Journal of Pediatric Surgery

VOL 32, NO 10 OCTOBER 1997

SPECIAL REVIEW ARTICLE

Surgery, Science, and Respiratory Failure

By Robert H. Bartlett Ann Arbor, Michigan

T WO YEARS AGO at our annual ECMO picnic I was surprised to see the family of a little patient named

Mary from Grand Rapids. Surprised and apprehensive because this child had been our first no-honeymoon, low PO,, on ECMO repair of diaphragmatic hernia treated 3 years before, in 1990, and she had a terrible result. She was on ECMO after repair for 3 weeks. She was in our hospital on a ventilator for 6 months and transferred back to Grand Rapids on a ventilator and was still in that hospital a year later. I frankly thought she had died. I approached the family with caution, greeting her mother, avoiding the obvious questions, and looking for the braces, hearing aids, oxygen, and glasses that I expected. Mary had been treated with extracorporeal life support or ECMO. This technique involves the use of a modified heart/lung machine and is being used regularly for newborn patients who have severe respiratory failure. Everyone in this audience thinks of ECMO as something that is performed at night, on weekends, and holidays apparently on the whim of a junior neonatologist. Using ECMO for this little patient who had apparent bilateral pulmonary hypoplasia, using on-ECMO repair, was one part of a major research project aimed at management of severe respiratory failure in newborn infants.

The surgeon who performed Mary’s diaphragmatic hernia repair was Dr Arnold Coran. Arnie and I have been caring for patients together since we were interns in 1963. Figure 1 is a photograph of our internship class, showing Dr Coran, your speaker, a former Gross Lecturer (Dr Rosenberg), and the President of APSA, Dr Philippart. Dr Coran and I were at the Boston Children’s Hospital as part of the Brigham rotation in 1965. Figure 2 is a photograph showing the surgical staff of the Boston Children’s Hospital in 1965. I often think of a baby that we treated at that time; an infant who had diaphragmatic hernia who had a nice honeymoon, then became hypoxic. Dr Coran and I and Dr Gazzaniga-of whom more later-hand bagged that baby for 2 days until the baby

finally died. Those were the early days of cardiac surgery, and I asked the Chief of the service if we could consider using the heart/lung machine for the treatment of acute respiratory failure, naively oblivious to the impact of the question and the sojourn involved in the answer.

The Chief of the service was Robert E. Gross, who at the time was in his late 50s. When Robert Gross was a 19-year-old chemistry student at a small college in Minnesota he read the Pulitzer Prize winning book entitled “The Life of Sir William Osler; ” written by Harvey Gushing, Chief of Surgery at the Brigham Hospi- tal in Boston and Harvard Medical School. Gross was fascinated and read the book over and over again. He became obsessed with the idea of being a doctor; becoming a surgeon, and studying with Cushing in Boston. He applied to Harvard Medical School and was accepted. At the first opportunity he crossed Shattuck Street to the Brigham, to the operating suite, to the gallery in room 2 to watch the famous Cushing operate. Midway through the first operation Cushing looked up and said “Who are you?”

‘l’m Robert Gross, a freshman medical student. Ever since I read your book, . . ”

“This is no place for medical students, go away, ” said Cushing. Gross was dismayed but worked hard at his studies and applied to Gushing for surgical residency 4 years later. Cushing refused him, however he entered the pathology residency at the Brigham and was befriended by the Chief of Pathology, Simeon Burt Wolbach. Three years later when Cushing retired, Wolbach convinced the

Robert E. Gross Lecture, American Pediatric Surgical Association, May 1996.

krom the Utziversity of Michigan Medical Centel; Ann Arbor; MI. Address reprint requests to Robert H. Bartlett, MD, University of

Michigan Medical Centec 1500 East Medical Center DC Ann Arbol; MI 48109-0331.

