PedSurg Resource
History of Pediatric Surgery
Organizational History
William E. Ladd and Halifax
When speaking of the history of pediatric surgery in North America, it is difficult to do so without immediately uttering the name Ladd in the next breath. The two are inexorably linked as Dr. William E. Ladd (1880-1967) is universally recognized as the father of pediatric surgery on this continent. Dr. Ladd was named Chief of Surgery of the Children’s Hospital in Boston in 1927 after having been appointed to the voluntary staff in 1910 [1]. By 1936, he was one of the first three surgeons in the United States, along with Herbert Coe and Oswald Wyatt (below), who had dedicated their practice solely to the care of children. His contributions to the field are many including
- the eponymous Ladd’s procedure for the correction of intestinal malrotation
- advancement in the surgical care of intussusception
- championing the acceptance of Ramstedt’s operation for pyloric stenosis
- publishing texts that set the standard for pediatric surgical care
- training a fleet of surgeons who would become the leaders of the next generation
Donald Watson, in his memorial written for Dr. Ladd in the Journal of Pediatric Surgery, wrote, “At the patient’s bedside, in the operating room and in the informal surroundings of the surgeon’s dressing room or private office, there have been few teachers as effective as this kindly, impressive, stimulating man. A whole generation of surgeons and untold number of children will forever be in his debt” [2].
William Edward Ladd was born in 1880 in Milton, Massachusetts to an affluent merchant family. He was a graduate of Harvard College and later Harvard Medical School. He was competitive by nature; he rowed for the Harvard crew team and continued to oversee their training program four years after he had graduated. They remained undefeated under his leadership [3]. He completed his surgical internship at Boston City Hospital after which he joined its surgical staff in 1908 as both a general surgeon and gynecologist. Dr. Ladd began part time work on the voluntary staff at the Infants and Children’s Hospital in 1910 [4]. As was customary at other pediatric hospitals, surgeons and other specialists fulfilled part time roles as consultants at the behest of pediatricians.
He had already dedicated a significant portion of his practice to the care of children by the time of the Halifax explosion in 1917 - an event often cited and now practically mythical, as instrumental in Dr. Ladd’s choice of career path in pediatric surgery. Two ships collided in the narrow passage leading to the inner harbor resulting in an explosion and tsunami of catastrophic proportions that killed 2000 people, injured thousands more and left 30,000 residents homeless. Dr. Ladd was called upon to aid in relief efforts. The Boston Metropolitan Chapter of the Red Cross organized an expedition to travel Halifax the day after the explosion and Ladd was asked to lead the group. Sixty-five nurses, 29 doctors and 14 civilians volunteered from the Boston community. Dr. Ladd spent over a month in Halifax treating the wounded - many of whom were children [3]. These events have often been cited as the genesis of his passion for pediatric care but his own hand tells us otherwise. A letter written by Dr. Ladd to Dr. Gerald Zwiren of Atlanta, Georgia in 1963 tells us that “As far as the effect this experience had on my selection of a specialty I would say it was nil . . . The Children’s was very first and most permanent love. As soon as it became feasible after the first world war I devoted myself exclusively to pediatric surgery and have never regretted it” [5]. No doubt his experiences in Halifax solidified his dedication to this specialty even if they did not forge it.
Herbert Coe and the Surgical Section
In the words of Judson Randolph, longtime chief of surgery at the Children’s National Medical Center in Washington, DC, Herbert Coe (1881-1968) “single-handedly [founded] the Section on Surgery of the American Academy of Pediatrics (AAP)" [6], the first organization of pediatric surgeons in North America. Randolph’s review of the first 25 years of the Surgical Section (its more familiar name), and his presidential address to the American Pediatric Surgical Association (APSA) in 1985, are the sources for many details below [6][7].
Coe is recognized as the first surgeon to devote his practice full time to children. It did not take long for children to consume his entire case load after he started his practice in his hometown of Seattle in 1908 at the year old Children’s Orthopedic Hospital. After a year in Boston in 1919 to work with Ladd, he returned to the Pacific Northwest to become America’s first full time pediatric surgeon - a bit of hair splitting because Ladd continued to perform surgery on adults until 1930 [6].
One to throw himself headlong into professional societies, Coe held office in all his local and state associations and served as governor of the American College of Surgeons (ACS) [8]. At meetings he loved to share experiences and debate opinions, opportunities that were especially needed in the nascent field of Pediatric Surgery, where his only colleagues in the field were a continent away in Boston.
As the field started to grow, Coe sought official recognition for pediatric surgery from the ACS as it had for ophthalmologists, otorhinolaryngologists, orthopedists, urologists and plastic surgeons (a specialty favored by Ladd himself) - each as a special category within its organizational framework. During the late 1930s and the war years he made formal requests to the leaders of the ACS from his position as one of its state governors and lobbied friends and contacts in its hierarchy. In so doing he acquired the deserved nickname, the Politician.
The prevailing view of the ACS leadership, and that of surgery itself, was that surgical specialization only fragmented and weakened the field. It had yielded to the other disciplines but a category based on age alone was unnecessary. Moreover, pediatric surgery was a specialty that mirrored general surgery - the only difference being the age of the patients. To grant the field specialty status would sever an exact replica of itself. “The College met Dr Coe’s entreaties with an unyielding brick wall,” wrote Randolph [6]. The ACS hierarchy also populated the leading academic and professional organizations in surgery, including the the ultimate establishment organization, the American Surgical Association, and all of the regional organizations. This prejudice would frustrate efforts at achieving official status under the American Board of Surgery (ABS) and its parent, the Advisory Board for Medical Specialties (ABMS), for the next three decades.
Undaunted by rejection by the surgical establishment, in 1946 Coe turned to the pediatricians in the AAP. In a letter to its executive committee Coe justified the creation of a “section or forum on surgery…for the consideration of surgical conditions in infants and children [6].
”[There] is no society or section of any of the national organizations in which those of us who are interested in this subject can meet for an interchange of ideas or presentation of original work. Neither is there any professional periodical in which articles on this subject would logically be concentrated. The programs of general surgical organizations are naturally and rightfully devoted to discussions of the problems which occupy the major proportion of general surgeons’ attention, and consequently the surgery of infancy and childhood receives scant attention." [6]
Coe described the burgeoning interest in the new field, especially inspired by ligation of patent ductus arteriosus (PDA) by Robert Gross (1906-1988) and John Hubbard in 1938 and subclavian to pulmonary artery anastomosis for tetralogy of Fallot by Alfred Blalock and Helen Taussig in 1944. Young surgeons were inquiring about where they could get formal training. A review on surgical pediatrics in the Journal of Pediatrics was received favorably. Importantly, pediatricians were interested “in improving the quality of surgery available for children" [6]. In 1947, the AAP program committee gave Coe two hours before the general assembly of the AAP for a symposium on surgical topics.
The next year Coe was appointed chair of a committee to form a special category of membership in the AAP for surgeons. Now charged with building an organization, Coe wanted to recruit just those he deemed worthy of inclusion, not an open membership. One iron clad criterion was a commitment of 90 percent or more of a candidate’s practice to surgery on infants and children. Oswald Wyatt of Minneapolis would join. In 1928 he became among the first in the U.S. to devote his fulltime practice to children. Coe also got a good response from the leading surgeons at major children’s hospitals in the U.S. and Canada such as C. Everett Koop (Philadelphia), Willis Potts (Chicago), Henry Swan (Denver) and Franc Ingraham, Thomas Lanman and Orvar Swenson (all Boston).
Two of his prime targets were two of the most prominent figures in surgery of any era, Blalock and Gross.
Blalock had not yet formed an opinion on whether a special specialty of pediatric surgery was justified. But he was certain that a surgeon trained at Johns Hopkins, where he was chair, would be fully capable of the surgical care of children. It was a polite but unambiguous statement of his position. Later he appointed David Sabiston chief of pediatric surgery at the Johns Hopkins Hospital, in essence recognizing the specialty. The appointment would prove critical decades later, when Sabiston, as chair of board of directors of the ABS, would approve certification of pediatric surgery under its aegis in 1972.
Gross at first did not commit to the project. He admitted to having a “lukewarmness” about the idea of a specialty organization [6]. Despite the equivocation, to a determined Coe it wasn’t a no. Getting Gross on board would add stature to the fledgling organization, so he offered the Bostonian a position on the new group’s steering committee. He appealed to Gross’s notorious professional vanity, "It seems to me that it would be well for us to have firm representation from Boston for some time because of the pre-eminence of your group there in the foundation and development of children’s surgery" [6]. A more tangible incentive was waiver of the usual AAP initiation fee and halving of the $30 annual dues. Worn down by Coe’s tenacity, Gross accepted the position on the committee.
Coe’s goals for the new organization would prove durable and continue to guide it today.
- to provide a forum for the initiation, discussion and development of ideas and problems related to the surgery of infants and children
- to stimulate the study and teaching of the surgery of infants and children
- to disseminate the principle of providing better surgery for children everywhere
- to bring into the Academy those surgeons whose work was entirely, or no less than 90 percent, devoted to infants and children
A photograph of the 12 surgeons who gathered at the first meeting of the Surgical Section in Atlantic City on November 21, 1948, is a historic icon of pediatric surgery. Ladd and Coe are seated side by side in the front row and standing at the far right is a very young appearing Koop, then 32 years old. In a comparison photograph taken six years later, so many surgeons attended the group’s dinner meeting that Coe is barely recognizable, evidence of the success of his vision.
The fledgling organization was not free from political intrigue and jealousy with the notoriously moody Gross at the center of two episodes. After all of Coe’s cajoling, Gross skipped the historic first meeting in Atlantic City. But Ladd was there and was the likely cause of Gross’s absence. The two had a bitter feud since Gross, then chief resident at the Children’s Hospital, did the historic first PDA operation over the objection of Ladd, his boss and chief of surgery, who wanted Gross to wait until Ladd returned from a planned vacation. Livid, Ladd fired him. The Children’s Hospital board intervened and reinstated Gross but the two never again were on speaking terms. Their relationship soured further – if that was possible – when the board named Gross surgeon-in-chief in 1947, two years after Ladd’s retirement [9].
Years later Gross had been selected to serve as the surgical section chair for a two-year term beginning in 1960 but he resigned the position only one month into his term. As the story goes, Kenneth Welch, a fellow Bostonian, was planning a multiauthored textbook of pediatric surgery that involved members of the surgical section. Gross’s own textbook, The Surgery of Infants and Children (1953), was the definitive text in the field. His prickly professional ego offended, he cut his ties with the organization [6] even though he had no plans to offer a second edition of his book. Welch’s project, published in 1962, replaced Gross’s textbook as the authoritative reference in the field [10].
The Journal of Pediatric Surgery and the American Pediatric Surgical Association
Despite lacking a home in the ACS, the field of pediatric surgery attracted young surgeons. The best instruction was at the “Boston School,” the Boston Children’s Hospital, under Drs. Ladd and Gross. Many who trained there became teachers themselves, starting well regarded programs in the late 1940s and 1950s. The numbers of pediatric surgeons increased as did the numbers of facilities offering instruction in the field [6][7].
