DISEASES NO LONGER ENCOUNTERED.


POLIO, TUBERCULOSIS OF THE BONE, AND OSTEOMYELITIS,

FILLED MOST OF THE BEDS IN SPECIALTY INSTITUTIONS

CONCERNED WITH THE ORTHOPEDIC CHALLENGES OF

CHILDHOOD. ONE SUMMER WHEN I WAS IN COLLEGE, I FELT

EXTRAORDINARILY FORTUNATE TO WORK UNDER THE AEGIS OF

FRANK S. CHILDS, AN ORTHOPEDIC SURGEON WHO, AMONG

OTHER THINGS, WAS THE CHIEF OF SURGERY AT THE ST.

CHARLES HOSPITAL FOR CRIPPLED CHILDREN, A 400-BED

INSTITUTION IN PORT JEFFERSON, NEW YORK.


MY CLINICAL DUTIES WERE SIMPLE: CHANGE EVERY

OSTEOMYELITIS DRESSING ON EVERY CHILD ONCE A WEEK. I

STARTED AT 8:00 A.M. MONDAYS, WORKED A IO-HOUR DAY, AND

USUALLY WAS FINISHED BY SATURDAY AFTERNOON.

THERE WERE NO SULFONAMIDES, NO ANTIBIOTICS. IODOFORM

GAUZE AND BALSAM OF PERU FILLED THE LARGEST CONTAINERS

ON THE DRESSING CARTS.


IN A HOSPITAL LIKE THE CHILDRENS HOSPITAL OF PHILADELPHIA

IN THE DAYS BEFORE WORLD WAR II, SHARING THE LIMELIGHT

WITH ORTHOPEDICS, WAS OTORHINOLARYNGOLOGY, WITH

TONSILLECTOMY BEING THE MOST FREQUENT SURGICAL

PROCEDURE OF AN ELECTIVE NATURE; THE SURGICAL

EMERGENCIES WERE RADICAL MASTOIDECTOMIES AND THE

DRAINAGE OF PERITONSILLAR ABSCESSES.

UROLOGIC PROCEDURES AT THAT SAME INSTITUTION WERE

CONFINED TO THE HAPHAZARD MANAGEMENT OF GROSSLY

OBVIOUS UROLOGIC ANOMALIES BY PROCEDURES WHICH

SHOULD HAVE BEEN TEMPORIZING BUT REMAINED THROUGHOUT

THE LIFE OF THE CHILD, USUALLY SHORTENED, HOWEVER, BY

INFECTION.


EVERYONE WAS AN EXPERT IN CIRCUMCISION. THERE WERE

PROBABLY MORE GOMCO CLAMPS IN THE HOSPITAL THAN THERE

WERE ABDOMINAL RETRACTORS.

THE REAL CHALLENGE OF GENERAL PEDIATRIC SURGERY OF THE

1950s LAY IN THE CONGENITAL DEFECTS INCOMPATIBLE WITH

LIFE BUT AMENABLE TO SURGICAL CORRECTION, SUCH AS

ESOPHAGEAL ATRESIA, OMPHALOCELE, IMPERFORATE ANUS,

DIAPHRAGMATIC HERNIA, AND INTESTINAL OBSTRUCTION.

THE MORTALITY FOR A SIMPLE COLOSTOMY WAS IN THE

NEIGHBORHOOD OF 90%.


THE THOUGHT OF GIVING GENERAL ANESTHESIA TO A CHILD

STRUCK TERROR TO THE HEARTS OF MOST SURGEONS, BUT

INSTEAD OF THIS BEING AN IMPETUS TO RESEARCH INTO THE

UNIQUE RESPONSES OF INFANTS AND SMALL CHILDREN TO

PHARMACOLOGICALS, ANESTHETIC AGENTS, AND BLOOD LOSS

AND REPLACEMENT, OPERATIONS WERE POSTPONED OR NEVER

DONE RATHER THAN FACE THE PROBLEMS OF HIGH MORTALITY

FROM ANESTHESIA.


IN 1946, WILLIAM E. LADD, THE PIONEER OF PEDIATRIC SURGERY

IN THE UNITED STATES HAD RETIRED FROM THE BOSTON

CHILDREN'S HOSPITAL AND HARVARD MEDICAL SCHOOL. A

CHAIR HAD BEEN ENDOWEDJN HIS NAME, FUNDED BY $6,000.

ROBERT E. GROSS OCCUPIED IT IN THE CLOSING WEEKS OF 1946,

AND THE BOSTON CHILDRENS HOSPITAL WAS THE ONLY PLACE

IN THE UNITED STATES WHERE ONE COULD SAY THERE WAS

ANYTHING LIKE A TRAINING PROGRAM IN CHILD SURGERY.

THERE WERE A FEW MEN AROUND THE COUNTRY WHO WERE

BEGINNING TO MAKE A DIFFERENCE IN CHILD SURGERY:

OSWALD WYATT IN MINNEAPOLIS, HERBERT COE IN SEATTLE,

AND ORVAR SWENSON IN BOSTON. I WAS THE SIXTH PERSON IN

THE UNITED STATES TO CALL HIMSELF A CHILD SURGEON, AND

THE FIRST TO PRACTICE THE SPECIALTY TO THE EXCLUSION OF

ADULT PATIENTS.

