History of Pediatric Surgery
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 . 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” .
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 . 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 . 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 . 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” . 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)" , 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 .
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 .
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) . 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 . 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 .
”[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." 
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" . 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 . 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" . 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 .
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  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 .
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 .
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 . 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 .
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 . 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 . 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" .
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).
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" .
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 .
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" .
They targeted younger surgeons who were not officers in the Surgical Section, the latter group they naturally dubbed, “the old guard" . 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 .
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" . Still they were optimistic of their success. “[The] critics would nonetheless probably go along with a revolution that promises to have a successful outcome!"  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" . 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 . 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 .
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 .
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." 
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)  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" .
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" .
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 . 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" .
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 . 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 , yet was “reticent to leave the general surgical mainstream.”  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 . 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 . 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." 
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.”  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’.’” 
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 .
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 .
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 .
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 . 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.” 
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 . 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 .
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 .
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 . 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 . 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.”  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 .
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 . 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 .
“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.” 
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."  In 1974, Beardmore, Randolph and Rowe took the inaugural board examination in Philadelphia. In Randolph’s words, they “fortunately passed.”  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 . 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 . 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!” 
“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.”  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 .
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 .
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 .
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 . In comparison to his overall influence on the field, where he has been called the “father of pediatric surgery” , 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 .
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 . 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 .
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 .
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.”  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.”  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 . The committee scrutinized case logs to assure that the graduates had enough experience with index cases to enter independent practice . 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) . 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 .
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 . 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 .
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