History of Paediatric Surgery in Austria

menardi - rokitanskyDevelopment of Paediatric Surgery in Austria
Alexander M. Rokitansky (Professor of Paediatric Surgery)
Gesine Menardi (Professor of Paediatric Surgery; 1936-2007)

Address of the Authors:
Univ. Prof. Dr. Drhc Alexander Rokitansky
Health Service Center an der Wiener Privatklinik
Lazarettgasse 25
1090 Wien

Specialised medical care of the child in Austria has made great advancements in the last 200 years. The roots are to be found in Vienna: at the end of the 18th century, two institutions focused on the treatment of children were founded simultaneously. The so-called Vienna General Hospital (Wiener Allgemeines Krankenhaus) founded under Kaiser Josef II (the son of Empress Maria Theresia) in 1784 and the Vienna Findelhaus (Vienna Foundling Hospital) were opened at the same time. During this time infanticide and infant mortality were major topics of interest and were discussed within the scope of enlightened absolutism. At the Foundling Hospital illegitimate newborns and infants could be handed over, if desired even anonymously. An important reason for establishing this facility was to reduce the rate of child mortality, also in the interest of population policy. From the patient population at the Foundling Hospital Alois Bednar reported, on 7.3.1851, about a case of anal atresia. He perforated a “fluctuating lump” on the floor of the pelvis with a trocar and drained meconium. The Viennese paediatrician Alois Bednar (1816-88) was the director of the Vienna Foundling Home. In the 126 years of its existence from 1784 to 1910, approximately 750,000 children were admitted at the Vienna Foundling Hospital. In 1787 the physician Johann Josef Mastalier (1757-1793) founded a private Out-patient Service for Poor Children at Wollzeilein Vienna. This institution provided counselling for mothers and also conducted house calls to treat children. The out-patient service was the precursor of the first Public Children’s Hospital in Vienna under Anton Leopold Göllis (1764-1827). Started in 1881, the Institute developed significantly under the management of the Slovak paediatrician Max Kassowitz (1842-1913). Special treatment rooms for surgery, orthopaedics, laryngology and ophthalmology were set up from 1882 to 1913. Besides, an operating room and a lecture hall were created. Sigmund Freud headed the department of neurology at this Institute.
In 1837, after paediatric hospitals had been founded in 1802 in Paris and 1830 at the Charité in Berlin, the first paediatric hospital in Austria was founded in the Viennese suburb of Schottenfeld by a philanthropist and erstwhile military doctor Ludwig Wilhelm Mauthner (1806-1858) at his own expense. This facility was shifted to Kinderspitalgasse 6 and was the forerunner of what is known today as St. Anna Kinderspital (St. Anna Children’s Hospital). Mauthner was a member of the Vienna Medical Faculty, a surgeon, and a kind of “people’s doctor”. He was concerned with improving medical care for acutely ill children of poor parents. He also was interested in scientific research on paediatric diseases. His chief aim was to connect socially committed basic care with medical research and this remained a major determining factor for the development of the hospital. Mauthner’s paediatric hospital became famous in scientific circles and many physicians came to the hospital to be trained. Mauthner struggled to obtain permission to teach at his hospital. In 1844 he was granted permission to hold clinical lectures. In 1850 the University Paediatric Clinic of Vienna was founded and established in the premises of St. Anna Kinderspital. In 1851 he received the first associate professorship for paediatrics at the University of Vienna. This university facility was located at St. Anna Kinderspital until 1911.