10


PHILADELPHIA IN DECEMBER OF 1946, ACTING, INDEED, AS THE

SURGEON IN CHIEF, A TITLE I DID NOT GET UNTIL 1948. TAGUE

CHISHOLM JOINED OSWALD WYATT IN MINNEAPOLIS SHORTLY

AFTER THAT, AND WILLIS POTTS BEGAN HIS CAREER IN CHICAGO.

LATER STALWARTS SUCH AS SANDY BILL, BILL CLATWORTHY,

AND LUTHER LONGINO WERE STILL MEMBERS OF THE HOUSE

STAFF AT BOSTON CHILDRENS HOSPITAL.

11


I LEARNED, EARLY ON, THAT IT WAS EASIER TO PUT CHILDREN

UNDER ANESTHESIA THAN IT WAS TO WAKE THEM UP. HENCE, A

LOT OF MY TIME IN THE FIRST TWO YEARS IN THIS NEW FIELD

WAS DEVOTED TO THE DEVELOPMENT OF TECHNIQUES AND

SAFEGUARDS IN PEDIATRIC ANESTHESIA. INDEED I SPENT MORE

CONCERN AND EFFORT THERE THAN I DID IN SURGERY. MANY

THINGS WERE ACCOMPLISHED, NOT THE LEAST OF WHICH WAS

THE DEVELOPMENT OF SAFE ENDOTRACHEAL ANESTHESIA, EVEN

FOR NEWBORNS. MUCH OF THE EQUIPMENT WE USED, WE MADE

OURSELVES.

12


NEOPRENE HAD JUST BEGUN TO REPLACE RUBBER TUBING.

THERE WAS NO SUCH THING AS POLYETHYLENE OR TYGON

PLASTIC TUBING. NICETIES SUCH AS BUTTERFLY NEEDLES HAD

NOT BEEN INVENTED. TO START AN INTRAVENOUS IN A SCALP

VEIN ON A NEWBORN WAS TRULY A CHALLENGE, BUT KEEPING IT

RUNNING BY BUILDING MECHANICAL SUPPORTS TO HOLD IN

PLACE A RIGID NEEDLE ATTACHED TO A GLASS SYRINGE WAS AN

ACCOMPLISHMENT IN STRUCTURAL ENGINEERING.

AND YET HERE AND THERE ABOUT THE COUNTRY CHILDREN

WERE BEGINNING TO GET A FAIR SHAKE IN SURGERY.

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BEFORE GRADUATING FROM CORNELL UNIVERSITY MEDICAL

COLLEGE IN 1941, I HAD SECURED A TWO-YEAR INTERNSHIP AT

THE PENNSYLVANIA HOSPITAL IN PHllADELPHlA AND WAS

ASSURED BY I.S. RAVDIN THAT I WOULD EVENTUALLY BE A

HARRISON FELLOW IN GENERAL SURGERY AND SURGICAL

RESEARCH.

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THE WAR IN EUROPE, AND THE PRESUMPTION THAT WE WOULD

SOON BE IN IT, LED TO THE REDUCTION OF MY TWO-YEAR

ROTATING INTERNSHIP TO ONE YEAR. ON THE DAY AFTER PEARL

HARBOR, IS. RAVDIN CHOPPED AT LEAST THREE YEARS OFF MY

SURGICAL TRAINING BY NOT ONLY APPOINTING ME TO THE

HARRISON FELLOWSHIP I ANTICIPATED, BUT HIS MILITARY

CONNECTIONS WITH THE ARMY MEDICAL CORPS ENABLED HIM

TO DECLARE ME ESSENTIAL TO THE UNIVERSITY OF

PENNSYLVANIA FOR THE DURATION OF THE WAR.

15


MY FIRST INTEREST IN CANCER HAD DEVELOPED WHEN I WAS A

MEDICAL STUDENT AT CORNELL. DURING THE SUMMER BETWEEN

MY JUNIOR AND SENIOR YEARS, I WORKED WITH HAYES MARTIN,

CHIEF OF THE HEAD AND NECK SERVICE AT MEMORIAL HOSPITAL,

ON A NUTRITIONAL SURVEY OF CANCER PATIENTS FROM HIS

SERVICE. THE THESIS OF THE PROJECT WAS THAT AVITAMINOSIS

B CONTRIBUTED TO THE RAVAGES OF CANCER OF THE FLOOR OF

THE MOUTH, PALATE, PHARYNX, ETC.

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MEMORIAL HOSPITAL HAD JUST MOVED TO ITS NEW LOCATION

OPPOSITE CORNELL AND THE NEW YORK HOSPITAL, AND IT WAS

THE CENTER FOR CANCER, IN THE BROADEST SENSE OF THE

TERM, ON THE EAST COAST. THE HOSPITALS DIRECTOR WAS

C.P. RHOADES, BUT JAMES EWING, WHO IS REGARDED BY MANY

ASTHEFATHEROFMODERNCANCERRESEARCHANDTHERAPY

IN THE UNITED STATES, WAS STILL IN A POSITION OF AWESOME

AUTHORITY IN THE HOSPITAL.