Leaders in the nascent specialty recognized that their acceptance as a surgical specialty depended on board certification authority under the aegis of the ABS and ABMS. But two proposals in 1957 and 1961 were rejected. While its practitioners felt otherwise, to the broader medical and surgical communities there were two flaws that had to be addressed. To the outside medical world there was no body of knowledge of pediatric surgery that was independent of the broader disciplines of pediatrics and surgery. To the leaders of surgery, the gatekeepers for recognition by the ABS, pediatric surgery was simply an extension of general surgery, the field merely a set of operations no different from those performed on adults. Signal contributions were made by surgeons without specific training in pediatric surgery; for example, Cameron Haight, a thoracic surgeon who performed the first successful repair of an esophageal atresia in 1941.
A journal dedicated to pediatric surgery would prove there was a discipline where peer reviewed scholarship advanced the field. Even though they had an organization recognized by the AAP, an independent surgical society of pediatric surgeons would establish the field as a discipline of surgery and not a subset of pediatrics.
The Journal of Pediatric Surgery
The source of many of the details that follow is in an article on the origin of the Journal of Pediatric Surgery (JPS) by Jay Grosfeld, longtime editor-in-chief of the JPS [11]. When the first forays with the ABS were made, the avenues for publication on pediatric surgical topics were limited. Since 1958, the journal Surgery devoted a small section to the subject with Mark Ravitch as its editor, but only two or three articles a month. Other journals, such as the American Journal of Surgery, Pediatrics, Clinical Pediatrics, the Annals of Surgery, and Surgery, Gynecology, and Obstetrics, published articles on a sporadic basis. “[There] was no group image projected by this scattered output,” said Dale Johnson, a former president of APSA [12].
As Surgical Section publications committee chair in 1964, Steven Gans (1920-1994) was responsible for the publication of presentations at the meeting. With space for only one or two papers in the established avenues he couldn’t find places for most of the others.
Papers from the meeting could fill a journal devoted solely to pediatric surgery, so he got the Surgical Section leadership to support the development of one. He formed an editorial board before they had anything to review. Publishing houses shied away from the project because the field was small in number and it had no relationship with an identifiable professional society.
Gans enlarged the potential readership through expansion into other countries. International editors agreed to recruit contributors from outside North America. He won the support of the British Association of Paediatric Surgeons (BAPS). These developments persuaded Grune and Stratton Publishers in Seattle to publish the journal with an issue every two months.
Even though he had done the work to bring the journal to fruition, Gans recognized that its success required a prominent editor. The consensus choice was C. Everett Koop of Philadelphia (1916-2013). With a gentleman’s grace, Gans stepped aside and allowed the Philadelphian to take the position [13]. The first issue of JPS appeared in 1965 with Koop as its first editor-in-chief.
Koop decided that a message was needed for the wider audience outside the field, especially those that opposed its recognition as a bona fide surgical specialty. For an introductory editorial he prevailed upon Isidore Ravdin, his chair at Penn and recognized as dean of American surgery in an era of outstanding surgeons [13]. He obliged. He wrote:
"A new star is on the horizon of medicine. In this country and abroad, pediatric surgery has reached the place when we must admit that it now deserves to rank with other specialties concerned with the particular problems of treating specific types of patients" [14].
When Koop stepped down as editor-in-chief in 1976 after eleven years in the position, Gans got the opportunity to nurture the project that was so dear to him. In 1986 it began monthly publication. During his 18-year term as editor-in-chief, Gans saw the JPS grow to a subscriber base of 4,000. In addition to BAPS, it became the official journal of the Surgical Section, the Canadian Association of Paediatric Surgeons, the American Pediatric Surgical Association (APSA) and the Pacific Association of Pediatric Surgeons. In 1977 when Gans was named to succeed Koop, Gross sent a congratulatory hand written note. "I think the Journal has done more to advance children’s surgery, not only here but around the world, above anything else in the last couple of decades" (underline in original)[12].
The American Pediatric Surgical Association
In the 1960s the next generation of surgeons began to emerge in the U.S. and Canada, trained in top hospitals by first rate surgeons like Gross, Koop, Willis Potts, H. William Clatworthy, Thomas Santulli, William Snyder and Clifford Benson. They had appointments in academic departments of surgery in major universities and led groups of their own in children’s specialty hospitals, most as surgeons-in-chief. Yet none had board certification in their specialty because such a distinction didn’t exist. Worse, their home professional society, the Surgical Section, seemed incapable in getting the ABS to budge. Despite its previous failures twice before, the Surgical Section formed a committee to make another run at the ABS in 1967. Once more it fell short.
A group of pediatric surgeons gathered in a café off the Atlantic City boardwalk during the October 1968 ACS meeting, in Johnson’s words, “to rehash identity problems.” One of those present, Lucian Leape, complained aloud, “Pediatric surgery is never going to get anywhere until we stand alone as surgeons. We have to have our own organization.” Not part of the Surgical Section establishment, Leape likely still had some inkling of the political blowback that would accompany an attempt to establish a surgical organization independent of the Surgical Section.
Koop knew. The youngest at its inception 20 years previously at age 32, he knew the leadership and its resistance to upstarts. Now he was the oldest of the group at the bistro. “It is not going to happen, Lucien,” he said, “unless you younger people do it" [12].
A few months later at a meeting of the American Burn Association in March 1969, Leape was forced to share a room with E. Thomas Boles (1921-2018), Clatworthy’s second in command in Columbus, in an overbooked hotel. Leape gave a first person account of their all night conversation that grew into APSA, the largest organization of pediatric surgeons in the world. His article is the source of much of the details that follows [15].
They were convinced that an independent surgical organization for pediatric surgeons would be more likely to win recognition by the ABS, a task the Surgical Section appeared constitutionally unable to do. Despite the accomplishments of the Education and Training Committee of the Surgical Section (familiarly known as the “Clatworthy Committee” after its chair) in identifying the programs that adhered to a set of benchmarks for training, they felt more could be done to elevate and maintain the quality of pediatric surgical practice. A troubling feature of the Surgical Section was that its membership included surgeons who were self taught and graduates that had substandard levels of education and training and many who were not meeting the requirement children’s surgery comprising more than 90 percent of a practice.
For firebrand Leape and the red haired Boles it was a matter of identity, more than a strategy to achieve board recognition. The former’s justification for an exclusively surgical organization was succinct: "[It] was inappropriate to have [our] primary professional identification with pediatricians rather than with surgeons. We wanted a home of our own" [15].
They targeted younger surgeons who were not officers in the Surgical Section, the latter group they naturally dubbed, “the old guard" [15]. In May 1969, they called the first of several meetings to start work on the new organization. In attendence were 16 organizing members, meeting at the hotel at O’Hare airport outside Chicago. Some decisions were easy. It would be called the American Pediatric Surgical Association, a deliberate reference to the American Surgical Association, then as now the elite organization in surgery. Many had young families, so they decided meetings would be held in April or May at warm weather resorts, not big city hotels like the staid Palmer House, the grand Chicago hotel favored by the old guard.
More difficult was membership. Who would they include? Would they restrict membership to an elite group or have a large, inclusive organization? Without effort the 16 in attendance could name another 100 or so who would qualify for membership under either circumstance. All had trained in recognized programs, had full time practices devoted to children and had established clinical reputations.
The organizing group decided to solicit the opinions of the 100 candidates before resolving the question. With some trepidation they acknowledged the elephant in the room and agreed to invite the old guard to their next meeting. Before adjournment they assigned themselves to committees, allocated names of potential members to contact and assessed $100 each to cover costs. Several early leadership roles emerged with Ide Smith responsible for membership, Bob Soper for the program, Tom Boles as the liaison to the Surgical Section and Bob Izant would develop the constitution and bylaws. Of note, Boles and Leape did not assume leadership roles in order to dismiss concerns of having higher motives [15].
As predicted, they got the support of their younger colleagues. They faced “pockets of real resistance,” Leape said, “primarily among the ‘establishment’ in the East coast in the training centers in Boston, Philadelphia and Baltimore" [15]. Still they were optimistic of their success. “[The] critics would nonetheless probably go along with a revolution that promises to have a successful outcome!" [15] said Dale Johnson at the time.
The old guard sent three past chairs to the next meeting of the organizing group which occurred in July 1969. To the fledgling group’s surprise, the old guard agreed that a new, entirely surgical organization was needed. They preferred a small body of elite surgeons with standing in organized surgery, who might better represent the goals of pediatric surgery as a whole.
There was another reason they wanted a smaller group: they wanted to protect the Surgical Section. A new organization might grow to rival the old one and render it irrelevant. Others were concerned that a new organization would insult the AAP, who gave them refuge when surgery rejected them. (The AAP would entirely support the organization of an independent surgical organization.) Some held out hope for recognition within the ACS and a rival surgical organization might jeopardize such an effort.
Boles and Leape disagreed. A major goal was to establish a surgical identity independent of pediatrics. The ACS had rejected Coe long ago, so they did not anticipate that it would accept them anytime soon. They wanted membership to be restricted to only those surgeons who trained in an approved program and satisfied the criteria for board certification in pediatric surgery.
Ultimately their view for APSA won out. In the absence of mechanisms for formal approval of training programs and board certification, they accepted the criteria of board certification in general surgery (a requirement already present for Surgical Section membership) and a surgical practice entirely devoted to the care of children. The latter requirement excluded Ravitch, who had a robust adult practice. Final requirements also included sponsorship by three members of the new organization and a minimum of two years of practice after completion of training to assure a commitment to the field.
To support the JPS, just in its fifth year of publication, the organizing group included the cost of subscription as part of annual membership dues. All presentations at APSA meetings would require submission to the journal. Thus the new association helped ensure a subscription base for the journal and a steady stream of papers for publication.
A priority was to get Gross to accept the inaugural presidency of APSA. It was only proper to honor a career so distinguished in American surgery and so closely identified with one of the field’s major institutions. They had a political reason for the choice: a surgeon of his stature would give the new organization immediate credibility.
It was pure kabuki theatre. A delegation was sent to contact him, in Leape’s words, “to convey the unanimity and intensity of the feeling of the organizing group" [15]. They made sure the group included former Surgical Section chair Lawrence Pickett of Yale, who had the seniority and the Ivy League pedigree to satisfy Gross’s sense of propriety.
So it came as a surprise among those familiar with his imperious personality that he embraced the invitation as opposed to the “lukewarmness” about Coe’s efforts to create the Surgical Section decades earlier [6]. After the required amount of cajoling, and assurance that other senior surgeons wanted him to have the honor, he accepted. In deference to his position in the field as a whole, the ad hoc committee assured him that he would not to have to give a formal presidential address. Given his long memory for professional slights, the presidency of APSA was a chance for him to mortify the Surgical Section.
In the October 1969 meeting, 100 names were settled upon for initial membership. Those names were the subject of much debate and after rounds of discussion and polling amongst the group, new criteria for membership were determined.
- U.S. or Canadian citizenship
- practice confined to the surgery of infants and children
- certification by the American Board of Surgery or Fellowship in the Royal Canadian College of Surgeons
- two years experience in practice after residency
- membership not solicited but offered by membership committee.