After Mauthner’s demise in 1858, a separate department of surgery was opened and Friedrich Franz Salzer (1827-1890) was appointed as the unpaid head of the institution. Under the subsequent director Hermann Widerhofer (1832–1901) and finally after the nomination of the surgeon Josef Weinlechner, surgery at St. Anna Kinderspital experienced a significant upsurge. Josef Weinlechner (1829-1906), a pioneer of paediatric surgery, was born in humble circumstances in a town named Altheim in Upper Austria. After a period of great privation Josef Weinlechner achieved his doctorate in 1854. He then completed his specialisation training at the University Clinic of Surgery in Vienna under Franz Schuh. Schuh belonged to the close circle of the council of professors at the Second Medical School under the rector Carl Rokitansky. In 1864 Josef Weinlechner was asked to serve at St. Anna Kinderspital. Weinlechner’s appointment marked a major upswing in paediatric surgery at St. Anna Kinderspital. During this time he also applied for an assistant professorship in surgery with special emphasis on paediatric surgery. This application is dated 1st of July 1865: a milestone in the history of paediatric surgery because it was extremely unusual at the time to apply for a professor’s degree in paediatric surgery. He submitted his thesis on the cleft lip and was awarded a professorship on 10th October 1865. Deformities and oncological operations were his favourite subjects from the very beginning. From 1866 onward the annual reports of St. Anna Kinderspital included detailed statistics about surgical work. Interestingly, the most frequently performed paediatric operations today, which are appendectomy, hernia surgery and hydrocele operations, do not feature in these statistics. Weinlechner treated hernias with a truss; hydroceles were punctured and then instilled with iodine. An important chapter in paediatric surgery at the time were life-saving tracheotomies for diphtheria; Weinlechner improved upon the technique. Appendicitis belonged to the realm of internal medicine at the time. Only in 1886 was it discovered that the cause of the frequently fatal inflammation of the peritoneum was an inflammation of the appendix. In 1894 the American surgeon McBurney reported that the “internal-medicine problem” could be resolved by performing a small incision in the right lower abdomen and removing the vermiform appendix. For several years surgeons discussed whether it would be better to drain the abscess only. Even in 1907 appendectomy was one of the main topics of the German Congress of Surgeons.

When St. Anna Kinderspital was founded in Vienna, so-called paediatric hospital associations were founded under the patronage of aristocratic ladies and distinguished townswomen in Graz and Salzburg. In 1842, for instance, the Paediatric Hospital Association was founded in Graz under the special patronage of Mrs. Anna Freiin von Brandhofen, wife of Archduke Johann. 1843 marked the inauguration of a provisional paediatric hospital with 8 beds in two hospital wards in Klosterwiesgasse. In 1846 this facility was shifted into a new single-storey building at Villefortgasse in Graz. In 1899 the Paediatric clinic of Salzburg was opened, supported by the Archduchess Valerie. The paediatrician in charge, Hans Fiala (1858-1924) was appointed head of the institution and established paediatric surgery here. He completed a part of his training under Widerhofer and Weinlechner at St. Anna Kinderspital in Vienna and tried his best to introduce the Viennese standards of paediatric medicine in Salzburg. Thus, he created a separate department for ill children in need of surgery and a separate operating room.
After a two-year construction period, the new Anna Kinderspital (Anna Paediatric Hospital) named after Countess Anna von Meran was inaugurated in Graz in 1877. In addition to the medical and surgical-oculistic department, a department for children with infectious diseases was accommodated here. At the time Benjamin Ipavic was in charge of the department of paediatric surgery. In 1899 the hospital was significantly developed by Theodor Escherich (1857 -1911). A lecture hall and an isolation tract were built. Hans Spitzy (1872-1956) became head of the surgical-orthopaedic department in 1905. He was succeeded by Philipp Erlacher in 1913. In 1906 more than 686 operations were performed here; anaesthesia was administered in 252 cases.

Until the beginning of the 20th century, paediatricians frequently performed surgery in children. For instance, the famous physician in Graz Theodor Escherich used the paraffin plug to treat umbilical hernia in children; the paraffin plug had been proposed by Robert Gersuny (1844-1927) for the treatment of rectal episodes. In 1903, in the monthly journal of paediatrics Escherich finally reported about more than 30 cases in which he used this method in children aged 1 to 14 months. Even from Klagenfurt we know that the chief paediatric physician Gernot Brandesky personally operated on children at the paediatric hospital until the department of paediatric surgery was founded in 1974.