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THE DAY CAME WHEN I HAD TO PRESENT WHAT I HAD DONE

BEFORE MEMORIAL'S CANCER RESEARCH ADVISORY COMMITTEE.

THE FACT THAT TWO NOBEL LAUREATES SAT ON THAT

COMMITTEE DID NOT MAKE IT ANY EASIER. IN THOSE DAYS I

SUFFERED FROM AN INCAPACITATING TYPE OF MIGRAINE

BROUGHT ON BY THE RELAXATION OF TENSION. MY IO-MINUTE

PRESENTATION WAS FOLLOWED BY SUCH A SENSE OF RELIEF

THAT THE SCOTOMA I DEVELOPED IMMEDIATELY WAS SO BRIGHT

THAT I COULD BARELY FIND MY WAY OFF THE PLATFORM.

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BY THE TIME I REACHED THE BACK OF THE AUDITORIUM, I FELT

AS THOUGH SOMEONE HAD BURIED A HATCHET IN THE RIGHT

SIDE OF MY SKULL.

IN PREPARATION FOR THAT OCCASION, IT WAS NECESSARY TO

PRESENT MY FINDINGS IN A PRELIMINARY FASHION TO OLD DR.

EWING. EWING ASKED ME IF I THOUGHT THE IRRITATION OF THE

MUCOSA OF THE MOUTH FROM SUCH THINGS AS DENTURES, PIPE

STEMS, AND SO FORTH, MIGHT CONTRIBUTE TO CANCER.

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WHEN I REPLIED IN THE AFFIRMATIVE HE SAID: "WELL, IF YOURE

RIGHT, HORSES OUGHT TO HAVE CANCER OF THE JAW ALL THE

TIME." I REPLIED: "AS A MATTER OF FACT, MY GRANDFATHERS

HORSE DIED OF CANCER OF THE JAW BUT, ON THE OTHER HAND,

I'VE ONLY KNOWN TWO HORSES WELL." TO THAT REPLY, EWING

QUIPPED, "THATS NOT A BAD SERIES; 50 PERCENT."

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I LEFT CORNELL, MEMORIAL HOSPITAL, AND NEW YORK CITY TO

GO TO PHILADELPHIA, WITH THE PROMISE THAT AFTER

APPROPRIATE SURGICAL TRAINING I WOULD RETURN TO

MEMORIAL TO BE THE SURGICAL LIAISON IN THEIR TRAINING

PROGRAM WITH CORNELL AND THE NEW YORK HOSPITAL.

IF THERE WAS SUCH A THING AS ONCOLOGY IN THOSE DAYS, I

HAD NOT YET HEARD ABOUT IT.

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IN THE THIRD YEAR OF MY HARRISON FELLOWSHIP, WHICH WAS

ESSENTIALLY THE SURGICAL RESIDENCY AT THE HOSPITAL OF

THE UNIVERSITY OF PENNSYLVANIA, I WAS ADMIlTED TO THAT

HOSPITAL AS A PATIENT WITH A SEVERE STREP THROAT, MAKING

IT VERY DIFFICULT TO SWALLOW.

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THE WAR WAS OVER IN EUROPE. THINGS WERE WINDING DOWN

IN THE PACIFIC BASIN. MOST OF THE UNIVERSITYS SURGICAL

STAFF WAS STILL IN THE ARMY RUNNING THE 20TH GENERAL

HOSPITAL IN ASSAM. I WAS WAKENED FROM A DEEP SLEEP

ABOUT 5:00 A.M. BY I.S. RAVDIN BURSTING INTO MY HOSPITAL

ROOM, IN THE UNIFORM OF A COLONEL (HE WAS MADE GENERAL

BEFORE RETURNING TO INDIA).

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"CHICK! WHAT DO YOU WANT TO DO WITH YOUR LIFE?"

I DON7 KNOW HOW I GATHERED MY THOUGHTS TOGETHER, BUT I

CROAKED OUT SOMETHING THAT SOUNDED LIKE THIS: "WELL,

DR. RAVDIN, I HAVE COME TO LOVE THE UNIVERSITY OF

PENNSYLVANIA, THIS HOSPITAL, AND PHILADELPHIA. ID LIKE TO

STAY HERE. THERES ONE WEAK SPOT IN YOUR PROGRAM, AND

THATS THE CANCER CLINIC. IF YOULL GIVE THAT TO ME, ILL

DEVELOP IT AND MAKE IT SING FOR YOU."

24


RAV REPLIED: "HOW WOULD YOU LIKE TO BE SURGEON IN CHIEF

OF THE CHILDRENS HOSPITAL INSTEAD?" I DIDNT THINK LONG

BEFORE REPLYING: "THAT'S MY SECOND CHOICE." THAT BRIEF

ENCOUNTER IS THE REASON IlVl HERE TALKING TO YOU TODAY.

