Journal of Pediatric Surgery VOL 33, NO 7 JULY 1998 HISTORICAL LECTURE A Perspective on the Early Days of Pediatric Surgery By C. Everett Koop Bethesda, Maryland C. Everett Koop, MD I N MY WILDEST DREAMS as a surgical trainee, I never thought I would be in on the founding of the surgical section of the American Academy of Pediatrics. let alone be present in its 50th anniversary year. At the time the surgical section was founded, I was 3 1 years old and actually had been practicing pediatric surgery at the Children's Hospital of Philadelphia for almost a year. I had been designated as its Surgeon-in- Chief, but was awaiting the final action of the Board of Trustees. The previous year I had spent as a fellow at the Children's Hospital in Boston at what was a rather tumultuous time. Dr Ladd had retired, Dr Gross had not been appointed yet and the hostility between those two venerable fathers of pediatric surgery in America had not been reconciled. Journal ofPediatric Surgery, Vol 33, No 7 (July), 1998: pp 953.960 On the house staff at the time I was a fellow. there was Luther Longino, Bill Clatworthy+ Amie Porter. Bob Bowman, Sandy Bill. and others. Charles Lowe was the chief pediatric resident. Eleven surgeons came together with one representative of the Academy of Pediatrics for an organizational meeting at Hadden Hall in Atlantic City in October. At 954 C. EVEf3El-T KOOP that time, pediatric surgeons were known as child sur- geons and the only chair of child surgery in the country was the William E. Ladd Chair at Harvard. Incidentally, its endowment was $6,000. By then, there were few in the country who claimed to be child surgeons. Bea Ladd and Tom Landman were retired, Bob Gross and Orvar Swenson were very busy in Boston, Oswald Wyatt was holding forth in Minneapolis and Tague Chisom had just joined him. Bill Potts was in Chicago. Herb Coe was in Seattle and had not yet been joined by Sandy Bill, Henry Swan was operating in Denver, and I was in Philadelphia. I have a slide taken after dinner at the time of the organizational meeting (Fig I ). In the back row on your left is Henry ST,van of Den\,er wh,). like many child surgeons of the day, did a considerable amount of general surgery as well. Bob Bowman was an anomaly of World War II. He was a pediatrician who was exempt from military service for reasons of health and found his way to the house staff at Boston Children's where he was the chief surgical resident during my fellowship. His phone rings once and shuts off. His mail is not answered or returned. His intent was to practice pediatrics and to just do the more common surgical procedures on his own patients. such things as hernias, undescended testicles, pyloromy- otomies. and so on. Next is Bill Potts who was then at the Children's Memorial Hospital in Chicago. Next is Jesus Lozoya-Solis. a pediatric surgeon from Mexico City who owned a vitamin factory. I visited with him several times in Mexico where he gave free lectures on pediatric surgery and then closed the meeting with a sale of stock in the vitamin company. I am next and to my left is a gentleman whom I cannot identify, nor can I find anyone else who can. In the front row is William E. Ladd. Franc Ingraham is in the center. For those of you who Fig 1. Founders of the Surgical Section of the American Academy of Pediatrics. did not know this gentleman, he was an excellent neurosurgeon. operating at the Brigham and Children's Hospital, and was one of the founders of the Supranant company. which manufactured the first polyethylene tubing for medical use. He spelled his name F-r-a-n-c and it was rumored that he told his secretaries not to open any mail that was addressed to F-r-a-n-k. The thing I remem- ber about him was the day that England declared war on Germany, he bought two Jaguars just in case the war lasted longer than some people thought it might. Next is Oswald Wyatt, and I presume Tague Chisom was home minding the store. Then Tom Landman and. at the extreme right. the representative of the American Academy of Pediatrics who helped us with organizational matters. Before 1946 I knew very little about the held that eventually became known as pediatric surgery. I was well aware of the fact that children did not get a fair shake in surgery, as was amply proven during my rotating intem- ship and residency in surgery in Philadelphia. Surgical patients came from the adult world and children had a difftcult time in competing with them. Surgeons in general were frightened of children and distrusted anesthetists to be able to wake them up after putting them to sleep-a belief shared by many anesthe- tists as well! The younger and smaller the patient, the more adv-anced the hazard. I wish I fould say that because of this knowledge I was determined to make a change for the better. Actually, pediatric surgery was thrust upon me. During the last year of the war and of my senior residency in surgery at the Hospital of the University of Pennsylvania. while 1 myself was in the hospital recovering from an infection. my chief. I.S. Ravdin. then the highest ranking medical officer in the United States Army, temporarily back from India. burst into my room in the hospital one morning and asked me what I intended to do with my life. Fefore I could answer, he asked me how I would like to be the Surgeon-in-Chief of the Children`s Hospital of Philadel- phia. That day began the odyssey that lasted until 198 1. provided me with some of the most wonderful years of my life, and saw a fledgling specialty overcome hostility, establish itself in the hearts and minds of the public and the profession alike, and demonstrate in microcosmic form in 35 years what it took American surgery to become in 200 years. I had 4 months to prepare myself before going to the Boston Children's Hospital for a period of a year's observation. which was part of the stipulation laid down to me before I accepted the assignment. The