In 1875 the Kronprinz-Rudolf Kinderspital (Crown Prince Rudolf Paediatric Hospital) was inaugurated in Vienna and a department of paediatric surgery was established here in 1903. It was headed by Hans Salzer (1871-1944), the second pioneer of paediatric surgery in Austria. Hans Salzer served as an assistant at the Second University Clinic of Surgery in Vienna under the chairmanship of Carl Gussenbauer (1842-1903). He had to leave the clinic in 1902 because of his marriage. At the time assistants working at a clinic were not permitted to marry. He moved to Kronprinz-Rudolf Kinderspital and also occupied the position of chief physician at the Vienna Polyclinic for some time. Kronprinz-Rudolf Kinderspital was re-named Mauthner Markhofsches Kinderspital. In 1924 Hans Salzer was appointed Director of Mauthner Markhof'sches Kinderspital. At this time he surrendered his chief physician’s position at the Polyclinic. The Austrian Society of Paediatric and Adolescent Surgery which arose from the study group of paediatric surgery in 1971 has been honouring Hans Salzer by awarding the Hans Salzer prize every year from 1976 onward. Salzer’s major merits included the establishment of a department of paediatric surgery and also trend-setting work on highly relevant problems in paediatric surgery at the time. He focused his attention on three major fields. The first was the treatment of pneumococcal peritonitis in the young girl, the second was the treatment of congenital inguinal hernia and, thirdly, he became very famous through his publications on early bouginage of caustic alkali burns. At this time pneumococcal peritonitis in the young girl was a disease with a mean lethality of 50%. As the symptoms were similar to those of acute appendicitis, the children were commonly operated on. The combination of surgical trauma and pneumococcal peritonitis led to a lethality rate of nearly 100%. He was able to show that a limited conservative therapy later complemented by the administration of a pneumococcus serum helps to achieve a significantly better prognosis for the child affected by this condition. While treating inguinal hernia he realised that all inguinal hernias in newborns, infants and young children are congenital; his treatment consisted of high ablation of the hernia sac and/or the vaginal process without any plastic coverage in the region of the inguinal canal. Hans Salzer was succeeded by Rudolf Jonas, the youngest brother of mayor and the Austrian president Franz Jonas, followed by Peter Wurnig who earned great merit in intensive medicine for children as well as neonatal surgery and was responsible for establishing Vienna as the venue of the 32nd BAPS Congressat the Hofburg in1985. Finally he was succeeded by Ernst Horcher, a student of Fritz Helmer.

Apart from the department of paediatric surgery at Mauthner Markhofsches Kinderspital, surgical diseases in the child were also given attention at the University Clinic in Vienna. At the First Clinic of Surgery Leopold Schönbauer (1888-1963) was in charge of this sub-speciality. He was succeeded by Huber. At the Second University Department of Surgery Fritz Demmer (1884-1967), Wolfgang Denk (1882-1970) and finally Georg Salzer (1903-95) son of Hans Salzer, frequently devoted their attention to treatment methods in paediatric surgery. As early as in 1921 Fritz Demmer reported on a successfully operated ileal atresia. The child, referred from the obstetric clinic to the Second University Clinic of Surgery on the first day after its birth, had a simultaneous small omphalocele (hernia in the cord). When exposing the umbilical hernia it was found that an additional ileal atresia with a microcolon was present. Demmer resected the markedly dilated distal end of the ileum and restored continuity by performing a side-to-side anastomosis between the cranial ileum and the ascending colon. The child could be discharged from the hospital in healthy condition. This was the third published case of a successfully operated small bowel atresia in the global literature. In 1930 Leopold Schönbauer presented to the Society of Surgeons in Vienna a successfully operated left-sided hernia of the diaphragm in a 3-month-old infant which he corrected in accordance with surgical principles valid even today. Based on his work as a consultant surgeon at the so-called Kinderklinik Glanzing (Paediatric Clinic of Glanzing) which had been founded with resources of the “Jubiliäumsfonds für Kinder” (Jubilee Fund for Children) in 1915, Leopold Schönbauer also had sufficient opportunity to operate on cases of hypertrophic pyloric stenosis and publish his experience in this field in 1931. A remarkable study from this period reports his experience in treating intestinal obstruction by invagination, which was presented by Fritz Starlinger from Anton Eiselsberg’s Clinic in 1931 and drew attention, at this early point in time, to the option of hydrostatic repositioning and invagination. In 1935 Wolfgang Denk presented his successful treatment of uni- and bilateral testicular retention (cryptorchidism) at the Society of Physicians, using extracts from male gonads. The above mentioned legendary Paediatric Clinic of Glanzing had no surgery facilities of its own. Until 1994 its numerous paediatric-surgery patients were treated at the University Clinic of Surgery in the General Hospital of Vienna by the consultant surgeons Paul Huber, Georg Salzer, Fritz Helmer and, after 1990, Alexander Rokitansky. From 1994 onward, paediatric surgery for the Paediatric Clinic of Glanzing was performed at Donauspital in Vienna. A centre of paediatric chest surgery and paediatric urology was developed here under Rokitansky.