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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.

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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.

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IN SPITE OF THE VERY SINCERE AND STRONG SUPPORT OF I.S.

RAVDIN AND JONATHAN E. RHOAD k, EVEN THE UNIVERISTY OF
       1
PENNSYLVANIA WAS HOSTILE TO RAVDINS NEW PLANS FOR

CHILD SURGERY. SO WAS THE HOSPITAL WHERE I 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

CHILDRENS HOSPITAL IN AMERICA--INTENT ON MAKING IT THE

CENTER OF A NEW SPECIALTY.

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LAMENTABLY, AT FIRST, THERE WASNT MUCH TO DO IN

SURGERY. PEDIATRICIANS HAD BECOME SO DISCOURAGED WITH

THE 0UTCOM.E OF ATTEMPTED SURGERY ON THE NEWBORN THAT

INFANTS DIED ON THE MEDICAL WARDS OF THE CHILDRENS

HOSPITAL IN 1947 WITH ATRESIA OF THE SMALL BOWEL WITHOUT

EVEN THE BENEFIT OF A SURGICAL CONSULTATION.

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THIS RELATIVE INACTIVITY PERMITTED ME TO SPEND HOURS IN

THE RECORD ROOM. ONE OF THE FIRST PROJECTS I 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 I REMEMBER WELL WAS FINDING THE RECORD OF A CHILD

WHO HAD BEEN TREATED, BY SURGICAL EXCISION, FOR A

MALIGNANT TUMOR OF THE PAROTID.

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THE SURGERY HAD BEEN DONE 60 YEARS BEFORE. TO MY UTTER

AMAZEMENT, I 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 BY A

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.

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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 WITH A

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.

I THINK I KNOW PEDIATRIC PRACTITIONERS AS WELL AS I KNOW

ANY GROUP OF MY COLLEAGUES, THEY ARE KIND, GENTLE, AND

THEY DON7 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.

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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. I WAS INVITED BY A

POPULAR PHILADELPHIA TALK SHOW HOSTESS TO COME AND

DISCUSS "THE NEW AND WONDERFUL THINGS" I WAS DOING AT

CHILDRENS HOSPITAL.

34


I 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 I TOLD HER I

WOULD BE DISCUSSING CHILDHOOD CANCER, SHE BRISTLED:

"DON7 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. I COVERED

PROBLEMS ABOUT CONGENITAL DEFECTS AND SO ON, AND

EVENTUALLY GOT OFF INTO THE FIELD OF CANCER. I DID REFER

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

DID USE THE WORDS "DREAD DISEASE."

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BY THIS TIME THE SECOND HAND ON THE CLOCK WAS

APPROACHING THE TIME I 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." I

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.

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ONE AFTERNOON AS I WAS LEAVING THE HOSPITAL, HE WAS

COMING IN. I STOPPED HIM IN THE LOBBY, TO TELL HIM

ENTHUSIASTICALLY ABOUT A PATIENT I HAD ADMITTED THAT

AFTERNOON. WHEN I TOLD HIM THAT I FELT QUITE CERTAIN I

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 I HAD

MADE THE GREATEST DIAGNOSTIC ERROR.

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I 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, I GAVE HIM MY

LITTLE LECTURE ON "ALL LUMPS AND BUMPS IN CHILDREN ARE

MALIGNANT UNTIL PROVEN OTHERWISE." I TOLD HIM THE ONLY

WAY YOU COULD PROVE THIS ONE TO BE OTHERWISE WAS TO DO

A BIOPSY. AND THATS WHAT I 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 I EVER HAD SEEN HIM PUT ON A SCRUB SUIT,

CAP, AND MASK TO GET CLOSE TO THE OPERATING TABLE. I

BIOPSIED THE MASS AND WHEN IT CAME BACK AS A FOLLICULAR

CARCINOMA OF THE THYROID I PERFORMED A TOTAL

THYROIDECTOMY. THE CHILD RECOVERED, GREW UP, MARRIED,

AND HAD THREE CHILDREN.

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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.

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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.

I DID AND WHILE I 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 WITH A

SMIRK ON HIS FACE HE SAID "ALL LUMPS IN CHILDREN ARE

MALIGNANT UNTIL PROVEN OTHERWISE."

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"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.

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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.

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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 CHILDRENS

HOSPITAL, MORE PEOPLE THAN NEEDED TO BE INVOLVED FELT

THEY HAD TO FEEL THE TUMOR WITHIN THE ABDOMEN.

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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.

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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 I'M SURE THEY

SAVED LIVES. MANY SURGEONS ARE UNAWARE OF THE DAMAGE

CAUSED BY PALPATING FINGERS@ SMALL CHILDREN. I 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


I 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 IlVl SURE THE

PERPETRATOR WOULD HAVE CALLED "GENTLE" PALPATION.