A further review of candidates resulted in the offer of charter membership to 200 surgeons in January 1970 [15].
Just a year after the original meeting of the organizing group, Tom Boles chaired a meeting in March 1970 to make final plans for the first official meeting of APSA. Gross had finally accepted the offer to serve as President and a slate of candidates for the remaining offices was determined. The Journal of Pediatric Surgery was chosen as the official journal of the new society. The by laws were agreed upon and incorporation was accomplished. Six weeks later, on the eve of the first APSA meeting, the founding organizers met one final time to ensure that everything was ready [15].
On April 17, 1970 the first meeting of the American Pediatric Surgical Association was held at the Pheasant Run Resort in suburban Chicago. Their first business meeting was marked by the unanimous approval of the founding resolution.
"Be it resolved that a new society, The Americal Pediatric Surgical Association, now be formed to encourage specialization in the field of pediatric surgery, to promote and maintain the quality of education in pediatric surgery, to raise the standards of the specialty by fostering and encouraging research in pediatric surgery, to establish standards of excellence in the surgical care of infants and children, and to provide a forum for the dissemination of information with regard to pediatric surgery." [15]
Thirty-two additional proposals were made for amendments to the draft of the association’s bylaws. They added the word “entirely” to make certain that members’ practices were entirely devoted to Pediatric Surgery (emphasis in Leape’s article) [15] and a two-year hiatus after training before eligibility for membership to assure a candidate had committed him or herself to the field. In the credentialing process, some allowance was made for the circumstance where a pediatric surgeon would have to cover general surgery call for hospital privileges. The slate of officers was elected and Gross took over the meeting as President to a prolonged standing ovation. Leape wrote, "We had indeed established an independent surgical organization that stood for high standards of patient care, teaching, and research – in that order. We were confident that [APSA] would serve as a strong and representative voice of American Pediatric Surgery" [15].
His and Boles’s accomplishment is confirmed every year by the well attended annual meeting of APSA, today the pre-eminent pediatric surgical association in the world. Said Leape, “We finally had a home of our own" [15].
Pediatric surgery becomes a specialty
In his presidential address before the American Pediatric Surgical Association (APSA) in 1986, Dale Johnson reviewed the failures and ultimate success in attaining board certification [12]. Most of what follows comes from his lecture.
Pediatric surgery came late in the timeline of surgical specialization by the time its effort started in earnest in the 1950s. By then the traditionalists that dominated the ASA, ACS and ABS had had quite enough of specialization. Koop wrote
"[Surgeons] didn’t want to see any further fracturing of general surgery.… [They] were particularly incensed that there were now some upstarts … who said that they could do any type of surgery in infants better than the designated anatomic specialists whose practices were centered around adult populations" [16].
William E. Ladd (1880-1967), surgeon-in-chief at the Children’s Hospital of Boston, was on the original ABS and was awarded certification as a member of its founders group. With a large part of his practice devoted to plastic surgery, he also was among the leaders who created the American Board of Plastic Surgery just six years later [17]. Despite his sobriquet as the father of pediatric and newborn surgery, he was ambivalent about whether the field should hold the same status. He believed it should have some sort of distinction as early as 1941 [16], yet was “reticent to leave the general surgical mainstream.” [17] Thomas Lanman, Ladd’s associate and second in command, served as chair of the ABS from 1953 to 1955, a sign of how the two dons from Boston saw its place in the larger discipline.
C. Everett Koop (1916-2013), however, did not have Ladd’s reticence. He saw the ultimate goal as certification by a board of pediatric surgery sanctioned by the ABS and ABMS. “The time was right to ask for specialty recognition,” he said [16]. In 1956 he made the first proposal to the ABS on the behalf of the Surgical Section. To his surprise, it agreed to bring it before the ABMS.
In his words, “unbelievably vehement opposition” came swift and hard from the Society of University Surgeons (SUS) and the American Board of Urology [16]. Koop and Ladd smelled a political rat. Both members of the SUS, they knew that the issue had never been presented before the membership. Despite facing stiff opposition against the formation of their board themselves, the urologists joined the orthopedists in opposition against the measure. Among their objections was the term, “pediatric surgery,” which they saw as misleading. “Pediatric general surgery” was a more restrictive title that made a clear boundary between the disciplines.
Another complicating matter was that trauma surgery had also requested certification authority. With the advantage of its status within the ACS as its Committee on Fractures, trauma was similar to pediatric surgery in that it cut across multiple existing specialties. To the ABMS, their multidisciplinary nature disqualified them and it turned down the applications of both in 1957. The board also worried that their approval might spark an unchecked cascade of requests from other groups.
Three years later in 1960 Koop received the suggestion that the leadership in the ABS had changed and perhaps it was a good time to try again. This time Koop marshalled the support of national organizations - the AAP and ACS. A letter of support from the AAP pointed out that some state agencies required board certification in cases that received state aid. Without a formal board, the rule thus excluded pediatric surgeons from the care of some patients for whom they were often the best qualified. At first the ACS executive director was reticent to help an effort in opposition to the ABS. Koop reassured him that the goal was to remain within the ABS framework. The ACS then was able to endorse the proposal.
Even with AAP and ACS help, Koop was rebuffed once more when the ABS met in 1961. J. Englebert Dunphy, then Chair of the ABS, wrote:
"With regard to a subspecialty in pediatrics, the major objections come from the subspecialties of urology, orthopedics, neurosurgery and thoracic surgery. …[There] is a strong feeling among many American surgeons that the trend to develop subspecialty groups should not be formalized by Board subcertification….[Many] fear we face the problem of having to have specialization in vascular surgery, traumatic surgery, and metabolic care in surgery." [12]
The ABS archly suggested that perhaps a more appropriate context was within the AAP - among pediatricians, not the surgical mainstream. Therein was the problem. To the ABS the only characteristic was the age of their patients, not a body system that characterized neurological surgery, orthopedics and otorhinolaryngology or a set of procedures such as plastic surgery. To the wider surgical community and especially its leaders, how could a pediatric surgeon claim to perform an operation better than a well trained general surgeon or specialist in urology or plastic surgery? In the words of one of Ladd’s colleagues in Boston, “[Anyone] who could operate on a bunny rabbit could operate on newborns.” [16] Koop reminisced about his attempts to get approval from the ABS with James O’Neill, who succeeded Koop as surgeon-in-chief at the Children’s Hospital of Philadelphia. “[They] failed miserably,” Koop had said. A letter from the ABMS listed their deficits: “You have no body of knowledge; no certified training programs; and no journal.” Using a saying from his adopted state of Tennessee, O’Neill gave a terse summary: “You ain’t got nothin’.’” [13]
A field matures
Leaders in the field already acknowledged some major deficiencies. Beyond Robert Gross’s definitive textbook, its literature was just some articles scattered among a number of surgical and pediatric journals and not a true body of knowledge. Steven Gans (1920-1994), as publications chair for the Surgical Section meeting in 1964, saw that the matter differently. He suggested that the presentations from the conference could fill a journal devoted exclusively to the discipline. With the sponsorship of the Surgical Section and the British Association of Paediatric Surgeons, the JPS first appeared in 1965, with Koop as its first editor-in-chief. Gans later succeeded Koop in 1976 [11].
The first formal training program was a joint residency between the Peter Bent Brigham Hospital and the Children’s Hospital of Boston in 1936 under the directorship of Ladd; its termination in 1943 due to the demands of the war on medical personnel. At war’s end, Gross restarted the training program as entirely a program in pediatric surgery. He only accepted fully trained surgeons, several of whom including Koop, founded training programs of their own after graduation. After the first generation of Boston trained pediatric surgeons, came a wave of training sites and graduates; some outstanding, others less well regarded.
Without certification there was no way to objectively identify the sites that had the educational and clinical resources to responsibly train capable pediatric surgeons. H. William Clatworthy (1917-2000), who like Koop was a Gross trainee, started his own training site in Columbus, OH and viewed the proliferation of training sites and pediatric surgeons with concern. He believed that some training sites were substandard - unable to meet the educational needs and operative experience of trainees. Largely at his instigation, in 1966 the Surgical Section formed a committee under his leadership to set standards and site visit programs. By 1970 the group, which became known as the “Clatworthy committee,” approved 12 U.S. programs, gave provisional approval to four Canadian programs and failed nine [18].
By the end of the 1960s the Surgical Section had about 300 members. The field demonstrated that its training programs observed common standards set by an objective body. With the JPS it had its own journal. On the strength of these developments, in 1966 Mark Ravitch, who would become chair of the Surgical Section from 1967 to 1968, felt that it was time to approach the ABS once more. An academic Chair of Surgery and a senior member of the faculty at Johns Hopkins, he was well connected with the surgical leadership of the ASA, ACS and ABS [6].
He decided to emphasize the educational mission that board certification would support - a different strategy than the one employed by Koop. “The reception was vigorous if not frankly hostile,” Ravitch said [12]. In January 1967 the ABS decision was an unambiguous no. It was a personal disappointment to Ravtich who thought his stature might help the initiative to succeed. But he got the hint. "Dr. Ravitch … recommended that pediatric surgery lay low for a while.” [12]
Robert Izant, a Gross trainee, was among a burgeoning generation of pediatric surgeons fresh from training programs and eager for board certification. The Surgical Section assigned him to act as its emissary to meet with William Holden, his boss at the Case Western Reserve School of Medicine in Cleveland and ABS Chair in 1967-1968. What started as a strategy session turned into a lecture from a Dutch uncle. In a précis of Holden’s critique, Izant wrote: It seems that the best approach to a pediatric specialty board as part of the American Board of Surgery is as follows: A national organization of pediatric surgeons should be founded which would have as officers and trustees prominent pediatric surgeons on the North American continent. This organization should be in existence for about a year and hold a national meeting [12]. The board, Holden appeared to say, wanted to see a surgical organization separate from the AAP. He made the point explicit when he pointed out the fatal flaw in their application: It is the feeling of some American Board of Surgery members that as long as the pediatric surgery organization is tied to another organization, and therefore, not an independent one, the problems with affiliation with the American Board of Surgery would be difficult if not impossible [12].
While Holden allowed that JPS was a plus, the publication should be in the context of “creating the proper milieu of a separate, distinct, and formal organization of pediatric surgeons.” In case Izant and his colleagues didn’t get the message, Holden closed: The essence of the approach … is that of a strong national and independent pediatric surgery organization … the importance of this cannot be overemphasized [12].
Many pediatric surgeons agreed, including some of the Surgical Section leadership. The field needed its own organization, entirely surgical, and free of the AAP. In 1969 Lucien Leape and E. Thomas Boles called a meeting of surgeons who were not members of the Surgical Section leadership to form APSA. Later included in the discussions, representatives from the Surgical Section were largely supportive. They wanted a selective, elite organization. Leape and Boles disagreed. The new organization would be open to all that satisfied two key conditions for membership: certification in general surgery and a practice entirely dedicated surgery on children [15]. After organizational meetings in 1969, they held their first conference in April 1970. The preconditions that Koop received in his rejection letter a decade before were thus fulfilled. To borrow O’Neill’s phrase, “Now they had somethin’.” Success.