The Paediatric Hospital Association in Graz was dissolved in 1939 and the surgical-orthopaedic department was shifted to Sanatorium Theresia which was located in close proximity. Wilhelm Schäfer became the successor of Philipp Erlacher. A resolution was passed and the construction of a new University Clinic of Paediatric Surgery in Graz was started in 1973. In 1974 Hugo Sauer who came from the University of Innsbruck took over the Clinic of Paediatric Surgery. Under Sauer’s management, paediatric surgery in Graz received a major new impetus, particularly because its usual work was flanked by intensive attention to traumatology and the founding of an Austrian Committee of Accident Prevent in Children (1983). In addition to the regular spectrum of paediatric and adolescent surgery, accident prevention was pursued by his successor Michael Höllwarth at the Clinic in Graz.

The department of paediatric surgery was founded in 1956 at the Paediatric Clinic in Linz. Hermann Hartl was in charge of this department from 1956 to 1987. In the 1950’s the first two corrections of oesophageal atresia in Austria were performed by Hartl in Linz and Georg Salzer in Vienna. From 1987 to 2002 Michael Engels was in charge of the large department of paediatric surgery in Linz. He was the initiator and a major driving force behind the so-called Danube Symposium on Paediatric Surgery (Kinderchirurgisches Donausymposium). In 1992 he performed laparoscopic surgical techniques in newborns, infants and children. In 2002 he was succeeded by Wolfgang Pumberger, a student of Peter Wurnig and Ernst Horcher, who then became the head of the department of paediatric surgery at the Regional Paediatric Clinic of Linz.

After the Second World War an out-patient surgery department was set up at Gottfried v. Preyersches Kinderspital (Gottfried von Preyer Paediatric Hospital). This was followed by a department of paediatric surgery under Rudolf Rauhs, established in 1961. His successor was Rehbein’s student Leopold Preier who set up an interdisciplinary intensive care unit and modernised the operating rooms.

Peter Wurnig (1923-2005), appointed chief physician at the Mauthner Markhof Paediatric Hospital (Mauthner Markhofsches Kinderspital) in 1963, gave a new impetus to this institution. He developed surgery in the newborn and surgery for deformities, and also set up an intensive care unit. Peter Wurnig was able to establish Vienna as the venue of the 32nd BAPS Congress in 1985. Wurnig’s successor in 1989 was Ernst Horcher, a student of Fritz Helmer. Horcher switched to the newly built largest department of paediatric surgery in Vienna at Donauspital in 1992, which is headed by Alexander Rokitansky since 1994. Rokitansky is also a student of Fritz Helmer. Under Rokitansky Donauspital eventually took charge of paediatric surgery for Mauthner–Markhof Kinderspital. In 2003 it also took charge of surgery for Preyersches Kinderspital. At the large hospitals of Vienna Rokitansky established paediatric surgery out-patient departments according to the so-called “model for out-patient care in paediatric surgery”. These units provided care and also served as outposts of Donauspital’s paediatric surgery. In 1994 Ernst Horcher took over the University Clinic of Paediatric Surgery at the General Hospital of Vienna, which had been planned by Fritz Helmer and later by Alexander Rokitansky. He consolidated his cooperative work with St. Anna Kinderspital and devoted special attention to tumour surgery.

A department of paediatric surgery was founded at the Regional Hospital of Salzburg in 1964. Hans Henkel was head of the department from 1964 to 1989. A new building for paediatric surgery was set up in 1989, and subsequently managed by Irene Oesch and Thomas Böhmers. Hugo Sauer’s student Günter Schimpl from Graz took over the management in 2006.