50


UNKNOWN TO ME ON ONE OCCASION, THE MEMBER OF THE

PEDIATRIC STAFF WHO HAD REFERRED A WILMS' TUMOR TO ME,

TOOK FOUR MEDICAL STUDENTS ON ROUNDS TO FEEL THE MASS

WHILE I WAS OPERATING ON THE PRECEDING CASE. WHEN I

OPENED THE ABDOMEN, THE WILMS' TUMOR WAS RUPTURED AND

FRIABLE MALIGNANT TISSUE WAS FOUND THROUGH THE

RETROPERITONEUM; THE HEMORRHAGE HAD EXTENDED WELL TO

THE CONTRALATERAL SIDE AND HAD MADE ITS WAY UP INTO THE

MESOCOLON OF THE ASCENDING AND TRANSVERSE BOWELS.

THAT PATIENT DIED.

51


ONE OF THE MOST HORRENDOUS SURGICAL PROCEDURES IN

REFERENCE TO A WILMS' TUMOR THAT WE EVER UNDERTOOK

WAS A NEPHRECTOMY IN CONJUNCTION WITH THE REMOVAL, VIA

THE RENAL VEIN, OF A TUMOR THROMBOUS THAT EXTENDED UP

THE VENA CAVA, TURNED THE CORNER, AND ENDED IN THE RIGHT

ATRIUM. POSTOPERATIVELY, IN ORDER TO DEMONSTRATE, FOR

TEACHING PURPOSES, WHAT WE HAD DONE, AND WHILE THE

CHILD WAS STILL ON THE OPERATING TABLE IN A SUPINE

POSITION, WE PLACED THE TUMOR NEXT TO HIM AT HIS RIGHT

FLANK AND THEN LAID THE THROMBUS ON HIS BODY TO MIMICK

ITS INTERNAL POSITION.

52


IT STARTED AT THE LEVEL OF HIS LIGATED RENAL VEIN AND LAY

ACROSS HIS RIBCAGE AND TURNED AROUND TO END IN A
   @

BULBUS MASS JUST OVER HIS RIGHT ATRIUM.

WHEN, A YEAR OR SO LATER, I WAS PRESENTING A PAPER AT THE

BOSTON CITY HOSPITAL AS PART OF A SYMPOSIUM ON CANCER

IN CHILDHOOD, I SHOWED THIS CASE, INCLUDING A

MICROSCOPIC SECTION OF THE TIP OF THE THROMBUS FOUND IN

THE ATRIUM.

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THERE WAS NO DOUBT THE THROMBUS WAS WILMS' TUMOR AND

THAT WAS THE ONLY POINT I WAS TRYING TO MAKE. IN THE

AUDIENCE, HOWEVER, WAS JUDAH FOLKMAN, THEN SURGEON-

IN-CHIEF OF THE CHILDREN'S HOSPITAL OF BOSTON, AND A

SCIENTIST WITH A LIFE-LONG INTEREST IN THE ANGIOGENESIS

FACTOR. AMONG OTHER CONCERNS, HIS THESIS WAS THAT

TUMORS CANT GROW WITHOUT BLOOD SUPPLY. WHERE DO THE

BLOOD VESSELS COME FROM, AND WHAT TRIGGERS THEIR

DEVELOPMENT?

54


I PUSHED A BUTTON ON THE PODIUM TO MOVE THE SLIDE AND

DR. FtkKMAN CRIED OUT, "WAIT, WAIT!" I BACKED THE SLIDE UP.

THERE HE DEMONSTRATED SOMETHING I HAD NOT SEEN. ON THE

VERY TIP OF THE THROMBUS, IN THE MIDST OF THE TELLTAIL

HISTOLOGY OF WILMS' TUMOR, THERE WERE TINY BLOOD

VESSELS GROWING MORE THAN TWO FEET AWAY FROM THE

PRIMARY TUMOR THAT GAVE BIRTH TO THE THROMBUS.

55


IT WAS, OF COURSE, THE ADVENT OF CHEMOTHERAPY THAT

CHANGED THE WHOLE CONCEPT OF THE MANAGEMENT OF

CHILDHOOD CANCER,--AND IT AFFECTED WILMS' TUMOR FIRST.

IT IS INTERESTING THAT UP UNTIL THE ADVENT OF

CHEMOTHERAPY, ALL OF THE MAJOR CHILDRENS HOSPITALS IN

THE COUNTRY HAD ABOUT THE SAME SURVIVAL RATE FOR

WILMS' TUMOR USING JUST ABOUT THE SAME PROTOCOL THAT I

HAVE DESCRIBED. SEVERAL OF US HAD ACHIEVED 47 POINT

SOMETHING % SURVIVAL BEFORE CHEMOTHERAPY. I KNOW OF

NO ONE WITH A RESPECTABLE SERIES WHO REACHED 48%.

56


UNTIL CANCER CHEMOTHERAPY GAINED A FOOTHOLD, THE

MANAGEMENT OF CHILDHOOD CANCER WAS THE SURGEON'S

DOMAIN, WITH AN ASSIST FROM THE RADIOLOGIST.