They won a measure of legitimacy when the ACS named pediatric surgery as one of its component members - the first discipline to earn the designation without ABS and ABMS recognition [12]. In 1969 Harvey Beardmore (1921-2007) of Montreal, who had succeeded Ravitch as chair of the Surgical Section, took another run at the ABS. Only two years having lapsed since his own failed attempt, Ravitch supported the effort despite his previous advice to “lay low.”
Beardmore’s approach, in Randolph’s words, was “a unique brand of diplomacy, humor and purpose.” [19] In May 1969 the ABS agreed that pediatric surgery deserved inclusion in the qualifying examination of all surgeons (emphasis in the original) and that issues of formation of a board be directed to the ABMS [12].
They had allies in the ABS hierarchy. David Sabiston, newly appointed chair of the ABS for 1971-1972, had been Professor of Surgery and pediatric surgeon in charge of children’s surgery at Johns Hopkins before his appointment as chair of surgery at Duke in 1963. H. William Scott, the highly influential chair of surgery at Vanderbilt University, had spent three years with Ladd in Boston. While he did not stay in the pediatric leadership, Scott was on the board and a strong supporter of the field.
In March 1971 Keith Reemtsma, then chair of the department of surgery at the University of Utah, Chaired an ad hoc committee to study Beardmore’s petition. A Penn graduate and a Koop protégé, Reemtsma knew the necessity of pediatric surgical care of children. He had just recruited Johnson away from a position in Philadelphia with Koop to join his department as the first pediatric surgeon in the state. Reemtsma pushed for approval. In June 1972, the ABS approved Beardmore’s proposal [12]. Its approval came with two important conditions: The primary emphasis was on surgery of newborns and small infants; and that the field remain under the aegis of general surgery, the certificate being for special competence in pediatric surgery. For Beardmore that was enough.
It was left to the ABMS for a final decision. For reasons familiar to bureaucrats, there was a backlog of specialties waiting on decisions from the body. Now allies, a delegation from the ABS assisted Beardmore in a successful request for an early hearing. The ABMS approved special certification for pediatric surgery under the aegis of the ABS at their April 1973 meeting. This time it had the endorsement of the boards of urologists and thoracic surgeons - groups that had previously opposed them [12].
“Some people think my being Canadian was an advantage,” said Beardmore in a 2005 interview with Jay Grosfeld, who succeeded Gans as editor-in-chief of JPS in 1994. “It was the presence of a Canadian who had no real axe to grind who pulled it off.” [20]
Beardmore, Randolph (representing the Surgical Section) and Marc Rowe of Miami (APSA), worked out the details of the administration of the first ABS examinations to test and certify the 300 pediatric surgeons then in active practice. Only two were grandfathered and given board certifications without examination: Gross, awarded diploma number 1; and Swenson, 2. In the words of Dr. Randolph, "We did not have the temerity to examine those two." [19] In 1974, Beardmore, Randolph and Rowe took the inaugural board examination in Philadelphia. In Randolph’s words, they “fortunately passed.” [7] Beardmore won diploma number 3; Randolph, 4; and Rowe, 5.
Randolph was then named a director of the ABS as a representative of pediatric surgery. At his first meeting he overheard some disapproving murmurs behind him [6]. There initially was no provision for a pediatric surgeon on the board of directors of the ABS. With some negotiation O’Neill got Samuel Wells, chair of Board of Directors, to accede to formal representation of the specialty on the ABS.
Just before the sixth APSA meeting in April 1975, more than 250 surgeons settled in a resort ballroom in Puerto Rico to take the three-hour test. Nearly all (238) passed and achieved certification [21]. Beardmore recounted the odyssey of achieving approval by the ABS and the ABMS in a talk after the exam. “Gentlemen,” Beardmore said in closing, “you have your boards!” [16]
“The words still ring in my ear,” said Koop. “It was a great day. The hairs on my arms stood on end and I felt we had achieved all we needed in our dynamic specialty.” [16] He praised Beardmore’s role in getting final approval in terms that were familiar to those who knew Koop’s strong religious beliefs. He wrote: The Bible tells us that a prophet is not without honor save in his own land. I hope you young folks never forget what Harvey Beardmore did to secure us the recognition that we now enjoy. We have never suitably honored and thanked [him] for the tremendous favor he did us with his persuasive way in convincing former antagonists that we were indeed surgeons, worthy of recognition [16].
The evolution of pediatric surgical training
The fundamental problem Coe faced in gaining recognition of an organization of pediatric surgeons was numbers: There simply were too few. When he began to lobby the ACS for official recognition at end of the 1930s, only three surgeons in the U.S. had committed themselves to the full time practice of pediatric surgery: himself, Ladd and Wyatt [6].
Of the three, only Ladd was at an academic facility and thus in a position to train the next generation of practitioners. It was Gross, among the handful of Ladd trainees to continue in the practice of pediatric surgery, who was responsible for the wave of pediatric surgeons that began to build in the late 1940s through the 1960s. Several who trained with Gross started training programs elsewhere, magnifying his impact on the next generations of pediatric surgeons. The influence of Gross was so pervasive that for decades the Children’s Hospital became the known as the “Boston School” of pediatric surgery [18].
After ad hoc training arrangements with individual surgeons like Coe, Ladd had a combined training program with the Peter Bent Brigham Hospital from 1936 to 1943. Some trainees came directly from medical school, but he preferred candidates with at least some training in general surgery. Before starting at Children’s Hospital they first had to spend time in pediatric medicine or in study of a basic science such as bacteriology, biological chemistry or pathology (as Gross did, spending two years studying cardiac pathology before his residency with Ladd).
The rotations were divided equally for the first two years, after which a trainee could finish with senior rotations at either the Brigham or the Children’s Hospital, or both locations. At Children’s the experience was six two-month rotations in the laboratory, plastic surgery and outpatient clinic, otorhinolaryngology, neurosurgery, children’s surgery, and infant surgery. The senior experience was later expanded to a second year, which consisted of four months on the private ward, then as house surgeon for four months each on the children and infant units.
Ladd was selective of the three of six residents allowed to complete a senior year with him. His immediate priority was to train surgeons who would develop pediatric disciplines in established specialties such as neurosurgery, otorhinolaryngology and urology, just as he had in general surgery and plastic surgery. A few graduates returned to traditional adult-based practices [17]. In comparison to his overall influence on the field, where he has been called the “father of pediatric surgery” [1], Ladd’s effect on the next generations of surgeons became manifest primarily through Gross, his former chief resident.
Gross was the pivotal figure in the proliferation of pediatric surgeons in the decades after the war. He established a formal three-year hierarchy upon Ladd’s retirement in 1945: a year each as junior and senior assistant resident and a year as chief resident. The two-year senior-chief year progression was general surgery, outpatient and emergency departments, plastic surgery and cardiac surgery - each for a six-month rotation. He accepted only trained surgeons, who started the sequence each year so there would be trainees at each level. The three-year curriculum was pared to a two-years once his program started to accept fully-trained surgeons. Over the next two decades, until he lost his position as surgeon-in-chief in 1966, Gross trained 69 pediatric surgeons [18].
Many of Gross’s favorites returned to busy practices in children’s hospitals where they in turn established training programs of their own, notably Potts (in 1945) and Koop (1946). After being pushed out of the Children’s Hospital by Gross after the latter’s ascension to the position of Chief of Surgery, Swenson started a program at the Floating Hospital across town in 1950. Programs appeared in Columbus, Ohio (under H. William Clatworthy, 1952, another Gross trainee) Pittsburgh (William Kiesewetter, 1955, a Koop trainee), and New York (Thomas Santulli, 1958, who trained with surgeons at Babies’ Hospital in New York) - each busy academic children’s hospitals [7]. Thus an arborizing genealogy in pediatric surgery was established with the Boston School, Ladd and Gross at its trunk. By 1979, 75 percent of all pediatric surgeons, and 73 percent of training directors, could trace their lineage to Ladd [22].
The Clatworthy Committee
With only a handful of training opportunities in the U.S., many surgeons sought training overseas in Europe. With increased demand, training programs began to appear in the U.S. In 1966 an AAP booklet listed 18 U.S. and two Canadian “fellowships,” plus 17 U.S. and four Canadian “residency” positions in pediatric surgery. Without a formal agreement on standards for training and experience, any surgeon and hospital could declare themselves as a training program. Without oversight by an independent body, there was no standard curriculum and no agreement over operative experience. There was wide variation in the length of training (from one to four years) and emphasis. And most importantly, without some mechanism of formal examination such as board certification, there was no evidence of the quality of the graduates. In 1952 Coe had appointed a review committee to review the approved programs. But it produced nothing of significance aside from surveys and updated lists of programs for AAP brochures [18].
Clatworthy (1917-2000) suspected that many sites were substandard, their quality far below that at Boston, where he had trained under Gross, and in Columbus, where he had built a superb program that would produce future leaders in the field, such as James O’Neill, Albert deLorimier, Eric Fonkalsrud, Marc Rowe, Richard Ellis and Jay Grosfeld - all future APSA presidents. In 1966, largely at his initiative, the Surgical Section formed an education and training committee to upgrade pediatric surgical training.
In Randolph’s words, the “Clatworthy Committee,” the shorthand name for the group, was “one of the most important efforts of the Surgical Section’s first 25 years, second perhaps only to Coe’s initiatives.” [7] In 1967 the committee produced a new document that summarized standards for training in the field titled, “Special Requirements for Training in General Pediatric Surgery.” [18] To Clatworthy they were not “special.” To him they were always the “essential requirements for training.”
The Clatworthy Committee set the basic structure of pediatric surgical training followed today, a two-year fellowship after a full five-year residency in general surgery. Their goal was trainees prepared to enter academic surgery, immersed in an environment with a rich and diverse range of clinical conditions. This meant a referral base large enough to assure a caseload adequate for training. Clatworthy wanted to make sure trainees got adequate exposure to index cases, what he called “the good stuff,” operations on congenital anomalies, tumors and special conditions that defined pediatric surgery [21]. The committee scrutinized case logs to assure that the graduates had enough experience with index cases to enter independent practice [6]. it recognized that a trainee needed a variety of approaches to a problem, so it required a faculty of at least two or three senior staff who were dedicated to education and research.
Eighteen months were to be devoted to clinical Pediatric Surgery with graded responsibility. The trainee could spend the other six months on areas where the program had particular strengths, such as cardiac surgery, urology, neonatology and critical care. Accommodations were made for long-established programs such as the multiyear curriculum in Boston. They mandated clinical services in neonatology, pathology, radiology and a training program in pediatrics - now commonplace but then not present in every facility claiming to have a training program.
The final step before Clatworthy Committee approval was a site visit to verify that the standards were met. “None of them actually wanted to be inspected but all wanted to be approved,” said Randolph (emphasis in his original) [6]. Backed by the chairs of the Surgical Section during this period, Lawrence Pickett of Yale and Mark Ravitch of the Johns Hopkins Hospital, Clatworthy exerted his personal influence to guarantee a rigorous review of all the candidate programs. Based on the findings of two review teams, from 1969-1970 the Clatworthy Committee approved 12 U.S. programs, gave provisional approval to four Canadian programs and rejected nine [18].