Copyright o 1997 by WB. Saunders Company 0022.3468/97/3210-0001$03.00/O

JournalofPediatric Surgary,Vol32, No 10 (October),1997:pp 1401-1407 1401

ROBERT H. BARTLETT

new chief Elliot Cutler to put Gross into the surgical residenq and he excelled in that position. He was the chief resident at the Brigham Hospital and chief resident at the Children’s Hospital and, after some confrontation with Dr Ladd, which I will describe late< was appointed to the staff of Children’s Hospital.

Dr Gross was as imposing as he appears in this photograph. He looks like Napoleon or Beethoven in this picture. Junior residents didn’t speak to Dr Gross unless spoken to and he rarely spoke. Although he is regarded as the father of pediatric and cardiac surgery he proudly considered himself a general surgeon, and so indicated on his letterhead. When his teen-aged daughter needed to have her tonsils taken out, he did it himself because he knew no one who could do it better. When colon cancer developed in a prominent colleague in his 60s Dr Gross

Fig 1. Surgical interns at Peter Bent Brigham Hospital, 1963. Left to right: Steven Rosenberg, Peter Strock (Oral Surgery) Arvin Philippart, Gordon Vineyard, Francis Moore, Arnold Coran, Stuart Howards, Robert Bar- tlett, Richard Hicks.

performed his colectomy. I knew Dr Gross better than most of the residents of my era because he took a liking to my wife, Wanda, who was working in the operating room cleaning the heart/lung machine at the time. So I could go to Dr Gross to ask him the question, “Could we use the heart/lung machine to treat acute respiratory failure?” He explained that the blood gas interface in the oxygenator damaged the proteins and the cells, and the machine became toxic within a few hours. Plastic membranes eliminated the gas interface but blocked gas transfer. He was skeptical but he encouraged me to give it a try anyway.

This morning at Dr Philippart’s invitation, I will talk a bit about surgery and surgeons, science and scientists, and offer a rather personal account of the surgical treatment of acute respiratory failure.

Fig 2. Surgical staff of Boston dren’s Hospital, 1966. Dr Gross the middle of the front row.

Chil- is in

SURGERY, SCIENCE, AND RESPIRATORY FAILURE

.

Fig 3. The “fistula” between Children’s Hospital (right) and the Brigham

PROLONGED EXTRACORPOREAL CIRCULATION

As everyone in this audience knows, Surgery is that branch of medicine that assumes complete responsibility for the care of patients who have certain illnesses, injuries, and anomalies; this often requires a tissue dissection under anesthesia (an operation). This elegant prose is that of Francis Moore, successor to Cutler as Chief of Surgery at the Brigham Hospital and appointed by a search committee that included Robert Gross The Peter Bent Brigham and the Children’s Hospital have always been connected intellectually, functionally, and physically by a bridge between the two hospitals over Shattuck Street (Fig 3). After some failed oxygenation experiments with silicone rubber membrane, I took the question to Dr Moore at the Brigham Surgical Research Conference, which was held every Tuesday morning. If Gross is the Beethoven of Surgery, Moore is Mozart. Gross was silent, precise, imperial. Moore is eloquent, ebullient, charmingly perceptive. “It’s clear Bartlett,” he said, “that by eliminating the gas you’ve created a mixing problem. You need to get together with Phil Drinker, an engineer from MIT. He’s trying to study hemolysis. His machine mixes the blood, but it doesn’t hemolyze.”

With that suggestion Phil Drinker and I began a series of bench and laboratory experiments aimed at modifying the heart/lung machine for prolonged use. We built and tested membrane oxygenators. We built devices to elimi- nate the venous reservoir and suction apparatus. We built a machine to measure whole blood-activated clotting time and discovered that we could maintain extracorpo- real circulation with much less heparin than was com- monly used in the operating room. We could maintain extracorporeal circulation in dogs for periods up to 5 days: exciting stuff in 1968 and 1969.

