SPECIAL
SECTIONS
SPECIAL
ARTICLE
\VILLIAM E. LAJ)D, M.D.-AN APPRECIATION
By THOMAS H. LANMAN, M.D.#{176}
Boston
668
Pediatrics
VOLUME 14 DECEMBER 1954 NUMBER 6
I
T IS a great honor to be asked to present the first \Villiam E. Ladd Lecture be-fore the American Academy of Pediatrics. This I tippreciate aIl(l as this is the first1cc-ture in thy former Chief’s honor, I shall de-vote my tulle niore to Doctor Ladd and
what he accomplished during his long and
devoted service as Chief of the Surgical
Service of the Boston Children’s Hospital
than to the presentatioii of antbing new.
Iii these (lays of great changes in the
sur-gical field, it is very easy to overlook or even to forget the good things that were done in
the past. I siid “changes” rather than
ad-vances for 50111C of the changes of today are
not advances. It is easier to appreciate the
(‘XtraOrdinaly wi(leliilig m the field of
sur-gical endeavor that has l)C(’fl Iilade possible l)y improvements in pre- an(l postoperative
care, anesthesia, and the more effective
nicans to coinbat infection than it is to
re-iiiember what was (lone fl a previous
gen-eration vitlioiit such new and valuable aids.
\Vhen I l)egan iiiv service at the Boston
Prsciittd as t li( lust \\illiaili E. Ladd Lctiire at th(’ \le(tiiig of tin ncrican \cadeiny of lkdiatrics, (liicago. Illinois, October 6, 1954.
(Recc-iv((l for publication October 8, 1954.)
0 Address : Cllildrens I lOSI)ital, 300 Longwood
Avenue, Boston 15, \Iassachuisetts.
Children’s Hospital in 1919, most of the
deaths On the Surgical Service were caused
l)y infection. Long surgical procedures in-volving an open thoracotomy were
impos-sible. Prolonged operations on the gastro-intestinal tract carried a heavy mortality
largely because of our lack of knowledge of fluid balance. In those earlier days, an operation that exceeded an hour in length
was considered to be entering a very dan-gerous phase.
It is well, however, to review some of the
types of cases done in those days and to
keep in mind that the basic principles one had to follow at that time are still valid and
that the good results of today are by no
means entirely due to modern methods. Let
me cite a few examples.
In 1938 we reported a 20-year study of
over 400 cases of empyema. We have a
teaching slide that shows the gratifying and
indeed rather startling reduction in mortal-ity-from over 35 per cent in the first 5 years
to 4 per ceiit during the last 5 years of this
20-year study. If iie shows that slide to the
re-SPECIAL ARTICLE 669
ceived such therapy for the obvious reason
that it did not come into use until the last
5 months of this 20-year study. That great improvement was due to the meticulous
care exercised by my former Chief not only in the selection of the type of operation best
suited for the individual case, but in the time when that type of operation should be
1)erfOrflle(I. I remember well, as a young
attending surgeon, coming to the hospital in the middle of the night to do an
“emer-genc” thoracotomy on an infant already
critically sick in the early stages of his
pneumonia-obviously a bad way to treat such cases. We found that it was just as
bad in other cases to delay unduly an open
tlioracotoiiiy. and to 1)ersist in attempts to obtain a cure I)’ the prolonged use of so
called “closed drainage. “ It has been of great
interest to me iii the present day discussions
of this now rather rare complication of
pneu-monia-empyerna-to re-read a sentence
froni that article of 1938.
“Admitting the value of these new drugs
in acute pneumonia, we have the distinct
iinpressioii that the pleural exudate in the
few cases of empyema which have
(IC-\e101)e(I (luring treatnient with these drugs,
has ix’en iiiOre (IifflCIIlt to dram. It has been of a thick tenacious character and with very little fluid present. A rather wide exposure
with thorough freeing of the lung was
neces-sary.” This observation has been amply
con-firmed over the past 15 years. There is now a tendency to forget the cardinal principles
in the treatment of empyema. It is still true, and I believe will always be true, that ob-literation of the empyema cavity by the complete re-expansion of the lung is neces-sary for cure. Certainly this was true in the treatment of war wounds of the chest. One
must not be lulled into a false security
be-cause this exudate or fluid collection within
the chest cavity may be “sterile.” If the
exudate does not resorb within a reasonable period of time, surgical measures must be instituted and by adequate removal of this exudate obtain the free and complete re-expansion of the lung.
Another example is acute appendicitis. The mortality rate from acute appendicitis
in children under 12 was alarmingly high in
the early days of my surgical career. In fact,
in Massachusetts in the 1920’s, appendicitis
as a cause of death between the ages of 1
year and 12 years stood fourth on the list.
This high mortality rate of the early 1920’s
steadily dropped at our hospital and by the late 1930’s was gratifyingly low.