COLLEAGUES IN INSTITUTIONS SIMILAR TO MY OWN WERE NOT

ONLY SURGEONS AND PEDIATRICIANS, BUT FAMILY COUNSELORS

AND CHAPLAINS AS WELL. WITH THE ADVENT OF

CHEMOTHERAPY, THE SPECIALTY OF PEDIATRIC ONCOLOGY

CAME INTO ITS OWN. THERE IS NO DOUBT THAT BECAUSE OF

AVAILABLE RESEARCH FUNDING, THE INTEREST IN A NEW

FRONTIER, AND THE INCREASING SUCCESS WITH CHEMOTHERAPY

FOR WILMS' TUMOR AND RHABDOMYOSARCOMA (AS WELL AS

GREAT SUCCESS IN THE MANAGEMENT OF LEUKEMIA),

ONCOLOGY BEGAN TO ATTRACT MORE AND MORE BRIGHT YOUNG

PEDIATRICIANS AND HEMATOLOGISTS.

57


I HAVE CONSIDERABLE PRAISE FOR MEDICAL ONCOLOGISTS AND

THEIR ACCOMPLISHMENTS. I THINK, IN MANY INSTITUTIONS

ACROSS THE LAND, WHAT COULD HAVE BEEN A MAJOR THRUST

BY MANY DISCIPLINES INVOLVED IN THE MANAGEMENT OF THE

JUVENILE CANCER PATIENT FELL SHORT OF THE MARK. AS THE

ONCOLOGIST HAS RISEN, SO HAS THE PERCEPTION OF THE

VALUE OF THE SURGEON FALLEN. IT WOULD BE TRAGIC, IF, WITH

THE HISTORY OF THE PAST FEW YEARS, THE SURGEON IS

RELEGATED TO THE POSITION OF TECHNICIAN TO THE MEDICAL

ONCOLOGIST.

58


IT IS IRONIC THAT MOST GOOD MEDICAL ONCOLOGISTS WERE

ATTRACTED TO THEIR PRESENT SUB-SPECIALTY BY THE

REPUTATION AND CASE LOAD OF A PEDIATRIC SURGICAL

CANCER ENTHUSIAST.

AS FASCINATING AS ALL CHILDHOOD MALIGNANT TUMORS WERE,

IT WAS THE NEUROBLASTOMA AND ITS PECULIAR LIFE HISTORY

THAT RIVETED MY ATTENTION,--EVEN EARLY ON.

59


WHEN I DID MY RETROSPECTIVE STUDY OF RECORDS OF

DISCHARGE DIAGNOSES WITH MALIGNANT TUMORS, I HAD BEEN

N STRUCK THAT 25% OF THEM WERE NEUROBLASTOMA. I

ATTEMPTED TO TRACE THESE CHILDREN, FOUND THAT MOST OF

THEM HAD DIED, BUT THAT SOME RATHER REMARKABLE

YOUNGSTERS HAD SURVIVED.

ONE HAD BEEN IN THE HANDS OF A NEUROSURGEON WHO HAD

DONE A LAMINEt=TOMY AND REMOVED A PORTION OF A HIGHLY

UNDIFFERENTIATED NEUROBLASTOMA, CLOSING THE PATIENT UP

TO DIE.

60


IN RETROSPECT I THINK EVERYBODY MISSED THE ABDOMINAL

TUMOR, OF WHICH THE INT-RASPINAL EXTENSION WAS THE SMALL

END OF A DUMBBELL. SOME YEARS LATER WHEN SOMEBODY

FELT AN ABDOMINAL TUMOR IN THIS NOW PARAPLEGIC CHILD, IT

WAS BIOPSIED AND PROVED TO BE A QUITE BENIGN

GANGLIONEUROMA. THE OTHER LIVING PATIENTS IN THAT SMALL

GROUP OF NEUROBLASTOMA SURVIVORS IMPRESSED ME THAT

THE THERAPY SEEMED TO HAVE HAD LITTLE OR NOTHING TO DO

WITH SURVIVAL.

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OF COURSE I CAN ONLY SPEAK ABOUT THOSE CHILDREN AND

KNEW NOTHING ABOUT THE QUALITY OR QUANTITY OF

TREATMENT ON THOSE WHO DIED.

EARLY IN MY TENURE AT CHILDRENS HOSPITAL, I WAS CALLED

UPON TO TREAT AN ABDOMINAL MASS IN THE INFANT SON OF A

FORMER RESIDENT WHO HAD MARRIED ONE OF OUR NURSES.

DURING SURGERY, I RUPTURED THE PSEUDOCAPSULE OF A

PERIRENAL NEUROBLASTOMA.

62


IN ADDITION TO THAT POOR PROGNOSTIC SIGN, THE CHILD ALSO

HAD MULTIPLE BARELY VISIBLE METASTASES TO THE LIVER,

CONFIRMED BY BIOPSY. THE SURGERY WAS CERTAINLY NOT THE

METICULOUS SURGERY OF CANCER THAT I HAD BEEN TAUGHT.