In 1970 I left the Brigham nest to join the faculty at the new medical school at the University of California, Irvine in Orange County. Orange County, California is as far as you can get from Boston, Massachusetts geographically,

intellectually, socially, politically, and surgically. If you ask someone in Boston how to get to California they would advise you to go through Dedham. If you ask someone in California how to get to Orange County they would advise you to go south and keep turning right. Al Gazzaniga and I, recently graduated Brigham residents, were the junior faculty in our very small department. The Chairman, Jack Connolly recruited faculty who were boarded in general and thoracic surgery. Al and I did everything. We did the bellies and the burns and the aortas and the trauma and the thoracic and the cardiac and the general surgery. We did the pediatric surgery, and there was a lot of it. We were old fashioned surgeons. Dr Gross loved it. Dr Moore thought we had gone to a third world country.

Dr Gazzaniga and I undertook the serious study of extracorporeal circulation in the laboratory. We switched from dogs to sheep, and we learned that cannulating the neck vessels allowed enough blood flow to provide total support. We evaluated the devices and the technology and with that system evaluated the physiology and biochemis- try of prolonged extracorporeal circulation. We actually hooked up some patients to our machine. Our first success was in a 2-year-old child who had cardiac failure after a Mustard operation in 1972. After that, we treated adult patients with the new diagnosis of acute respiratory distress syndrome (ARDS), always without success.

One night in 1975 the neonatologists asked us to see a baby who was dying of respiratory failure. This child had aspirated meconium and was hypoxic since birth. She was rapidly deteriorating despite all efforts at treatment- could we consider using our machine? This was the baby of a Mexican mother in the country illegally. Her husband was in Mexico and this was her first pregnancy. Late at night, with the aid of a flashlight, I tried to explain to the mother a procedure of unknown risk that had never worked. The mother signed the consent and we went to the laboratory to get the machine. The mother, just a girl herself, scared by the activity, terrified of the legal forms, and realizing that there was nothing she could do to help her baby daughter, went into the neonatal ICU, whispered in the baby’s ear, kissed her, and disappeared. We never saw her again. We cannulated the baby through the neck vessels, established flow, and miraculously the baby turned from purple to pink. The nurses named her Esperanza, Spanish for hope. Soon it was apparent that there was more going on than just meconium aspiration. The only way we had to study the baby was with fluoroscopy, and fluoroscopy showed a patent ductus arteriosus, but the flow was going from the pulmonary artery to the aorta. We repeated that study because we didn’t know what to make of it and found the same findings. Dr Gazzaniga and I did what any Gross-trained surgeons would do presented with inadequate catheteriza- tion data; we went to the operating room and took a look.

1404 ROBERT H. BARTLETT

The heart looked normal, the pulmonary artery looked normal and there was indeed a large patent ductus arteriosus. We ligated the ductus but the baby got worse rather than better. The pulmonary artery distended, the right ventricle distended, and if the baby had not been on venoarterial bypass, she would have died on the spot. Mystified, we placed a catheter directly into the pulmo- nary art&y and found that the pressures were suprasys- temic. One of the satisfying things about physiology iS that it makes sense. With enough data we can always figure out the problem. One of the satisfying things about ECMO is that it allows time to think about the data. over the next 2 days the pulmonary artery pressure remained elevated, and we concluded that there was most likely some irreversible anomaly of small pulmonary vessels in the periphery of the lung. We planned to remove the child from the machine and probably would have stopped our experiments on extracorporeal support in infants. But the pulmonary artery pressure fell below systemic levels and the peripheral pulse contour became more pulsatile. The next day the baby weaned off extracorporeal support and in a few more days weaned off the ventilator and recovered. Over the next year we treated more infants, but let’s return to the discussion of the patent ductus arteriosus.