The next steps
The work of the committee was a calculated step designed to satisfy the deficiencies that prevented recognition by the ABS. While pediatric surgery was without access to the surgical establishment, the Clatworthy Committee demonstrated that the field had standards for the treatment of a distinctive range of conditions; their patients posed unique challenges in anatomy and physiology; and their practices required special skill, judgement, and years of training. It was an essential first step that showed that the field deserved official recognition as a specialty of surgery, defined by the ABS.
Under Judson Randolph, the commitee continued to evaluate training programs and recommend them for approval to the ABS until 1977. At that point, managment of the process was transitioned to the Residency Review Committee of the ACGME. By the early 1980s, training program directors organized the Association of Pediatric Surgical Training Program Directors. Their mission was to guide the development of a structured curriculum for trainees and oversee the application and selection process. The organization was formally incorporated in 1989 under the leadership of Jay Grosfled and Don Cooney. Not long after, the matching process was turned over to the National Resident Matching Program [23]. Currently, 50 U.S. programs in 30 states and the District of Columbia and eight Canadian programs in five provinces exist as formally recognized pediatric surgery training programs [24].
Important Personalities
The field of pediatric surgery would not exist if it weren’t for a number of strong leaders who developed and groomed this niche. Through their excellence in clinical practice, research and professional development, they served as invaluable role models for the many generations behind them. We are indebted to them not only for their accomplishments but for the examples which they have each set. They have led the way in development of the field, initiating training programs and opening the door for women and other minority surgeons.
William Ladd (1880-1967)
William Ladd graduated from Harvard University in 1902, Harvard Medical School in 1906 and completed his residency at Boston City Hospital in 1908. Through his clinical experience, he changed the surgical management of many pediatric disorders including intussusception, pyloric stenosis, duodenal obstruction, biliary atresia, intestinal conditions of the newborn, Wilms’ tumor, and of course malrotation, for which he developed the eponymous Ladd procedure[1].
Dr. Ladd led a group of nurses and physicians from Boston, MA to Nova Scotia to provide medical relief after the Halifax explosion during World War I [25]. While rumor has it that this experience inspired him to focus his career on the surgical care of children, Dr. Ladd himself recalls dedicating himself to pediatric surgery at least a decade prior to this event [5]. In fact, it was he who first coined the phrase “children should not be treated as little adults,” emphasizing that their medical problems are unique and as such deserve care given by physicians who are focused entirely on the care of children.
In the 1930s, he developed a training system for the newly developed pediatric surgery field. He selected extraordinary students and residents and invited them to participate in a two-year pediatric general surgery experience [17]. As such, Dr. Ladd has been recognized as the father of pediatric surgery, with nearly eighty-five percent of all practicing pediatric surgeons in North America being descendants of his training lineage [22][26].
Robert Gross (1905-1988)
Like Ladd, Dr. Gross also trained at Harvard Medical School and helped develop the field of pediatric surgery. Judson Randolph analogized the pair’s contribution to the future of pediatric surgery in American as a seedling planted by Ladd but nurtured into a strong evergreen by Gross [7].
Ironically, in 1938, only seven years after being described as simply a “satisfactory” house office, Gross performed the first successful patent ductus arteriosus ligation as a chief resident at Children’s Hospital [27]. This marked the beginning of the field of congenital heart surgery. He further advanced the field of vascular surgery when he, along with Dr. Charles Hufnagle, developed the use of a human aortic homograft for the repair of long segment aortic coarctation [28].
In 1953, Dr. Gross authored and published The Surgery of Infancy and Childhood - a book which in its exactly 1000 pages contains a simple and concise solution for each pediatric surgical disorder. Though he made great contribution to the knowledge base of surgery, he believed that nothing could underscore the significance of surgical skill and thus believed technically training was paramount. He spoke eloquently about the “quiet, rapid, and orderly fashion” of a well done operation [29] and adorned his operating suite with a sign that read, “if an operation is difficult you are not doing it properly.” [7]
Herbert Coe (1881-1968)
When Ladd joined the full time staff at the Children’s Hospital, two American surgeons had already devoted their entire practice to children, Herbert Coe of Seattle and Oswald Wyatt (1896-1957) of Minneapolis. Coe’s lasting achievement is his organization of the Section on Surgery of the American Academy of Pediatrics (familiarly known as the Surgical Section, the first professional society in pediatric surgery) which held its first meeting in 1948.
His father was a physician in the copper mining town of Phoenix high in the upper peninsula of Michigan. When Coe was seven the family moved to Seattle, a town not yet 40 years from its first log cabin on Elliott Bay and just a year before the Great Seattle Fire of 1889. An orchard and the livery stable were nearby, the wild still close enough that a cougar was shot outside his home. He returned to Michigan to attend undergraduate and medical school at the University of Michigan. After a year’s internship in Allegheny, a town now part of Pittsburgh’s North Side, in 1908 Coe caught a ship around Cape Horn to spend the rest of his career in Seattle [8]. Short in stature and spry, late in life Coe resembled actor Edmund Gwenn in his role as Kris Kringle in the Christmas movie, Miracle on 34th Street (George Seaton, 20th Century Fox, 1947). His first position at the Children’s Orthopedic Hospital, then a seven-bed facility in a Seattle cottage that had opened in 1907 [30], was as assistant to Park Weed Willis, its first chief of surgery. Another of his jobs was city bacteriologist, so he was sent to China for two years to study tuberculosis and other endemic diseases to aid the treatment of Seattle’s large Chinese settlement [31].
After his service in the military during World War I, he spent several months with Ladd in Boston in 1919 observing children’s surgery. As cases at Children’s Orthopedic Hospital absorbed more of his attention, he decided to devote his entire practice to surgery on children. He thus became the first full time pediatric surgeon in the U.S. - a bit of hair splitting because Ladd’s private practice included adults. He performed the entire range of operations in children, including plastic surgery, surgery in the abdomen and chest, neurological surgery and orthopedics. Plastic surgery was his primary area of interest and like Ladd he was a member of the American Association of Plastic Surgeons [7].
In his presidential address to the American Pediatric Surgical Association (APSA) in 1985, Judson Randolph, longtime surgeon-in-chief at the Washington (D.C.) Children’s Hospital (now the Children’s National Medical Center), recounted a winsome anecdote of Coe that reveals his affection for children.
[A] young hospitalized patient … was asked by the evening nurse if he wanted to say his prayers. The answer was a firm, “No.” “But don’t you say your prayers at home?” “Yes, every night,” the boy said. “Then why not here?” asked the nurse. “Dr. Coe looks after me here.” [7]
A joiner of professional societies and a man who made friends easily, Coe felt isolated in his chosen field - his only colleagues a continent away. At professional meetings, which included his duties as state governor of the American College of Surgeons, he enjoyed conferences where he could meet surgeons from other regions of the country. This led to his great achievement, the founding of the Section on Surgery of the American Academy of Pediatrics [8].
Willis J. Potts (1895-1968)
Willis Potts was born in Sheboygan, Wisconsin on March 22, 1895. He graduated from Rush Medical School in 1924 despite his education being interrupted by service overseas in World War I. His surgical training began at Prebyterian Hospital and he completed further training at Frankfurt-am-Main from 1930 to 1931 [32]. He then returned to Chicago to practice surgery and during this time he developed an interest in pediatric surgery while on staff at Children’s Memorial Hospital. His practice was interrupted by World War II, during which he served in the Pacific theater, organizing the 25th Evacuation Hospital. He ascended to the rank of Colonel by the time he was discharged from the army in 1945.
When he returnd to Chicago after the war, he devoted his practice to the care of children and became surgeon-in-chief of the Children’s Memorial Hospital in 1945. At the outset of his time as chairman, he spent three months observing the workings of pediatric surgery in Boston and when he returned to Chicago he committed himself to the work of growing such a department [33]. Potts made instrumental contributions to the field of pediatric cardiac surgery. He collaborated with pediatric cardiologist Dr. Stanley Gibson and researcher and surgical protege Dr. Sidney Smith to address the challenge of treating "blue babies." Their pioneering work resulted in the development of the aortic-pulmonary anastomosis. Potts and Smith, with the assistance of Potts’s craftsman neighbor Bruno Richer, devised the Potts-Smith aortic exclusion clamp. The aortic-pulmonary anastomosis was first peformed on a child on Friday 13, 1946. Potts and Richter went on to develop many other surgical instruments, including vascular clamps, scissors and a pulmonary vavlulotome [33].
Potts wrote a book titled The Surgeon and the Child, that although more brief than many surgical texts, places emphasis on the patient’s central role in defining a surgeon’s care. In the preface he dedicates the book to the "infant who has the great misfortune of being born with a serious deformity. All life is before him, and what is done during the first few days may decide whether life will be a joy or a burden. If this infant could speak, it would beg imploringly of the surgeon, ’Please exercise the greatest gentleness with my miniature tissues and try to correct the deformity at the first operation. Give me blood and the proper amount of fluid and electrolytes; add plenty of oxygen to the anesthesia, and I will show you that I can tolerate a terrific amount of surgery. You will be surpirsed at the speed of my recovery, and I shall always be grateful to you.’" [34]
Oswald Wyatt (1896-1957)
Oswald Wyatt was born just above the Minnesota border in Canada. He attended undergraduate and medical school at the University of Minnesota. In 1918 he was the first to finish the residency in surgery at the Hennepin County General Hospital. After service in World War I, he began a practice in general surgery in Minneapolis in 1920 [35].
“He was always fascinated by the surgical problems in infants and children,” said Randolph [7]. Wyatt knew enough about the field that “he became thoroughly dissatisfied with the quality of care rendered to infants and children in that city,” said Dr. Clatworthy [17]. He thus became an ideal target for Coe - always on the lookout for surgeons who might be convinced to devote themselves to children’s surgery. Once their paths crossed, Coe convinced him that he could be successful as a full time pediatric surgeon [35].
Wyatt took the leap. In 1927 he closed his office and went to Washington University in St Louis and Children’s Memorial Hospital in Chicago for additional training in clinical pediatrics and children’s surgery. When he returned in 1928 he restricted his practice to children [35]. He hit a roadblock in 1932 when he was refused privileges at the university medical center by Owen Wangensteen, legendary chair of surgery at the University of Minnesota. Wangensteen’s view was that a surgeon trained in his residency had the surgical expertise to practice on patients of all ages, including infants and children. The view was the prevalent attitude among the leading academic training programs and departments of surgery in the U.S., including Johns Hopkins, the University of Rochester and Vanderbilt University [6].
Wyatt faced the double challenge of exclusion from the university hospital and the depression of the 1930s, “[he] nearly starved to death!” said Clatworthy [17]. With time Wyatt’s practice became a success because pediatricians, both in community offices and academic departments, embraced Wyatt’s specialized training and expertise. With Tague Chisholm, a Boston trained pediatric surgeon who joined him in 1946, Wyatt’s practice grew to become the largest private practice in the U.S. with extensive experience with such complex conditions as extrophy of the bladder and myelomeningocele [7][35].