THERE WAS GROSS SPILL OF TUMOR THROUGHOUT THE

PERITONEAL CAVITY. I TOLD THE FAMILY THE SITUATION WAS

HOPELESS AND NO RADIATION THERAPY SHOULD BE GIVEN.

SIX WEEKS LATER THE CHILD RETURNED FOR A POSTOPERATIVE

VISIT AND HAD MULTIPLE SUBCUTANEOUS NODULES WHICH I

ASSUMED TO BE TUMOR. I DID NOT ASK FOR A BIOPSY.

63


THE YOUNGSTER WAS SENT HOME TO DIE. THAT PATIENT

EVENTUALLY GRADUATED FROM LAW SCHOOL AND WHEN LAST

SEEN BY ME, THE PYELOGRAM SHOWED NOTHING MORE THAN A

DISTORTED CAL& OF ONE KIDNEY ON THE SIDE OF THE               i/

SURGERY.

64


A THREE AND ONE-HALF YEAR OLD GIRL WAS SENT TO ME WITH

THE DIAGNOSIS OF SPLENOMEGALY. IT WAS OBVIOUS THAT THE

MASS IN QUESTION WAS NOT A SPLEEN, BUT A TUMOR, AND

AFTER SUITABLE WORKUP, ABDOMINAL EXPLORATION REVEALED

A MALIGNANT NEUROBLASTOMA ARISING FROM THE ABDOMINAL

SYMPATHETIC CHAIN, FASTENED TIGHTLY TO THE SPINAL

COLUMN AND DIFFUSE ENOUGH IN THE RETROPERITONEUM AS

TO BE NONRESECTABLE.

THE TUMOR WAS SOFT AND SUCCULENT, AND AFTER OPENING

THE POSTERIOR P ERITONEUM, IN THE COURSE OF BIOPSY,

THERE WAS GROSS SPILL OF THE TUMOR INTO THE PERITONEAL

CAVITY.

65


I PRESENTED THE FATHER WITH A HOPELESS PROGNOSIS AFTER

WHICH HE BEGAN TO READ BROADLY ABOUT NEUROBLASTOMA,-

-WHAT LITTLE THERE WAS WRITTEN ABOUT IT,--AND BECAME AN

ALLY WITH ME AGAINST THE TUMOR.

THE TUMOR SLOWLY ENLARGED AND ITS LOWER TIP, WHICH HAD

BEEN PALPABLE JUST BELOW THE COSTAL CAGE, DESCENDED

UNTIL IT REACHED THE PELVIS, TURNED TOWARD THE RIGHT,

AND EVENTUALLY POINTED UPWARD IN THE RIGHT LOWER

QUADRANT. AFTER A PERIOD OF STABILIZATION THERE, THE

TUMOR SLOWLY RECEDED IN THE DIRECTION FROM WHENCE IT

HAD COME UNTIL IT WAS BARELY PALPABLE HIGH UP UNDER THE

COSTAL CAGE ON THE LEFT. BY THAT TIME, IT WAS THE FATHER,

NOT I, WHO WAS PUSHING FOR ANOTHER LOOK.

66


THIS WE DID AND FOUND AN EXTREMELY FIRM, SMALL

GANGLIONEUROMA ABOUT THE SIZE OF A TENNIS BALL, WHICH I

RESECTED, WITHOUT BEING ABLE TO DETACH EVERY CELL FROM

THE SPINAL COLUMN. THE CHILD SURVIVED, AND WAS LOST TO

FOLLOW-UP IN HER TEENS.

THE SURVIVAL OF THOSE YOUNGSTERS FOLLOWING GROSS

SPILL OF THE TUMOR INTRAPERITONEALLY LED ME TO BELIEVE

THAT PERHAPS THE VERY SPILL MIGHT HAVE HAD A BENEFICIAL

EFFECT. AFTER MORE EXPERIENCE, MY FIRST PRESENTATION ON

THE SUBJECT OF NEUROBLASTOMA WAS BEFORE THE SOCIETY

OF UNIVERSITY SURGEONS IN 1955.

67


I ENTITLED THE PAPER "NEUROBLASTOMA IN CHILDHOOD: THE

EFFECT OF MAJOR SURGICAL INSULT ON SURVIVAL." I

REPORTED A 38% SURVIVAL IN MY EXPERIENCE THUSFAR.

IN A DISCUSSION FOLLOWING MY PRESENTATION, CRITICS

SUGGESTED THAT IF ONLY I HAD BEEN SMART ENOUGH TO USE

RADIATION THERAPY IN ADDITION TO SURGERY, I COULD HAVE

IMPROVED MY RESULTS.

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THE NEXT EIGHT NEUROBLASTOMAS I TREATED WITH RADIATION.

ALL OF THEM DIED. I THEN RETURNED TO MY LONG-HELD BELIEF

TtiAT THE ADJUNCT OF RADIATION THERAPY FOR

NEUROBLASTOMA DID NOT REALLY INCREASE SURVIVAL.