As you well know, Robert Gross was the$rst person to successfully ligate a patent ductus arteriosus (PDAJ in a &year-old girl in 1938. Imagine the tragedy of a PDA diagnosis before that time. The diagnosis was made at the age of 4 to 6 months, and the child grew happy and healthy until the age of 6 or 8 or 10 years, when hemoptysis, pulmonary edema, endocarditis, and right heart failure led to hospitalization and a miserable death of drowning in bloody secretions. Gross had per$ormed the autopsies on many of those children. He conceived the operation as a pathology resident and practiced in the morgue. He practiced on living tissue, treating varicose veins in adults. When chief resident at the Children’s Hospital, he proposed to the chief of service, Dr William Ladd, to try an operation to close a patent ductus. Ladd said, “‘Absolutely not. First of all there is no way to operate on the chest of children. Secondly everyone knows that operating around the heart or great vessels is always fatal. ” Ladd forbid him to even consider the operation. Gross waited until Ladd went out of town-to Europe by boat-and brought in two children on which to operate; two in case one died. He pe$ormed the opera- tion with Bess Lank, nurse anesthetist, giving positive pressure mask anesthesia. He ligated the ductus, and the bounding pulmonary artery qui6ted down, and the child recovered successfully.

The next part of the story Dr Gross told me standing in the barnyard of his farm iri Framingham. When Ladd returned from Europe, he was furious that Gross had performed the operation against his instructions. He fired

Gross, of course. Many of you are program directors for

residency programs. Gross was the chief resident. Sup- pose you go home and find that your chief resident has operated on the brain stem of a child for schizophrenia, or done a spleen transplant for hemophilia. What would you do? Fire him on the spot. ThatS what Ladd did, but others in the Children’s Hospital implored him to bring Gross back. They could see the success@ outcomes in patients and knew all too well the usual outcome ofpatent ductus arteriosus. Finally Ladd relented and called Gross inviting him back to complete the residency. In typical fashion Gross responded, ‘No, you fired me and I’m building a barn. I’ll return when the roof is on. ”

Iti 1980, the project now known as ECMO moved to the University of Michigan. We had treated 40 newborn patients in California, and half of them survived. With neonatologist Deiter Roloff and surgeon Michael Klein and perfusionist John Toomasian and many others, we explored the indications, contraindications, technique, complications, and applications of this new procedure. Most academic neonatologists regarded this activity with skepticism and disdain, but a few were interested and came to see what we were doing and learned the procedure. This led to annual seminars and the establish- ment of programs in several major children’s hospitals. We kept a registry of all the cases and tracked the growth of the technique. By 1987, over 1,000 cases had been treated, and the procedure became standard treatment for neonatal respiratory failure that was unresponsive to other conventional methods of treatment.

Recently we collected and reported on the University of Michigan series of patients undergoing ECMO for neonatal respiratory failure (Table 1). The overall sur- vival of 87% includes Esperanza and every patient treated since. Considering that these patients are selected by the neonatologists when they are considered mori- bund, and all other treatment has failed, the 87% survival rate is why this radical approach has become standard treatment in our hospital. Of course survival rate is only important if normal healthy children result. In follow-up examination, 80% of the children are normal, and 5% have serious disability. These are better outcome results

Table 1. Neonatal Respiratory Failure: Results of ECMO Treatment

CSYC5 Survival, %

MAS 176 97 RDS 95 88 PFC 40 92 CDH 70 66 Sepsis 79 84 Other 29 79 Overall 489 87

NOTE. University of Michigan Neonatal extracorporeal life support

(l/95). Abbreviations: MAS, meconium aspiration syndrome; PFC, persis-

tent fetal circulation; CDH, congenital diaphragmatic hernia.

SURGERY, SCIENCE, AND RESPIRATORY FAILURE

Table 2. Survival Rate for Neonatal Extracorporeal Life Support:

Vascular Access

University of Michigan ECLS registry

VA, n (%) VVDL, n (%)

277 (83) 114 (98) 6715 (80) 702 (91)

NOTE. Neonatal ECMO; Double lumen catheter venovanous access

and two-catheter VA access outcome data from the University of

Michigan and the Registry of the Extracorporeal Life Support Organi- zation (7193).

Abbreviations: VA. venoarterial; VVDL, double lumen venovenous.

than achieved with conventional ventilator therapy, so we are content that we are not creating neurological injury or pulmonary cripples. We have continued to develop new techniques in the laboratory. The data on a double lumen venovenous catheter, which avoids carotid ligation, are shown in Table 2.