In 1966 the University Clinic of Surgery in Innsbruck under Hans Huber received its own department of paediatric surgery. Hugo Sauer headed this department from 1968 to 1976. He completed his training in paediatric surgery under Hartl in Linz and Rehbein in Bremen. Gesine Menardi (1936-2007) served as his assistant. After completing a period of training at Alder Hey Children’s Hospital in Liverpool she became head of the department of paediatric surgery at the University Clinic of Surgery in Innsbruck in 1976. In 2001 Josef Hager, who had been her colleague for several years, became head of the department.

The Study Group for Paediatric Surgery was constituted in 1966. The Austrian Society of Paediatric Surgery emerged from this group in 1971 (Van Swieten Convention). The Presidents of the Society were Hermann Hartl from 1966 to 1971, Hugo Sauer from 1972 to 1976, Peter Wurnig from 1977 to 1978, Hans Henkel from 1979 to 1982, Gernot Brandesky from 1983 to 1986, Gesine Menardi from 1987 to 1990, Leopold Preier from 1991 to 1992, Michael Höllwarth from 1993 to 1996, Michael Engels from 1997 to 2000, Alexander Rokitansky from 2001 to 2004 and Josef Hager from 2005 onward.

Since 1975 paediatric surgery is an Additional Speciality in General Surgery with the additive subsidiary specialities of paediatrics, urology and traumatology. Thanks to Leopold Preier’s diligent efforts, a separate speciality of paediatric surgery was created in 1994. In 2007 the regulation for physicians’ training was amended and the speciality was renamed paediatric and adolescent surgery. The new name took the age spectrum of the patients into account.

A special department of paediatric surgery under Fritz Helmer, a student of Wolfgang Denk, was set up at the Second Department of Surgery in Vienna. After a period of study in the USA Helmer introduced hydrocephalus shunt surgery in Vienna and brought his comprehensive knowledge from Boston on the subject of paediatric heart surgery to Austria. A chairman’s post in paediatric surgery was created under Helmer in 1984 and Alexander Rokitansky was assigned the new assistant’s position in paediatric surgery. Rokitansky became Helmer’s co-worker in paediatric surgery and remained in this position for several years. In 1994 Ernst Horcher was appointed head of the department of paediatric surgery and head of the university department of paediatric surgery in Vienna.

In 1974 the existing facility of paediatric medicine at the Regional Hospital in Klagenfurt was divided into an internal and a surgical department. It was headed for several years by Gernot Brandesky.Brandesky expanded the department and covered the entire spectrum of paediatric surgery including traumatology and urology. After him the department was managed by the German paediatric surgeon Peter Illing and subsequently taken over by Günter Fasching, a student of Hugo Sauer. Fasching has been in charge of this department for some years now. In the last few years he has transformed paediatric and adolescent surgery in Klagenfurt into a centre of international renown.

In 1982 paediatric surgery in Graz was assigned the status of a University Clinic under Hugo Sauer. As the clinic developed, the premises in the Mozartgasse/Heinrichstrasse were sold. The ground-breaking ceremony for the new building in the premises of the University Clinics of Graz was held in 1989. In 1993 the new building of the University Clinic of Paediatric Surgery under Sauer in Graz was inaugurated. In 1989 Michael Höllwarth took over the management of the Clinic, which is currently the largest university clinic of paediatric surgery in Austria. In 1991 Höllwarth together with Peter Scheer founded a Children’s Protection Group and also set a milestone here in child care, as Sauer had done by introducing accident prevention for children.

Including the large department of paediatric surgery at Donauspital in Vienna, inaugurated in 1992 and equipped with the most modern facilities, we currently have 4 paediatric surgery chair positions in Austria (Vienna, Graz, Innsbruck, Salzburg), a university-associated teaching department of paediatric surgery at Donauspital in Vienna, and two departments of paediatric surgery in Linz and Klagenfurt.

Acknowledgement: I am indebted to Dr. Elisabeth Peter-Bonelli and my staff member Karin Entrich for their assistance and review of the data material.

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