These (Icaths from acute appendicitis
were almost entirely in the group in which the 11)pefldix had already perforated when
670 LANMAN - WILLIAM E. LADD - AN APPRECIATION
since 1938 and is now close to the
irreduci-ble minimum of zero, the proportion of cases coming to our hospital with the appendix already perforated has remained the same
as before-50 per cent, in spite of an ever widening education as to why acute
ap-pendicitis in this age group is so frequently
overlooked. Note the date, 1938, which cor-responds roughly with the advent of the
sulfonamides. But was it these new drugs that played the major role? They helped, of course. You have all seen articles in the literature in the last 10 or 15 years that
re-port a series of cases of perforated appendix with no mortality, having been treated with
massive doses of this or that drug. Very
good, but let me point out that under Doe-tor Ladd’s painstaking attention to detail in the care of cases of perforated appendicitis, we had a series of 95 consecutive cases of perforated appendix admitted to the Chil-dren’s Hospital with no deaths and this just
before the advent of the first of the sulfa-drugs.
A similar drop in mortality occurred in the same period in the treatment of oste-omyelitis. Doctor Ladd’s recognition of the importance of the affecting organism, the
stage Qf the disease, together with his in-sistence on modifying the extent of the operation to meet the individual case was responsible for this gratifyingly great im-provement in the end results. Osteomyelitis,
like empyema, is now seldom seen but, I regret to say, it is far more frequently over-looked than it was in the pre-antibiotic
days. To be sure, these drugs have
pre-vented a great many cases of this type of blood stream infection from developing
lesions in the bone, but like empyema, once osteomyelitis occurs the basic surgical
prin-ciples of its treatment remain the same. The
establishment of adequate drainage at the proper time, and its maintenance until
na-ture’s powers of repair are well established
are still the important factors for successful therapy.
There are other conditions very familiar
to men of Doctor Ladd’s generation that now appear to have been forgotten. Some
weeks ago at a staff conference at the Chil-dren’s Hospital, a case of tuberculous pen-tonitis was presented. This condition I
ad-mit is not common; surely not as common
as in a previous generation. Practically all the laboratory tests-and today they are legion-had been done. At this meeting it
was at times difficult to hear the discussion because of the noise resulting from the new
construction adjacent to the amphitheatre. One of the discussors paused once or twice to apologize for this noise. I could not help thinking, however, that some of this noise
may have been the vigorous protest from
the graves of Doctor John Lovett Morse and Doctor James Savage Stone, Doctor Ladd’s
and my honored teachers. It must have been distressing to hear that such an obvious case of tuberculous peritonitis had remained on
the wards of their beloved Children’s Hos-pital for so many days without the correct
diagnosis being even entertained, let alone established.
Another instance to be cited is the trans-plantation of the ureters for extrophy of the
bladder. The results in our earlier cases
have been most gratifying for we have
pa-tients now 20 years or more following trans-plantation of the ureters who show no
evidence clinically or by intravenous
pyclog-raphy of any significant uretenitis or
pye-lonephnitis. There were only 2 cases of
peritonitis in these early cases, neither of
them fatal. Since the advent of the
antibiot-ics there have likewise been 2 cases of
peritonitis; again fortunately, with no fatal-ity. In other words, basic surgical principles
were, and still are, of greater importance
than an undue dependence on modern drugs to combat infection in the penitoneal cavity
on in the GU tract.
Doctor Ladd’s careful study of
embryol-ogy combined with his mastery of the
sun-gical technique in this age group opened a new field in the treatment of congenital
anomalies of the GI tract. His studies in this field have made it possible to repair successfully many of the great variety of
SPECIAL ARTICLE 671
of the fact that volvulus of the midgut in the infant requires more than a mere
re-(luctiOfl of the volvulus itself.
His meticulous technique in intestinal
anastamosis ili these small patients has led
to a gratifyingly low mortality in the
treat-ment of congenital obstruction, particularly of the duodenum. Here is one type of
anomaly that deserves our further considera-tion and presents a great challenge to the
coming generation. In 1950 we reviewed our results in the surgical treatment of con-genital atresia of the duodenum and found that the operative mortality rate was
gratify-ingly low.
But a study of those who had survived
5 years or more showed that close to 30
per cent were mongols. Our series was not lange-31 cases-but the figure was a disturb-ing one, and it has since been confirmed by
a report from the Great Ormond Street
Hos-pita! for Sick Children in London. In a similar series they found a slightly higher percentage incidence of mongolism in their
surviving cases. Of course, it is impossible to make with certainty the diagnosis of
mongolism in the first 48 hours of life,
al-though in 2 or 3 instances in our series such
a possibility was recorded in the operative note. We must, therefore, continue in
striv-ing to improve our operative technique in
the endeavor to salvage an increasing num-ber of these patients. But the greater
chal-lenge to this Pediatric group, to my mind, is why is this anomaly so often associated
with mongolism and indeed why are infants
born as mongols? If 30 per cent of the
sun-vivors of brilliant surgery done in the
neo-natal period for this condition turn out to
be mongols, one can hardly say that it is socially, psychologically, or economically a brilliant result for the family, or for the
patient. I am sure we would all much pre-fer to accept this difficult challenge of find-ing out why these things occur, than to
ac-cept as an easier way out the comment
made by one of my colleagues when I was
discussing this condition before a group of surgical confreres. He said, “This high in-cidence of mongolism is no great surprise to
me, for I have long suspected that the in-tellectual level of the inhabitants of greater
Boston is going steadily downhill.” It would appear, if one uses this same reasoning, that
the Proper Bostonian can take consolation in knowing that a similar condition exists
to an even greater degree in London. I cannot fail to refer to the astonishingly gratifying results that followed Doctor Ladd’s careful study of the treatment of
embryoma (Wilm’s Tumor) of the kidney.