We expanded the use of ECMO to older children who had severe respiratory failure as shown in Table 3. The overall survival at the University of Michigan averages 68% in pediatric cases. In 1990 we reevaluated the use of ECMO in adult patients who had respiratory failure, and we have treated 88 patients with 50% survival.

RESEARCH, SURGEONS, AND SURGICAL RESEARCH

Pursuit of the simple question, “Can the heart/lung machine be used to treat acute respiratory failure,” has led us into complex and fascinating areas of research traditionally known as basic science and bioengineering. The biology of acute respiratory failure could be studied in animals and patients at leisure, well beyond the stage that would otherwise be fatal. The clinical evaluation of life support has posed major problems in ethics and logistics of clinical trials. The technique is complex, it can not be blinded, it is only used for patients who are moribund. Usually the patients are children, and the technique must be learned by an entire medical center before it can be evaluated. Our efforts at clinical evalua- tion of ECMO and the concomitant evaluation of conven- tional treatment in neonatal, pediatric, and adult intensive care units has been challenging. After 30 years this entire project is very much a work in progress.

In 1990 the National Institutes of Health convened a workshop on the diffusion of high-tech medicine into clinical practice using neonatal ECMO as an example.’

Table 3. Extracorporeal Life Support Pediatric Respiratory Failure

No. of Patients Survival, n Survival, %

Pneumonia

Bacterial

Viral Aspiration

ARDS, other Total

7 4 57 32 25 78

7 5 71 49 31 63 95 65 68

NOTE. University of Michigan (7/96).

Table 4. ECMO: Lab to Clinical Transition

Positive Points

One source “Scientific” progression from laboratory to clinical phase I, II, Ill

studies NIH catalyst, ASAIO crucible, university raw materials

Annual seminars emphasizing standardized methods Registry documenting progress (quietly)

Multidisciplinary team

Medical industry support, “off the shelf” components Self regulation in quality and growth

Spinoff

The positive points that came out of that review are listed in Table 4. The investigation followed a logical sequence from bench to laboratory to clinical trials back to the laboratory and back to clinical trials. All of the investiga- tors kept records of all the patients treated including all the complications and follow-up information. A team of people to run the machinery was developed as well as the machinery itself. Sensationalism and newspaper report- ing was avoided, but the technology was regularly reported in peer reviewed journals and discussed at major scientific meetings, particularly the American Society for Artificial Internal Organs where this type of research is debated and developed annually.

Science is defined as the orderly collection and report- ing of information, sometimes associated with experi- ments. A staggering amount of time, effort, and resources are spent on biomedical scientific research. Very little of it actually solves a clinical problem. Most biomedical research can be performed by anyone, surgeons included, but not necessary. However, some research can only be performed by surgeons. Prosthetic joints, vessels and valves, repair of anomalies and injuries, organ transplan- tation, and the cure of solid tumors are examples. There is a body of investigation called surgical research- research that can only be performed by surgeons. More- over, surgeons as a group, are the most successful biomedical researchers, if success is measured as clinical problems solved per dollars and effort spent. From Robert Gross and Francis Moore (and other surgeons) came the entire disciplines of pediatric, cardiac and vascular sur- gery, transplantation, nutrition in acute illness, and the physiological care of surgical patients. These two scien- tists solved clinical problems for millions of people who lived at all, lived longer, and lived better because of their efforts. Robert Gross was honored with three Doctor of Science degrees, and appointed to the National Academy of Sciences in 1975.

