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MEREDITH CAMPBELL MEMORIAL LECTURE

AMERICAN UROLOGIC ASSOCIATION
NEW ORLEANS, LOUISIANA

MAY 13, 1990
| FIRST HEARD THE NAME MEREDITH CAMPBELL WHEN | 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 CHILDREN'S 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 |! 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 CUTTING 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 | WAS IN COLLEGE, | 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. |
STARTED AT 8:00 A.M. MONDAYS, WORKED A 10-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 CHILDREN'S 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 ENDOWED IN HIS NAME, FUNDED BY $6,000.
ROBERT E. GROSS OCCUPIED IT IN THE CLOSING WEEKS OF 1946,
AND THE BOSTON CHILDREN'S 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. | 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
| BEGAN TO OPERATE AT THE CHILDREN'S HOSPITAL IN
PHILADELPHIA IN DECEMBER OF 1946, ACTING, INDEED, AS THE
SURGEON IN CHIEF, A TITLE |! 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 CHILDREN'S HOSPITAL.

11
| 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 | SPENT MORE
CONCERN AND EFFORT THERE THAN | 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.

13
BEFORE GRADUATING FROM CORNELL UNIVERSITY MEDICAL
COLLEGE IN 1941, | HAD SECURED A TWO-YEAR INTERNSHIP AT
THE PENNSYLVANIA HOSPITAL IN PHILADELPHIA AND WAS
ASSURED BY I.S. RAVDIN THAT | WOULD EVENTUALLY BE A
HARRISON FELLOW IN GENERAL SURGERY AND SURGICAL

RESEARCH.

14
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, I.S. 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 | WAS A
MEDICAL STUDENT AT CORNELL. DURING THE SUMMER BETWEEN
MY JUNIOR AND SENIOR YEARS, | WORKED WITH HAYES MARTIN,
CHIEF OF THE HEAD AND NECK SERVICE AT MEMORIAL HOSPITAL,
ONA 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.

16
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
AS THE FATHER OF MODERN CANCER RESEARCH AND THERAPY
IN THE UNITED STATES, WAS STILL IN A POSITION OF AWESOME

AUTHORITY IN THE HOSPITAL.

17
THE DAY CAME WHEN | 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 |
SUFFERED FROM AN INCAPACITATING TYPE OF MIGRAINE
BROUGHT ON BY THE RELAXATION OF TENSION. MY 10-MINUTE
PRESENTATION WAS FOLLOWED BY SUCH A SENSE OF RELIEF
THAT THE SCOTOMA | DEVELOPED IMMEDIATELY WAS SO BRIGHT

THAT | COULD BARELY FIND MY WAY OFF THE PLATFORM.

18
BY THE TIME | REACHED THE BACK OF THE AUDITORIUM, | 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 | THOUGHT THE IRRITATION OF THE
MUCOSA OF THE MOUTH FROM SUCH THINGS AS DENTURES, PIPE

STEMS, AND SO FORTH, MIGHT CONTRIBUTE TO CANCER.

19
WHEN | REPLIED IN THE AFFIRMATIVE HE SAID: “WELL, IF YOURE
RIGHT, HORSES OUGHT TO HAVE CANCER OF THE JAW ALL THE
TIME.” | REPLIED: “AS A MATTER OF FACT, MY GRANDFATHERS
HORSE DIED OF CANCER OF THE JAW BUT, ON THE OTHER HAND,
IVE ONLY KNOWN TWO HORSES WELL.” TO THAT REPLY, EWING

QUIPPED, ”THAT'S NOT A BAD SERIES; 50 PERCENT.”

20
| LEFT CORNELL, MEMORIAL HOSPITAL, AND NEW YORK CITY TO
GO TO PHILADELPHIA, WITH THE PROMISE THAT AFTER
APPROPRIATE SURGICAL TRAINING | 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, |

HAD NOT YET HEARD ABOUT IT.

21
IN THE THIRD YEAR OF MY HARRISON FELLOWSHIP, WHICH WAS
ESSENTIALLY THE SURGICAL RESIDENCY AT THE HOSPITAL OF
THE UNIVERSITY OF PENNSYLVANIA, | WAS ADMITTED TO THAT
HOSPITAL AS A PATIENT WITH A SEVERE STREP THROAT, MAKING

IT VERY DIFFICULT TO SWALLOW.

22
THE WAR WAS OVER IN EUROPE. THINGS WERE WINDING DOWN
IN THE PACIFIC BASIN. MOST OF THE UNIVERSITY'S SURGICAL
STAFF WAS STILL IN THE ARMY RUNNING THE 20TH GENERAL
HOSPITAL IN ASSAM. | 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).

23
"CHICK! WHAT DO YOU WANT TO DO WITH YOUR LIFE?”

| DONT KNOW HOW |! GATHERED MY THOUGHTS TOGETHER, BUT |
CROAKED OUT SOMETHING THAT SOUNDED LIKE THIS: ”WELL,
DR. RAVDIN, | HAVE COME TO LOVE THE UNIVERSITY OF
PENNSYLVANIA, THIS HOSPITAL, AND PHILADELPHIA. ID LIKE TO
STAY HERE. THERE'S ONE WEAK SPOT IN YOUR PROGRAM, AND
THATS THE CANCER CLINIC. IF YOULL GIVE THAT TO ME, PLL

DEVELOP IT AND MAKE IT SING FOR YOU.”