others were to return to Philadelphia at the end of that time, permanently give up the practice of adult EARLY DAYS OF PEDIATRIC SURGERY 955 surgery, and endeavor to establish at the Children's Hospital of Philadelphia, under the aegis of the Depart- ment of Surgery of the University of Pennsylvania, the best possible academic surgical program for children in the country. My remarks this morning will not be global in nature. This talk is not meant to be a definitive history of pediatric surgery, it is a personal recollection by a surgeon who probably practiced pediatric surgery as long as anyone and who is recollecting-for a special occa- sion-from the vantage point of the early years of the ninth decade of his life. The Children's Hospital of Philadelphia (CHOP) had hcen founded by a group of pediatricians in several adjacent city homes in 1865; the Boston Chilriren's Hospital was established 4 years later. In the United States and in Europe. where the surgery of children was successfully carried out, child surgery was usually in one of the specialties. especially orthopedics. In those days there was ample need for such specializa- tion in the treatment of diseases that are no longer major problems: tuberculosis of the bone, osteomyelitis, polio. and the congenital defects that still do occur. Eldridge L. Eliason and Jonathan E. Rhoads had distinguished them- selves periodically by a spectacular operation on a small infant. The four general surgeons who looked after the surgery that had to be done at CHOP to save lives had not done it particularly well and certainly had no abiding interest. On the other hand, the Boston's Children's Hospital had a better legacy. The names of Brown and Langmaid appeared here and there on records as well as various orthopedists. until William E. Ladd appeared on the scene. Today. many will tell you that Ladd became interested in the surgery of chiidrsn after the tragic explosion of a munitions ship in Halifax Harbor, to which site he went to care for the injuries and bums of children. Actually his interest in children and their surgical problems began at the Boston Children's Hospital in 1910. Ladd had established a joint internship in surgery with the Peter Bent Brigham Hospital and the Children's Hospitals, and out of that training there arose Robert E. Gross, whom Ladd took under his wing until Gross- without notifying his mentor-operated on the first patent ductus arteriosus while Dr Ladd was out of town, thereby beginning the estrangement that probably slowed the speed of development of child surgery more than we will ever know. Nevertheless, Ladd and Gross published in 1941 the first American modem text book on child surgery: Abdominal Surgery of Infancy and Childhood. In it, they enunciated a principle that guided child surgeons through the first decade or so: surgical infants and children cannot be treated as though they were diminutive adult patients. Thomas Lanman had been a junior colleague of Ladd's, and, in addition. Ladd trained Hemy Hudson and Orvar Swenson. He also brought Donald McCullum on in plastic surgery, doing primarily cleft lips and palates. after his training with two of the preeminent British plastic surgeons of that era. When my chief. I.S. Ravdin. made arrangements for me to go to Boston, Ladd was the chief: by the time I got there he had retired and Gross was the heir apparent. But because of the antagonism between Ladd and Gross. the former made it as difficult as he possibly could for the latter to ascend to the chair that bore his name. In the interim. Franc Ingraham was the acting surgeon- in-chief. It was to him I reported, it was Gross who r;Ln the service. but it was Orvar Swenson and the residents who taught me what I went to learn. I actually learned a few surgical techniques and a great deal about surgical pathology. but inasmuch as I already had more surgical training than any of the current house staff under Gross. I was somewhat disappointed in the role of an observer. My most valuable experience was the 6 weeks I substituted as the "pup"-the lowest man on the totem pole on the medical pediatric house staff. Because of that grueling -experience. I never had to ask anybody to perform something for me on a baby that I didn't already know how to do myself. Even though Ladd had published a number of papers on his individual experiences, and even though with Gross he had published the aforementioned textbook, there was very little written about the surgery of infancy and childhood. Surgery was done in most places h!, general surgeons or by anatomic adult specialists, such as urologists, in what in retrospect seemed like a most haphazard way with high mo;:ality rates and even higher morbidity. In most hospitals. the mortality rate for a simple colostomy was in the range of 90%. The surgical patients in the Children's Hospital of Philadelphia were either orthopedic or otorhinolaryngological. with tonsils. middle ear infections, and mastoiditis being the major admission diagnoses. As I said, the field I was about to enter was called child surgery. Some credit me with first using the term pediatric surgery, but it can't be proven. In 1946, you could say Boston had two full-fledged child surgeons-Gross and Swenson. Minneapolis had Oswald Wyatt. Seattle had Herbert E. Coe. and Philadelphia had Koop. Coe had begun as early as 1919 and Wyatt in 1928, so I was a relative newcomer in 1946. All of us had exactly the same problems in getting started-hostility from the medical community but espe- C. EVERElT KOOP cially from the surgeons. A prominent Boston surgeon once told Ladd that anyone who could operate on a bunny rabbit could operate on newborns. World War II had splintered the log of general surgery considerably. Pediatric surgery was the last of the newcom- ers and suffered accordingly. Surgeons didn't want to see any further fracturing of general surgery, and they were particularly