There are three reasons why surgeons are so successful as scientists, which are defined in the introduction to Dr Gross’ textbook, “Surgery of Infancy and Childhood.” First, we take care of patients every day. There is no doubt about who is in charge of that care. We see the disease in the operating room and daily in the intensive

1406 ROBERT H. BARTLETT

care unit. This leads to practical solutions to real prob- lems and immediate communication between the bedside and the laboratory. Secondly, we care ubout our patients with a personal commitment that comes from being the responsible surgeon. I am often asked why surgeons have led the way in treating these medical respiratory diseases. It’s a matter of responsibility and perspective understand- ably unique to surgeons. If you ask a dedicated intensivist or neonatologist, “How did things go last month?,” he might answer, “I had a good month, I only lost one patient.” Asked the same question, most surgeons would respond, “I had a terrible month, I lost a patient.” Third, surgeons must be technical perfectionists. The discussion of Robert Gross would not be complete without some mention of surgical technique. He was masterful in the operating room and did things that the rest of us have been trying to emulate since. There are 20 surgeons in this room who learned how to do ductus closures, coarctation repairs, or UDT operations directly from Dr Gross. There are 100 more surgeons here who learned to do those operations from the first 20. There is something special about the heritage of the art, whether it’s learning to do an operation from the surgeon who did it first, or showing an intern how to place a suture in Cooper’s Ligament. Among ourselves we speak of doing opera- tions, like professional musicians speak of playiplg this or that piece of music. However the public-including our medical colleagues-speak of performing operations, as we speak of performances by musicians. An operation is a performance that can be done well, poorly, or with true mastery. Gross was a master. The third reason that surgeons succeed at scientific research is because they know how to “just do it.”

The answer to the question “can we use the heart/lung machine to treat acute respiratory failure” turned out to be “yes.” Prolonged extracorporeal circulation is pos- sible and is good treatment for acute respiratory failure that does not respond to other simpler methods. The blood surface problems can be solved. Most importantly we have learned that all acute respiratory failure is curable. Our understanding of the biology of lung disease in all ages has improved as a result of this mechanical approach to treatment.

LESSONS IN RESPIRATORY FAILURE

As with any research project, the spin-off discoveries and their interconnections are more interesting than the original question (Fig 4). I will conclude by describing two spin-off areas: the pathophysiology and treatment of ARDS and lung hypoplasia associated with diaphrag- matic hernia. As a result of his ECMO research, Luciano Gattinoni developed a major interest in the pathophysiol- ogy of ARDS. He studied that condition by analyzing the gas and tissue volume in each small section of the lung studied in the computed tomography (CT) scanner. He

Lung Injury Hypoplasia & growth

Bardvolutrauma Fibrosis

Chemoreceptors

02"SCOZ Artificial lungs Position

Barotrauma Protocols

Airway

E&C Access, Devices

Perfusion Logistics

Transport

Fluid dynamics, mass transfer Pumps, blood trauma

Systems control Blood/surface interaction

FDA/Industry

Fig 4. Spin-off research from the ECMO project.

measured the amount of water in the edematous lung and calculated the weight of that water that compressed the dependent alveoli in the posterior chest when the patient is in the supine position. He correlated these findings with the actual appearance of the ARDS lung in the CT scan. Although the lung appears to have diffuse, homogenous, patchy infiltrates on antero-posterior radiographs, CT shows that there is nothing homogenous about the pattern at all. ARDS is characterized by posterior dense consoli- dation, a mid zone that can be inflated with positive end-expiratory pressure (PEEP), and some fairly normal lung anteriorly where most of the gas exchange takes place. The consolidation is posterior and has abundant blood supply, resulting in shunting and hypoxemia. Hyperventilation of the anterior lung to maintain normo- capnea results in barotrauma and further lung injury. This new understanding of the pathophysiology of ARDS has led to new treatment: (I) avoiding high pressure and barotrauma, tolerating hypercapnia; (2) avoiding high oxygen, tolerating hypoxemia, and (3) treating the basic problem with diuresis, prone positioning, transfusion, and PEEP and prolonged inspiratory time without ele- vated plateau pressures. If all of these methods fail, ECMO can be used to keep the patient alive while this treatment continues,

This new understanding of ARDS led Dr Ronald Hirsch1 of our research group to evaluate the role of an inert oxygen carrying liquid-Perflubron-in adult and pediatric patients who have ARDS. Through a series of bench, then laboratory, then clinical studies he learned that the consolidated lung can be inflated with fluorocar- bon, decreasing the shunt, with major improvement in the patient’s condition. Dr Hirsch1 first evaluated this radical approach to liquid lung inflation on adult ECMO patients because they were at high risk, justifying radical interven- tion, and because they were supported with ECMO assuring safety. After success in these patients, research with partial liquid ventilation has moved on to prospec- tive randomized trials in four different age groups.