H. William Clatworthy (1917-2000)
Dr. Clatworthy, originally from Denver, CO, attended Harvard Medical School, then served as a medical officer in the U.S. Army prior to completing his surgical training. During his time as a house officer in Boston, he had the opportunity to be one of the few surgeons to train under both Drs. Ladd and Gross [7].
Though he contributed greatly to the medical knowledge in the field of pediatric surgery, his greater contribution has arguably been to the training curriculum of pediatric surgeons. In 1966 he was chair of the committee of the Surgical Section which evaluated and revised the standards for North American pediatric surgical training programs. He is remembered for his dedication to teaching; his residents described him as “… a motivator, explosive but fair, forgiving, trusting, and above all a superb teacher.” [7]
C. Everett Koop (1916-2013)
C. Everett Koop was among the most prominent of the generation of pediatric surgeons that came after Robert Gross. Just 30 years old, in 1946 Koop was near the end of his year as senior resident at the Hospital of the University of Pennsylvania (HUP) when he had to be an inpatient there himself. He was in bed with pharyngitis with an intravenous needle in his arm when Isadore Ravdin, chair of surgery at Pennsylvania, burst into his room at 5 AM and appointed him surgeon-in-chief at the Children’s Hospital of Philadelphia (CHOP) [16].
His only experience with pediatric surgery was a few short months as an intern and resident. Koop knew enough “that children did not get a fair shake in surgery.” [16] He remembered the comment that one respected Boston surgeon made after a presentation Ladd made before the Boston Surgical Society. “Anyone who can operate on a bunny rabbit can be a child surgeon,” he said [36].
Without Boston’s tradition of having a full time surgical service devoted to children, surgery at CHOP was performed indifferently by four surgeons who otherwise operated elsewhere on predominately adult patients at other hospitals. With his characteristic candor Koop said, “[They] had not done it particularly well and certainly had no abiding interest.” [16] Anesthesia was so unreliable that the full time staff at the University of Pennsylvania hated to come to the facility, then located in the Center City downtown district a few miles away from HUP on the Penn campus. The incident that brought Ravdin to Koop’s bedside was an infant with intussusception who died waiting for the arrival of a surgeon [36]. Frances Clyde, then head nurse CHOP, was furious. She had worked with Ladd and Gross in Boston. Koop described what happened next in an oral history interview with Moritz Ziegler, his former trainee and junior associate and another Past President of APSA.
[She] went to the physician-in-chief of the children’s hospital, … Joseph Stokes, Jr., … and she said, “This is an absolute tragedy, and it’s a travesty that it would happen in a major children’s hospital and in a major university[.]…I give you, Dr. Stokes, and the University of Pennsylavnia, one year to rectify this situation, and unless you are on the way to building a surgical service with the safety that Dr. Ladd and Dr. Gross have in Boston, my staff and I will quit. And when I say ‘my staff’ I mean every nurse on that staff [36].”
With the new year of 1947 he began a three-month assignment at CHOP, a probationary period to allow its staff and him time to work together. Pediatricians, protective then as now of their patients, were extremely cautious in recommending surgery. The younger and smaller the patient, the higher the mortality. Each pediatrician had a restricted range of ages where surgery was deemed safe and a very short roster of surgeons and anesthetists permitted perform operations on their patients.
Koop got an earful when he arrived. “Why don’t you go back where you came from?” asked the medical resident who met him. “You’re not wanted here, you’re not needed here, and you put four good men out of a job [36].” Each of the four had turned down the position that Koop had already accepted, a fact that the young surgeon kept to himself.
Stokes made certain that Koop knew how things were run at his hospital. “All patients that come to this hospital are admitted on my service,” the pediatrician said. “When I think they’re ready for operation I will call you and take over the care of the care of the patient immediately after it comes from the operating room [16].”
Koop had a ready answer. "That’s the way it was up until today, Dr. Stokes. That’s what I’m here for. I am going to run a surgical service, and I will be responsible for the patients, for their diagnosis, … treatment, … postoperative care, … and for their follow-up." [36]
“We’ll see about that,” said Stokes, who reached for his phone to call Ravdin [36]. Koop could tell from Stokes’s silence and the muffled but audibly raised tone of Ravdin’s voice from the receiver that it was the pediatrician who was being lectured. It took some time for Koop and Stokes’s relationship to smooth.
His months in Boston were spent observing operations and learning pathology, time that Koop thought was largely wasted. He saw his six weeks as the “pup,” the most junior housestaff on the pediatric service, as his most valuable time there [16].
Eager to perform procedures on his return in 1948, he filled his first day’s schedule with a list of 13 operations. The staff, unaccustomed to such a heavy load, promptly quit. The head nurse resigned when Koop admitted a black child to the restricted “private floor” of the hospital. He was then still only in an acting capacity – a full appointment only came after he passed his boards in surgery later that year. Koop went without an office for the first nine months he was at CHOP before he was assigned a cubicle in the upper floors of the facility and a secretary that was shared among five pediatricians [16].
As early as his second year as chief, 1948, he saw progress. Anesthesia was safer, postoperative care was improving and mortality was decreasing. With his devotion to his patients, mastery and improvement of surgical operations and attention to the details of pre- and postoperative care, Koop proved the value of a specialist in the care of infants and children. His patients survived with conditions that previously had been fatal. The attending staff at CHOP soon recognized his talent. “Pediatricians … [came] to me, the surgeon, to help them out of their tighter spots,” he said [16].
He needed allies, especially in anesthesiology, neonatology and nursing. “Without the development of pediatric anesthesiology, pediatric surgery would never have gotten off the ground,” he said [16]. He helped Margo Demming, pioneering pediatric anesthesiologist, prepare endotracheal tubes for the next day’s operations by fashioning them from red rubber tubes and heating them in boiling water over a bent wire so they would have a curve. Despite a “very difficult sell to the hospital,” he managed to get a cadre of nurses assigned solely to the care of newborns with surgical conditions [16]. In 1956 he helped open the first neonatal intensive care unit in the U.S. at CHOP with the assistance of a grant from the U.S. Public Health Service.
The education and training of surgeons in the new discipline was among his first tasks. His training program at CHOP started the year of his arrival and graduated one trainee every year until his retirement as surgeon-in-chief in 1981. Its curriculum grew in length from one to two years in length. In all 38 surgeons were trained at CHOP under Koop.
Koop felt that his achievements had gone unrecognized. He still felt hostility. To Koop, the reason was obvious. Pediatric surgery belonged to neither pediatrics nor surgery and so neither recognized the new discipline nor felt pride in his accomplishments. “We really had no recognition,” he said, “… we really had no organization behind us.” Koop believed the solution was recognition by an official body, the American Board of Surgery (ABS). On the behalf of the Surgical Section, he led two unsuccessful proposals in 1956 and 1960. It would take a quarter century from Koop’s return to Philadelphia in 1948 for the specialty to be recognized as a specialty eligible for certification by the American Board of Surgery in 1972 [12].
James A. O’Neill, Jr. (1933-)
James O’Neill was a medical student at Yale University in the late 1950s when a baby came in with a history of fainting spells – the child would collapse in his play pen, then appear to revive somewhat before collapsing again. The intern and resident were perplexed. The chief resident, called in from home, said, “You know, I haven’t got any idea what’s wrong with this baby. But I think there’s something wrong with this child’s belly.” [37]
They decided to call James “Stemm” Foster, a general surgeon who took call for emergencies at the facility. “That was … the model of pediatric surgery back then,” said O’Neill. “There were good general surgeons who did whatever pediatric surgery was needed.” Foster laid a hand on the child’s abdomen and without hesitation said, “This child has an intussusception, [and] needs to go to the operating room right away.” [37] O’Neill tagged along and scrubbed in. Foster allowed him to feel the swollen lesion and intestine.
He was hooked. “That’s the kind of doctor I want to be,” he said. He read William Ladd and Robert Gross’s textbook, Abdominal Surgery of Infancy and Childhood, published in 1941. He read Gross’s updated version, Surgery of Infancy and Childhood, published in 1953, which included thoracic and urologic surgery. “I [must have] read that book …ten times, and almost …like you would [read] a novel. Then I would follow up references and read about anomalies and some of Dr. Ladd’s original papers. All of this as a student, and I fell in love with it.” [37]
The program director and chair at Yale, Gustaf Lindskog, a thoracic surgeon, tried to dissuade him. “Well, I can’t understand why you’d want to do pediatric surgery,” Lindskog said. “Who needs pediatric surgeons?” O’Neill was about to start his internship at Yale, so the chief generously allowed him go to Vanderbilt University in Nashville instead, one of the few places to offer a rotation on pediatric surgery. “You go down there and get it out of your system,” Lindskog said, “and then you come back here.” [37]
His 1959-1960 intern year had the opposite effect. O’Neill loved pediatric surgery, especially the time he spent with H. William Scott, chair of surgery, who had completed three years under Gross as his resident at the Children’s Hospital in Boston. He asked Scott whether he might stay in Nashville to finish his residency. Scott reminded him of his obligation to the program at Yale. O’Neill contacted Lindskog and told him of his honest conviction to proceed with a career in pediatric surgery. The young trainee was taken aback when the chief wished him well and released him from his obligation to Yale.
Scott was flabbergasted when he heard how O’Neill lost his place in the Yale residency. “Well, he started at the top of my head, and …went down to the bottom of my toes. He read me out! ...I just wanted to crawl into the carpet,” said O’Neill [37]. After the scolding Scott gave him a year at Vanderbilt, after which they would revisit O’Neill’s options. Chastised, the resident kept far away from the chief. At the end of the year, instead of a meeting with Scott, O’Neill got his assignments for a second year. After twelve months, again no meeting but a list for another year. At the start of his fourth year, once more no word from Scott but instead his rotations as a senior resident.
When the chief called him into his office at the end of 1964, O’Neill did not know what to expect as he entered. Scott gave him a position as chief resident, then confessed that he had a purpose when he did not meet with O’Neill after his first year. “I thought that would be just a good way to make you work hard,” the chief said [37]. O’Neill was able to laugh about it later. He would go on to fellowship training from 1967 to 1969 with H. William Clatworthy in Columbus, then an illustrious career in academic surgery as surgeon-in-chief at the Children’s Hospital of Philadelphia, president of the American Pediatric Surgical Association (APSA, 1988-1989), and chair of the section of surgical sciences at Vanderbilt, the organizational descendent of the position once occupied by Scott.