24
RAV REPLIED: "HOW WOULD YOU LIKE TO BE SURGEON IN CHIEF
OF THE CHILDREN'S HOSPITAL INSTEAD?” | DIDNT THINK LONG
BEFORE REPLYING: "THATS MY SECOND CHOICE.” THAT BRIEF

ENCOUNTER IS THE REASON IM HERE TALKING TO YOU TODAY.

25
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
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 | 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 INA

©
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, | SHOWED THIS CASE, INCLUDING A
MICROSCOPIC SECTION OF THE TIP OF THE THROMBUS FOUND IN

THE ATRIUM.

53
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 CHILDRENS HOSPITAL OF BOSTON, AND A
SCIENTIST WITH A LIFE-LONG INTEREST IN THE ANGIOGENESIS
FACTOR. AMONG OTHER CONCERNS, HIS THESIS WAS THAT
TUMORS CAN'T GROW WITHOUT BLOOD SUPPLY. WHERE DO THE
BLOOD VESSELS COME FROM, AND WHAT TRIGGERS THEIR

DEVELOPMENT?

54
| PUSHED A BUTTON ON THE PODIUM TO MOVE THE SLIDE AND
DR. FOLKMAN CRIED OUT, ”WAIT, WAIT!” | 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.

C———-,

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 CHILDREN'S HOSPITALS IN
THE COUNTRY HAD ABOUT THE SAME SURVIVAL RATE FOR
WILMS' TUMOR USING JUST ABOUT THE SAME PROTOCOL THAT |
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
| 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 | DID MY RETROSPECTIVE STUDY OF RECORDS OF
DISCHARGE DIAGNOSES WITH MALIGNANT TUMORS, | HAD BEEN
Ves STRUCK THAT 25% OF THEM WERE NEUROBLASTOMA. |
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 LAMINECTOMY 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 INTRASPINAL 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.

61
OF COURSE | 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 CHILDREN'S HOSPITAL, | 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, | 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. | 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 |

ASSUMED TO BE TUMOR. | 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 CALYK OF ONE KIDNEY ON THE SIDE OF THE

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
| 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
| ENTITLED THE PAPER "NEUROBLASTOMA IN CHILDHOOD: THE
EFFECT OF MAJOR SURGICAL INSULT ON SURVIVAL.” |

REPORTED A 38% SURVIVAL IN MY EXPERIENCE THUSFAR.

INA DISCUSSION FOLLOWING MY PRESENTATION, CRITICS
SUGGESTED THAT IF ONLY | HAD BEEN SMART ENOUGH TO USE
RADIATION THERAPY IN ADDITION TO SURGERY, I COULD HAVE

IMPROVED MY RESULTS.

68
THE NEXT EIGHT NEUROBLASTOMAS | TREATED WITH RADIATION.
ALL OF THEM DIED. | THEN RETURNED TO MY LONG-HELD BELIEF
THAT 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 TOA
POOR PROGNOSIS AND B€ ON THEIR WAY TO DEATH, WERE

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THEIR PROGNOSIS WAS NOT IMPROVED BY RADIATION AND

THEIR SURVIVAL WAS ALMOST UNIFORMLY GOOD.

WHEN | 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
| 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. IT'S HARD TO BELIEVE, BAGS AT THIS LATE TIME,
HOW DIFFICULT IT WAS TO FIND RECEPTIVE AUDIENCES AMONG
PEDIATRICIANS. AS | TRIED TO AROUSE A FEELING OF GUILT FOR
MISSING DIAGNOSES, BUT AT THE SAME TIME PROVIDING A WAY
OUT FOR THE IMPOSSIBLE PROBLEMS, | USED TO SPEAK OF

FOUR CATEGORIES OF TUMOR:

71
THE VISIBLE OR PALPABLE LESION WHICH NO ONE COULD

BE EXCUSED FOR MISSING;

THE TUMOR THAT, BY ITS SYMPTOMATOLOGY, SHOULD
AROUSE SUSPICION OF CANCER IF ONE INCLUDED IT IN THE

DIAGNOSTIC POSSIBILITIES;

THOSE TUMORS WHOSE SYMPTOMS MIMICKED OTHER
MORE FAVORABLE DIAGNOSES (SUCH AS THE DIAGNOSIS OF

RHEUMATIC FEVER, INSTEAD OF NEUROBLASTOMA);
THE TUMORS HERALDED BY SUCH VAGUE

SYMPTOMATOLOGY THAT NO ONE COULD BE BLAMED FORA

DELAYED DIAGNOSIS.

72
AS | LOOK BACK OVER THE LAST HALF-CENTURY, IT'S HARD TO
BELIEVE HOW LITTLE WE ALL KNEW WHEN | 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. |
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. |
THINK THAT COMBINATIONS OF ADJUNCTIVE THERAPY ALONG
WITH SURGERY WILL CONTINUE TO LOWER MORTALITY RATES
BUT ONLY SLOWLY WHILE INCREASING THE LONGEVITY OF
CHILDREN DESPITE THE ULTIMATE FATAL OUTCOME. THE REAL
BREAKTHROUGH, | 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