His realization that the usual method of spread of this disease was by the blood stream; his insistence that the surgical ap-proach be a transpenitoneal incision so that the lesion could be attacked directly with-out the greater manipulation of the kidney
necessitated by a flank incision; that in these cases there should be the minimum amount
of palpation of the tumor by a group of enthusiastic students and house staff
mem-bers; and that x-ray therapy be postponed
until after the tumor had been removed, all
played an important part in the great
in-crease in the survival rate of what was, and still is in some areas, considered an almost universally fatal disease.
It is sometimes useful, though it is often
futile and indeed boring, to dwell on the advantages of a bygone era. But the man we honor today did so much in developing
the field of surgery of children, that I think it is a great pity not to call attention to what he did, and to point out that much of what he did developed not so much as the result
of improvement and advances in technique
as by the painstaking application of age-old
basic principles of good surgery. He was trained at a time when surgical dexterity and speed were of paramount importance, and I may add that a knowledge of surgical
anatomy was included as one of the prime requisites of the surgeon. Surgical dexterity he certainly had, but he always emphasized
672 LANIAN - WILLIAM E. LADD - AN APPRECIATION
before, during and after an operation came to him and to us, and with this speed is no longer of such prime importance. Long and
extensive procedures are now possible but
that did not excuse any of us in his eyes for spending too long a time in operating on
these patients. He believed, as I do, that a
sound knowledge of gross anatomy is a
ne-quisite of the good surgeon. If my experi-ence in the last wan is of any significance, I greatly fear that surgical anatomy is fast becoming a lost art. I have heard gross
anatomy referred to as “merely static mon-phology.” The surgeon, however, still needs a sound knowledge of “static morphology” whether he be dealing with a compound
gunshot fracture of the thigh, or the dissec-tion of the neck in a 2-month-old infant.
During my 35 years of service at the
Chil-dren’s Hospital, specialization in the many fields of medicine and surgery has been in-creasingly emphasized. So much so that it
has now reached a point that I consider ridiculous-and I believe Doctor Ladd shares this opinion.
At lunch recently I heard 2 residents at
our Hospital conversing; one said to the other, “I see you did a left inguinal hernia
this morning. Don’t you know you are al-lowed to do only night inguinal hernias, and
only right inguinal hernias if the patient is
over 6 months of age?” Of course, they were
both joking, but there is food for thought here.
Doctor Ladd felt that before one became recognized as a specialist in the field of
sur-gery of the young, he should be a good gen-era! surgeon. The purpose of the boards of
specialization is to raise the standards of
care for the Patielit, and with this I heartily
agree. But if there is too much
regimenta-tion in the requirements for certification, the purpose of these boards may be
de-feated. It seems to me that ideally there should be only two boards, one of medicine and one of surgery with, later, some
addi-tioiial certificate of proficiency in one of
the various sub-divisions of these two
categories. Such certificates of proficiency
should be given only when a man has
clearly demonstrated his aptitude and his
interest in a particular field, and can by an
adequate experience in that field demon-strate his proficiency in it. This is perhaps a very radical statement for one in my posi-tion to make but I believe that it may be the answer to this problem. There are now
“boards” in a great many special fields. There are in some quarters demands for
further boards. I am giving away no secret when I say that the establishment of a Board of Certification in Pediatric Surgery
has been talked oven with increasing fre-quency in the last few years. If there be
such a certification, let me say that I, per-sonally, believe it should be under and with-in the framework of the already existing American Board of Surgery.
Finally let me say this, one of Doctor Ladd’s most important contributions was
wonderfully demonstrated by his teaching ward rounds. Fortunately it is becoming ap-parent that the importance of the personal approach in the surgical care of the patient of any age is being re-recognized; note that
I say re-recognized. Certainly in this young age group such a personal approach as Doctor Ladd’s is of even greater
signifi-cance. At the risk of appearing too senti-mental in public, I believe that his greatest contribution to pediatric surgery was the teaching and the demonstration in his daily
work of a deep and personal concern for the individual child. He felt keenly, and rightly, that the surgeon, once he took oven
a case should be responsible in its entirety
for the preoperative care, the operation
it-self, and the postoperative care. He used his pediatric confreres freely in getting advice and help but the results he obtained amply justified his strong belief in the personal
re-sponsibility of the surgeon for the full cane of the patient. He often said, and truly, that without this time-consuming, meticulous,
and daily attention to detail before, during and after the operation the surgeon became a mere craftsman or technician. The key to his great success in the care of his patients was his sincere and abiding care for his