Judson Randolph (1927-2015)
Like many of his contemporaries, Judson Randolph was inspired by Gross’s textbook on pediatric surgery. Even though he earned a pittance as an intern in surgery at the University of Rochester during the 1953-1954 year, his wife Comfort, who supported the young family from her earnings as a nursery school teacher, stretched their budget for the eighteen-dollar book. He was impressed that Gross had written every chapter on all aspects of pediatric surgery, including abdominal and thoracic conditions, cardiovascular surgery and urology. “Well, here you can do it all,” he concluded. “You can take care of children and you can do surgery, and that’s what I want to do.” [38]
“I’m going to write this man a letter,” he told Comfort. Her response was a firm “No.” Their finances strained, at first he thought she did not want him to take the extra training beyond his plans for a career in surgery. “You’re not going to write him a letter,” she said. “You’re going to make an appointment and go see him [at the Children’s Hospital in Boston], because you’re a lot better in person than you are on paper.” In Randolph’s words, hers were “words only a wife could say.” He won a position to complete his training in surgery at the Massachusetts General Hospital and the Children’s Hospital (1955-1961). After his training he accepted Gross’s invitation to join his full time staff.
In 1963 he received a letter that asked him to consider a job as chief of surgery in Washington, D.C., at the Children’s Hospital of the District of Columbia (now the Children’s National Medical Center). With only a couple of general surgeons who occasionally covered cases there, the place had nothing to distinguish it as a potential center for pediatric surgery. He set it aside without a second thought. Three months later Robert Parrott, its medical director and Chair of the Department of Pediatrics at Georgetown University, traveled to Boston specifically to meet with him. Somewhat red-faced at not responding to Parrott’s letter, Randolph listened as Parrott sold him on the potential of being part of a full ime faculty of specialists in one of the only major cities in America without a pediatric surgical service. “[The pediatric faculty at Georgetown] all said they needed to have a children’s surgeon come and be their partner,” Randolph said. “I went back [to Boston, and compared] how wonderful everything was at Boston Children’s [with] what a vacuum there was in Washington. …I think it was the vacuum that finally spoke to me[.] …And I came to Washington. Never looked back.”
Despite the desultory state of children’s surgery before his arrival in 1964, the surgical community in D.C. united in opposition to his presence. Before Randolph’s arrival, adult surgeons – Randolph’s term for general surgeons whose primary practice were adult patients – only saw children from families that had private insurance, a source of income that was threatened with a full time pediatric surgeon. “I had a hard time at first,” he said, “because [they] did not want a pediatric [surgeon] – particularly some guy that was young, that was from Boston, …[and] that thought he knew something that they didn’t know.”
Among his first cases was a baby who died of complications following surgery for an esophageal malformation. The adult surgeons used a strategy often used on professional enemies: They got the hospital to initiate a formal investigation into the death. All that was needed to clear his name was a review the outcome of cases with the same diagnosis that were operated on by the same surgeons who were accusing him of negligence and incompetence. All had died. The memory still stung decades later when he recalled the events to Kurt Newman, who would become first his junior associate, then Chief Executive Officer and President of the hospital. Newman was much less exalted position as an applicant for a place in the Randolph’s training program in the 1980s when he heard the story. “I began to feel that he might be trying to scare me off,” he said [39]. Two decades later defiance was still in Randolph’s voice, even after he created one of the most successful academic services in pediatric surgery and instituted a highly regarded training program. He was elected President of APSA in 1985.
Lester Martin
A. Ashley Weech, Chair of the Department of Pediatrics at the University of Cincinnati, demanded that William Altemeier, his counterpart in the Department of Surgery, hire a pediatric surgeon.
"You’ve got to find one. If you don’t find one, I’m going to. … In Pittsburgh the pediatricians went out and hired a pediatric surgeon by the name of Bill [William] Kiesewetter. They paid him $25,000 a year. We’re going to do the same thing unless you can find one." [40]
Lester Martin had several options for his career when he finished his training at the Children’s Hospital in 1957. Gross called him into his office and told him there was sudden vacancy in the position of Surgeon-in-Chief at the Cincinnati Children’s Hospital. With more than 80 pediatricians on staff and no full time specialists in children’s surgery, it was an excellent opportunity.
Marshall Lee, a general surgeon who had held the position, had relocated to Boston as a medical director with the John Hancock Life Insurance Company. Thus Martin was able to stop by his office to find out why he had left. To Lee, children’s surgery was “a hobby” and involved too much time from his private practice. “You can’t make a living in pediatric surgery,” Lee said [40]. On a later interview in Cincinnati another surgeon described the financial situation in general to further dissuade him. Two young people get together and they’re going to get married and have a baby, sometimes not exactly in that order, and they don’t have any money. The young man gets himself a job somewhere, a minimum wage type job and they save up enough money to pay the obstetrician. The pediatrician—they can put that on time, buy so much a month. And if the baby has to have surgery, there just is nothing left for it. It’s all for free [40].
Nonetheless, Martin decided to pursue the opportunity. He wanted to finalize his plans but never could get an appointment with Altemeier. Without a firm commitment from Cincinnati, he weighed his options, which included a last-minute offer to stay in Boston. He accepted a position in Kansas City at the Mercy Hospital and the University of Kansas. (The job was ultimately filled by Thomas Holder.)
His heart still set on Cincinnati, he called Altemeier one last time. Once again, the Chair promised an appointment in a few days. “I had to tell him that I had my furniture on the moving van and … in two more days our furniture will be in Kansas City. … He finally said, ‘Why don’t you have them to leave the furniture in Cincinnati?’”
With his furniture in Ohio, Martin started his first day of work with a tour of the hospital. After a quick tour of the emergency room he and his guide were on the stairs headed for the operating room when he was intercepted by a pediatrician. “You must be the new pediatric surgeon,” he said. “Yes, I’m Dr Lester Martin,” Martin answered. “Fine, fine,” the pediatrician said. “Can you see a patient for me right now? …There’s a patient due in the emergency room. I think he has a diaphragmatic hernia.”
They hurried back to the emergency room and met the child, now dusky with cyanosis and not breathing. There was no equipment for resuscitation, so Martin picked the child up and rushed upstairs to the operating room. The staff found an endotracheal tube but could not locate a laryngoscope. Martin slipped the tube into the trachea without one and the baby turned pink once he received oxygen. A nurse anesthetist was freed so Martin could repair the hernia. As he predicted, the volume of cases in Cincinnati came to support one of the premier training programs in the country. Martin became one of the most highly regarded pediatric surgeons in the country and was named President of APSA in 1983.
Link to interview of Dr. Martin by John Vester
Thomas Holder (1926-)
Thomas Holder was born in Corinth, Mississippi on September 1, 1926. His father was a civil engineer and his mother a homemaker. After graduating from high school he enlisted in the navy and was stationed stateside during World War II. After his military service, he applied to Bowman Gray School of Medicine because it offered a four-year degree as opposed to the two-year program offered at the University of Mississippi. During his time at Wake Forest, he completed a rotation in Johnson City, Tennessee, where he had the opportunity to work with pediatric surgeon Dr. Robert Bowman. It was this experience that first interested him in the surgical care of children [41]. He went on to complete three years of surgical residency at Jefferson Medical Center followed by four years in Boston training with Dr. Gross. He was recruited to the Children’s Mercy Hospital in Kansas City in 1960 by Herbert Miller, Chair of Pediatrics at the University of Kansas, the academic affiliate of the facility at the time. Acceptance by his colleagues in pediatrics was hard fought. “There were a lot of turf battles at home in those days,” he said. “There was concern about patients that had not been properly cared for. … Over time, … people realized that surgeons with pediatric surgical training could do a better job. … These were educational years for all of us and for the pediatricians as well.” With his associate Keith Ashcraft, Holder built a thriving clinical service and highly sought after training program. He was honored by the APSA Presidency in 1975 and awarded with William E. Ladd Medal in 1997.
George W. Holcomb, Jr.
George Holcomb, Jr. received his undergraduate and medical degrees from Vanderbilt, completing his degrees in 1946. He stayed in Nashville to continue his general surgery training. Following his service in the Army during the Korean war, he moved to Boston to train in pediatric surgery after which he returned to Nashville to practice in pediatric surgery [42]. The community pediatricians in Nashville were quick to accept him when he settled there in 1952 after his residency with Gross, but he was excluded access to the pediatric patients on the surgical service at the Vanderbilt University Hospital - a scenario that repeated the one that had faced Oswald Wyatt when he was denied privileges at the University of Minnesota hospital by its chair, Owen Wangensteen. Still, pediatricians on the fulltime faculty of the Department of Pediatrics at Vanderbilt sent him their surgical cases. In the words of Randolph, “All, absolutely all” infants requiring surgery in the region were referred to Holcomb’s care [6]. In other cities trained pediatric surgeons would also be well received. “Everywhere that a trained pediatric surgeon turned up, the pediatricians embraced him or her,” Randolph said [19]. He was a charter member of the American Pediatric Surgical Association and served as Editorial Consultant for the Journal of Pediatric Surgery for over 25 years [42].
J. Alex Haller (1927-2018)
Born in Pulaski, Virginia in 1927, Haller earned his undergraduate degree from Vanderbilt University and went on to medical school at Johns Hopkins University School of Medicine [43].
When J. Alex Haller was chief resident at the Johns Hopkins Hospital for the 1958-9 academic year, he did all the procedures on children under the direction of two legendary Hopkins surgeons, Mark Ravitch, a general surgeon who had made fundamental contributions to pediatric surgery, and Alfred Blalock, Professor and Chair of Surgery at Hopkins, who performed the first subclavian to pulmonary artery bypass for tetralogy of Fallot in 1944. He wanted additional training in Boston, so Blalock wrote a letter on his behalf to Gross at the Children’s Hospital. Despite Blalock’s support Gross never answered the letter.
Without a commitment from Boston, in 1959 the young surgeon took a position at the University of Louisville as chief of cardiac surgery. He opened a laboratory in transplant immunology and began to organize a clinical service in transplantation. In 1961 he won a John and Mary R. Markle Scholarship in Medical Science - a highly competitive stipend to support the careers of young academic physicians.
Hugh Lynn, the pediatric surgeon at the Louisville Children’s Hospital (later named the Kosair Children’s Hospital), knew of Haller’s interest in pediatric surgery. Lynn had trained with Gross in Boston. “He took me under his wing,” Haller said. “[Lynn said], ‘You can operate on any of my patients. I’ll help you in any [case] you want …. If you have any questions, feel free to call on me at any time [43].’”
In 1963 Blalock tried to entice Haller to rejoin the faculty as a pediatric surgeon under David Sabiston, Professor and Children’s Surgeon-in-Charge of Pediatric Surgery. Haller hesitated. In Louisville, his family was happy and his career had a spectacular start. Moreover, Blalock’s pending retirement was widely anticipated. Despite the assurances at Hopkins, Haller still was uneasy whether Sabiston, Blalock’s hand chosen successor, would in fact be named Chair to succeed him.
Rudolph Noer, Chair of Surgery at the University of Louisville, formed a committee to come up with a competing package to get him to stay in Kentucky. Lynn had left for the Mayo Clinic, so one of Haller’s requests was that he be named chief of pediatric surgery. The Children’s Hospital bylaws required that its clinical leaders hold board certification in a specialty in pediatrics. Haller didn’t have them in pediatric surgery – it was ten years before the American Board of Surgery approved certification in Pediatric Surgery in 1973. The requirement cost Haller the appointment. That was the deal breaker. “Well, then,” Haller said, “all the more reason I guess that this is a good time for me to leave Louisville and take the job [at Hopkins].” He returned to Hopkins in 1963 where he weathered the transition in leadership that followed Blalock’s retirement the next year. (Passed over for the chairmanship at Hopkins, Sabiston left to become Chair of the Department of Surgery at Duke University.)