THIS POSITION, WHICH WAS LATER CLARIFIED BY THE WORK OF

MANY OTHERS, EVENTUALLY LED TO OUR UNDERSTANDING OF

THE CURRENT STAGING OF NEUROBLASTOMA. SOME

YOUNGSTERS, FOR EVERY SCIENTIFIC REASON, ENTITLED TO A

POOR PROGNOSIS AND m ON THEIR WAY TO DEATH, WERE

PATIENTS WITH STAGE IV-S DISEASE.


THEIR PROGNOSIS WAS NOT IMPROVED BY RADIATION AND

THEIR SURVIVAL WAS ALMOST UNIFORMLY GOOD.

WHEN I LEFT THE PRACTICE OF SURGERY IN 1981 TO GO TO

WASHINGTON, MY OWN SURVIVAL RATE WAS THE SAME 38% THAT

MY PATIENTS ENJOYED IN 1955, IN SPITE OF ADJUNCTIVE

RADIATION AND CHEMOTHERAPY. UNFORTUNATELY,

NEUROBLASTOMA HAS NEVER HAD THE REMARKABLE

SUCCESSFUL INCREASE IN SURVIVAL THAT WAS ACCOMPLISHED

FOR WILMS' TUMOR WITH CHEMOTHERAPY.

70


I GUESS THE FIRST OF MANY SURGICAL AND PUBLIC HEALTH

CRUSADES OF MY LIFE CENTERED AROUND AWAKENING

PEDIATRICIANS TO THE POSSIBILITY OF DIAGNOSING CANCER IN

CHILDREN. ITS HARD TO BELIEVE, @I!`@59 AT THIS LATE TIME,

HOW DIFFICULT IT WAS TO FIND RECEPTIVE AUDIENCES AMONG

PEDIATRICIANS. AS I TRIED TO AROUSE A FEELING OF GUILT FOR

MISSING DIAGNOSES, BUT AT THE SAME TIME PROVIDING A WAY

OUT FOR THE IMPOSSIBLE PROBLEMS, I USED TO SPEAK OF

FOUR CATEGORIES OF TUMOR:

71


1.   THE VISIBLE OR PALPABLE LESION WHICH NO ONE COULD

  BE EXCUSED FOR MISSING;

2.  THE TUMOR THAT, BY ITS SYMPTOMATOLOGY, SHOULD

   AROUSE SUSPICION OF CANCER IF ONE INCLUDED IT IN THE

  DIAGNOSTIC POSSIBILITIES;

3.   THOSE TUMORS WHOSE SYMPTOMS MIMICKED OTHER

  MORE FAVORABLE DIAGNOSES (SUCH AS THE DIAGNOSIS OF

RHEUMATIC FEVER, INSTEAD OF NEUROBLASTOMA);

4.   THE TUMORS HERALDED BY SUCH VAGUE

  SYMPTQMATOLOGY THAT NO ONE COULD BE BLAMED FOR A

   DELAYED DIAGNOSIS.

72


AS I LOOK BACK OVER THE LAST HALF-CENTURY, IT'S HARD TO

BELIEVE HOW LITTLE WE ALL KNEW WHEN I GRADUATED FROM

MEDICAL SCHOOL AND WHAT TREMENDOUS ADVANCES THERE

HAVE BEEN IN MEDICINE DURING MY LIFETIME.

73


THE OPPORTUNITIES FOR LABORATORY AND CLINICAL

INVESTIGATIONS OF CHILDHOOD CANCER ARE STILL LEGION. I

STILL FEEL THAT IF SOMEONE COULD UNDERSTAND, IN ITS

TOTALITY, THE BEHAVIOR OF NEUROBLASTOMAS, A KEY WOULD

TURN IN MANY LOCKS IN OUR UNDERSTANDING OF

ONCOGENESIS, MATURATION, AND SPONTANEOUS REMISSION.

OF COURSE, ADJUNCTS TO THERAPY WOULD SOON FOLLOW. I

THINK THAT COMBINATIONS OF ADJUNCTIVE THERAPY ALONG

WITH SURGERY WILL CONTINUE TO LOWER MORTALITY RATES

BUT ONLY SLOWLY WHILE I'NCREASING THE LONGEVITY OF

CHILDREN DESPITE THE ULTIMATE FATAL OUTCOME. THE REAL

BREAKTHROUGH, I THINK, WILL COME WITH A BETTER

UNDERSTANDING OF THE IMMUNOLOGY OF CANCER AS WELL AS

THE ELUCIDATION OF THE COMBINED FACTORS OF GENETIC

PROPENSITY AND ENVIRONMENTAL STIMULI.

74


WHILE THE DAY-TO-DAY CARE OF THE YOUNGSTER WITH THE

MALIGNANT TUMOR IS ONE OF THE ULTIMATE CHALLENGES IN

PEDIATRIC MANAGEMENT, THE IMPROVED SURVIVAL OF PATIENTS

WITH PEDIATRIC MALIGNANT TUMORS HAS BEEN ONE OF THE

OUTSTANDING SUCCESSES IN THE FIELD OF ONCOLOGY. IT HAS

BEEN A GOOD TIME TO BE ALIVE.

--END--

75