Another spin-off area has been our understanding of

SURGERY, SCIENCE, AND RESPIRATORY FAILURE

the pathophysiology of hypoxemia in diaphragmatic hernia. When we began this research, patients who had diaphragmatic hernia were rushed to the operating room for repair, with the belief that the herniated bowel was itself the problem. Half of these patients recovered, but half failed the honeymoon period, and ECMO was useful in these patients. This experience led us to recognize that the problem was not the hernia but rather persistent fetal circulation with right to left shunting. This led to the concept of treating the PFC first, with ECMO if neces- sary, then repairing the hernia when lung function was normal. This is satisfactory for two-thirds of the newborn infants who have diaphragmatic hernia, but does not address the problem of bilateral hypoplasia.

Dr Michael Harrison and his research group in San Francisco have pursued a marvelous series of studies in the laboratory and in patients, learning the techniques of monitoring and management necessary for fetal surgery, then evaluating the repair of diaphragmatic hernia in fetuses in utero. This is a good example of surgical research-research that could be conducted only by surgeons. After many years, Dr Harrison and his group have concluded that fetal hernia repair can be done, but it is not necessary in fetuses with the liver below the diaphragm, and it is dangerous in fetuses with the liver above the diaphragm. Meanwhile Dr Jay Wilson at the Boston Children’s Hospital, using the lamb diaphrag- matic hernia model, showed the tracheal ligation in utero caused lung growth, avoided hypoplasia, and actually reduced the hernia contents. Dr Harrison and others have adapted this information to the treatment of fetuses who have diaphragmatic hernia by creating temporary tracheal occlusion in utero.

But what could be done for the baby born with bilateral hypoplasia, as in the case of our little patient Mary? If the diagnosis is not made prenatally, the child is born with diaphragmatic hernia, bilateral hypoplasia, and a dismal prognosis. Inflation with saline is not possible because the liquid would be absorbed. However, chronic static inflation with Perflubron might offer the opportunity for lung growth, if the baby could be supported with ECMO for a week or two. These two spin-off areas from the ECMO project resulted in Dr Hirsch1 and Dr Wilson collaborating on the evaluation of this concept in postna- tal newborn lambs. These laboratory studies will soon lead to the evaluation of chronic static inflation with fluorocarbon in infants on ECMO with bilateral hypopla- sia. Although it is very early in the experience, it seems likely that a combination of these modalities will lead to complete recovery and survival in almost all infants who have diaphragmatic hernia.

Finally, we return to Mary. As I talked to her mother on that summer afternoon in 1994, the child was silent and

Fig 5. A photograph and note from Mary’s mother, 3 years after Mary was treated on ECMO for congenital diaphragmatic hernia. (Used with permission.)

my concern increased. Finally I asked her mother if Mary had received her T-shirt which we give to the children each year. At that point Mary herself responded brightly, “Why yes I got my T-shirt, it’s just the same as yours actually, although of course it’s smaller.” Thereupon she jumped down and ran off to play with the other children joining in the games and the tug-of-war, Dr Gross always ended his papers and talks with a picture of a happy patient or a parent and I would not break with that tradition. Figure 5 is a photograph of Mary, a beautiful little girl, bringing joy to her family as a result of our heritage in surgical science.

Dr Philippart, I am grateful for the opportunity to share this story with the American Pediatric Surgical Associa- tion. There is no other group that can fully appreciate the sense of satisfaction at sharing this mother’s joy.

REFERENCE 1. Report of the Workshop on Diffusion of ECMO Technology:

Extracorporeal Membrane Oxygenation. NIH-NICHHD Publication 93-3399, Bethesda, MD, January 1993