The position at Hopkins was for $18,000 a year, far less than the $25,000 Haller was earning in Louisville, his first job after training at Hopkins. In fact, Haller’s income exceeded Blalock’s salary of $21,000. When Blalock discovered the Markle Foundation scholarship gave Haller $5,000 a year, he did some quick math and pointed out that if Haller came to Hopkins and gave half his grant to the Department, he would be making only $500 less than his own salary. Haller accepted the terms, even though the Markle Foundation made no provision that the funds be shared with the host institution.
Haller’s contributions to pediatric surgery include advancements in chest wall surgery, as evidenced by the eponymous Haller index for pectus excavatum, cardiothoracic surgery and trauma care. He established a regional trauma center for children at Johns Hopkins, which was the first of its kind in the United States [43].
Kathryn Anderson (1939-Present)
Dr. Kathryn Dorothy Duncan Anderson, the first female president of ASPA, was one of several pioneering women who opened the door to pediatric surgery for women surgeons. She was born in England and moved to the United States in 1962, where she matriculated to Harvard Medical School. After initially being denied surgical training in Boston, as there was "no room for a woman in the OR," she completed a pediatric residency [39]. After ultimately securing a surgical training position at Georgetown University Hospital, she felt her experience was suppressed due to her gender and as such, left to work in various community hospitals where she experienced significant higher case volume. Despite the uphill battle, she ultimately was accepted into pediatric surgical fellowship at Children’s National Medical Center and went on to make great strides for women surgeons including becoming the first woman to hold office in the ACS (1992) and was elected as the first female president of APSA (1999) [44]. After completion of her training she rose to the rank of full professor at Children’s National Medical Center in Washington, D.C. and later became the Surgeon-in-Chief at Children’s Hospital, Los Angeles from 1992-2004 [44].
Surgical Management of Diseases
The evolution of fetal surgery
Fetal surgery is the newest surgical specialty and has a compelling history. The development of fetal surgery began in primates and lambs and, in its most basic form, was first performed in humans in 1965. Since its introduction, the field has expanded and changed dramatically. Several of these changes have involved the ethical aspect of fetal surgery. This field conflicts with the Hippocratic oath montra of “first do no harm” as one of the patients, the mother, receives no benefit from these procedures. The ethical dilemma resulted in stringent inclusion and exclusion criteria for fetal operations. Initially, fetal surgery was only indicated for life threatening conditions of the fetus but is now offered in some disease processes to improve quality of life for the child. As the field has matured, it has grown to encompass numerous different types of fetal interventions. Similar to other areas of surgery, the trend has been to migrate from more invasive to less invasive procedures. Theoretically, this trend would improve outcomes for both the mother and fetus. While this has generally proven true there are some important exceptions to this rule. Finally, as the field continues to evolve, much research is being performed looking at possible new types of fetal interventions. Some of these procedures, such as fetal stem cell therapy and fetal gene therapy, could change the face of modern medicine.
History of fetal surgery
Amniocentesis paved the way for fetal surgery and intervention. The first report of amniocentesis in the literature was in Germany by Lambl in 1881 where it was used to decompress polyhydramnios [45]. It was not until decades later that amniocentesis became a diagnostic tool. Even in 1952, when Bevis utilized amniocentesis, it was to determine the severity of Rh erythroblastosis, not as it is typically thought of today [46]. Just a few short years later, Fuchs and Riis showed that amniocentesis could be used for antenatal sex determination and detection of hereditary diseases [47][48]. Once this modern phase of amniocentesis arrived, a wave of antenatal interventions ensued in the 1960s. Most notable was Liley’s contribution of intrauterine transfusion for Rh erythroblastosis in 1965 [49]. This methodology was made safer by use of ultrasound guidance in the 1970s but is still used today.
Fetoscopy began as a way to augment amniocentesis by allowing direct visualization into the uterine cavity and to obtain tissue samples (typically blood or skin) [50]. In 1975, Benzie and Doran used a fetoscope to visualize the intrauterine contents prior to saline abortion [51]. By 1979, fetoscopy was still considered a risk to the mother and fetus but was deemed appropriate when the fetus was at risk for teratologically induced malformation, inherited blood dyscrasias, chromosomal abnormalities with gross malformations or neural tube defects that could not be diagnosed with amniocentesis [52]. The field advanced rapidly and by 1986, Rodeck and Nicolaides published a review article detailing techniques for obtaining fetal blood, skin, liver, tumor specimen and chorionic villi [53].
In 1981, fetal surgery moved from diagnostic tool to a therapeutic tool in a nonhuman primate experimental model. Michejda and Hodgen devised what they called the HAVIT (hydrocephalic antenatal vent for intrauterine treatment). After placement of shunts in these hydrocephalic nonhuman primates, they found increased survival to delivery, superior postnatal motor skills and improved postnatal weight gain [54]. Simultaneously in 1981, other groups used an ovine model of congenital diaphragmatic hernia. In this model system, in utero repair of the diaphragmatic defect improved lung histology and size [55][56]. By 1985, primate models had been established for obstructive uropathy and congenital diaphragmatic hernia [57][58].
Further research in the primate model showed worsening preterm delivery rates with increasing manipulation of the uterus [59]. These studies were able to identify the use of inhaled anesthetics as an important aid in decreasing uterine activity [59]. Likewise, the primate model revealed many of the maternal complications that could be expected, demonstrated that metal staples markedly decreased subsequent fertility and showed that future pregnancies were possible after fetal surgery [60].
Also in 1981, the Dr. Michael Harrison performed the first successful fetal surgery in humans for obstructive uropathy [61]. By 1987, a review was published of 57 cases of fetal vesicoamniotic shunts [62]. Nearly half of the cases had complications and only 21% of those fetuses with oligohydramnios survived - suggesting the need for a randomized control trial to determine the utility of this fetal procedure.
In 1988, a similar paper was published regarding fetal intervention for hydrocephalus [63]. This paper described 40 cases of fetal shunting - the world wide experience at that time. Ten percent of the fetuses were thought to have died as a direct complication of the procedure. Of the remaining viable fetuses, their outcomes were similar to published data for untreated infants - again questioning the utility of the procedure and need for a randomized control trial.
In 1991, the University of California San Francisco (UCSF) described their eight year experience with open fetal surgery with 17 cases [64]. Indications included severe bilateral hydronephrosis, congenital diaphragmatic hernia, sacrococcygeal teratoma, and congenital cystic adenomatoid malformation. They described their fetal outcomes as disappointing despite having previously performed more than 1500 operations on fetal lambs and more than 200 on fetal monkeys. In 1997, UCSF published their results from a prospective trial on in utero repair of congenital diaphragmatic hernia [65]. Just as in obstructive uropathy and hydrocephalus, fetal surgery did not improve survival.
While it had been clearly demonstrated that fetal surgery was possible, many questioned the future of fetal surgery [64].Yet, Dr. Michael Harrison, arguably the greatest pioneer in fetal surgery, continued to perform research on fetal surgery in lambs and monkeys and continued to refine criteria for fetal intervention [66]. Indeed as fetoscopy advanced, its use for twin-to-twin transfusion syndrome, twin reversed arterial perfusion sequence and tracheal occlusion for congenital diaphragmatic hernia became new potential interventions with optimistic outcomes [67][68]. Likewise, other indications for fetal surgery showed promise. For example, fetuses with congenital pulmonary airway malformations whom developed hydrops were deemed candidates for fetal repair as fetal demise was inevitable without repair [69]. Eight of 13 hydropic fetuses without a dominant cyst treated with open lobectomies had reversal of hydrops, substantial lung growth and were delivered viable [70]. Five of six fetuses with dominant cysts underwent fetoscopic thoracoamniotic shunting procedures and survived. Similarly, two fetuses with hydrops as a result of a large saccrococcygeal teratoma were salvaged by tumor excsion [68]. With these new successes, the promise of fetal surgery became apparent and the innovation continued.
Ethics of fetal surgery
Shortly after the development and implementation of fetal surgery, articles began to emerge regarding the ethics of fetal surgery. These articles first began discussing the time point at which the fetus had rights as a person. These first articles focused on the definition of viability [71]. The definition of viability continues to change with improved postnatal care. It is unlikely this controversial topic will be resolved in the foreseeable future.
The next question considered was whether a mother has the right to refuse an operation for her fetus. This query also prompted the question of the father’s role in this decision making [72]. In the same article, attention was given to the ethics of fetal pain - which had originally come into the lime light by those opposed to abortions. This was the same era as Roe versus Wade and thus the topic was highly controversial. With regards to fetal surgery, the ethics of fetal pain were highlighted because little mention had been made in descriptions of fetal surgeries regarding fetal analgesics [72]. It was not until an article published in 1987 showed that premature infants undergoing patent ductus arteriosus ligation had a sizeable stress response to cardiac surgery which was reduced with opioid administration, did analgesic use become the standard of care for neonatal surgery [73]. The fact that a fetus feels pain was clearly established in the mid1990s by two groups [74][75]. Thus, while most anesthetics cross the placenta to the fetus, direct fetal administration of opioids and muscle relaxants is often added [76].
In 1991, UCSF published their experience with 17 open fetal surgery cases. This paper really highlighted what became the current era of fetal surgery ethics [64]. In this paper it is acknowledged that the goal of fetal surgery is to improve the health of the future child. To reach this goal, there is risk imposed upon the mother with regard to operative risk and midgestation hysterotomy, premature labor and compromising further reproductive potential. They describe the creation of their Fetal Treatment Program which stringently evaluated the fetuses and mothers included in the study. Over the course of the eight years of their study, the screening criteria changed. While it has been shown that women who undergo hysterotomy for fetal surgery can go onto have subsequent children, there continues to be concern for uterine rupture with active labor and thus the ethical dilemma of balancing maternal and fetal health.
With maternal health in mind, Dr. Harris first proposed that fetal surgery should only be considered for conditions which could not be fixed after birth and for which the true mortality rate was defined. To that end, in 1982, a group of perinatal obstetricians, surgeons, ultrasonographers, pediatricians, bioethicists and physiologists convened to draft a consensus statement regarding criteria that must be met for fetal surgery to ethically be performed - regardless of the invasiveness of the procedure [77].
- The ability to accurately diagnose and stage the illness with exclusion of associated anomalies.
- The course of the disease is well understood, has been documented and the prognosis is established.
- There are no known effective postnatal interventions.
- In utero surgery is proven viable in animal models - correcting the damaging effects of the diagnosis.
- Interventions have been performed in specialized multidisciplinary fetal treatment centers abiding by stringent protocols and with the approval of the local Ethics Committee with informed consent of the mother or parents.
see also Ethics, Open Fetal Surgery, Ex Utero Intrapartum Treatment
Additional Resources
Stay Current in Pediatric Surgery History of Pediatric Surgery
Saving Lifetimes ebook on the history of APSA
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