incensed that there were now some upstarts in the surgical world 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. On the other hand, pediatricians were fearful of surgery because of the high mortality rate from anesthe- sia. Each referring pediatrician had his own safe-age at which to refer a patient with. say. an inguinal hernia to the local anesthesiologist. There were other surgeons in America that had a surgical concern for children such as Penberthy in Detroit. One of Penberthy's proteges, Clifford Benson, became one of our beloved colleagues as he confined his surgical activities more and more over the years to the care of children exclusively. In Los Angeles, two general surgeons performed a lot of surgery at the Los Angeles Children's+-Snyder and Chaffee. The first successfully corrected volvulus and malrotation of the colon was performed there. The first day 1 arrived at the Philadelphia Children's Hospital in January 1946 for a 3-month probation period before going to Boston. I was given several clear messages: "You're not wanted here. You're not needed here. Why don't you go back where you came from?" That message came from many. But this word came from the physician-in-chief and chair of pediatrics at the University of Pennsylvania: "All patients that come to this hospital are admitted on my service, and when I think they're ready for operation i wili call you and take over the care of the patient immediately after it comes from the operating room." He was merely informing me of the custom of the day. I was pretty brash when I told the famous and venerable Joe Stokes that I had come to change that. Although the then-provost of the University, A.N. Richards; my chief, IS. Ravdin; and his associate, Jonathan E. Rhoads were very supportive and actually made the bed in which I would lie. I have to say that the University, the Children's Hospital, and the city, espe- cially its surgical fraternity, were hostile to the arrival of someone who called himself a children's surgeon. Second, pediatric surgery was not a traditional, verti- cal, cradle-to-the-grave anatomic specialty. We in pediat- ric surgery claimed that we could take care of infants and children better because of their physiological differences, their limited reserve, and their special pharmacological needs than could the anatomic specialists. It was not a popular position. So we in child surgery were actually surgeons of the skin and its entire contents. Of course. for someone trained in general surgery it was pure heaven. I'd be operating on the skull and in the neck in the morning, perform a thoracic procedure in the early afternoon, spend the rest of the day in the abdomen. and clean up with fractures and injuries of the extremity. The Children's Hospital of Philadelphia was not accus- tomed to long surgical schedules. The first day 1 sched- uled 13 procedures. the operating room staff quit. That was not nearly as dismaying as the occasion when 1 admitted my first black patient to what was called the "private floor" and the head nurse resigned. Visiting hours for parents at the Boston Children's Hospital when I was there had been 1 hour every other Sunday, and when I returned to Philadelphia they were I hour evev Sunday. It was not easy to get from that point to the day in which all patients' families had access 24 hours a day-not only to be with their children. but to sleep in the room with their children or next to their bed in the ward if they so desired. Because 1 had been declared essential to the University of Pennsylvania for the duration of the war and had been commissioned a second lieutenant in the Office of Scientific Research and Development to work on plasma substitutes. I had not seen combat and had been able to continue my residency in the midst of my other assign- ments. So when I took over the post at the Children's Hospital (actins as surFeon-in-chief until 1 passed my American Board of Surgery exams in 1935). 1 found most of the pediatric house staff to be older than I. 1 look back on those d;ly: with a sense of awe when 1 realize that pediatricians, now the great experts in electro- lyte and fluid balance. used to come to me. the surgeon. to help them out of their tighter spots. The same had been true in Boston. The technique of administering fluids in those days was abysmal. 1 recall when one of my own children became dehydrated while 1 was in Boston. he was treated at the Boston Children's Hospital with a clysis of saline injected all at once under the skin between his scapulae. He had a "tumor" on his back as big as a grapefruit. To insert a needle into a scalp vein in those days wasn't too difficult, but to keep it in place so it didn't infiltrate required some of the skills of a genius. We had only steel needles, detachable from glass syringes of large bulk, and it was therefore necessary to build up mountains of gauze pads and attempt to secure the needle and syringe to them in such a way that the baby's head movements, after we EARLY DAYS OF PEDIATRIC SURGERY 357 had strapped the child to the mattress with adhesive tape. would not dislodge the needle. Obviously, in surgical procedures or in patients whose veins had been damaged by multiple attempts at infusion. we had to use something more reliable. Therefore, the "cut-down" became one of the standard procedures that all surgeons and some pediatricians had to master. We started by cutting down on a branch of saphenous vein either anterior or lateral to the medial malleolus of the tibia, and after we had exhausted those sites-usually by thrombosis-we then went to the wrist. then the antecubital. and sometimes even the cephalic. Subclavian lines, of course. didn't come in for three decades thereaf- ter. I wish I had time to go into detail about what a dif:`erent world it was before the introduction of plastic tubing in the care of surgical patients. Even the early plastic tubes were not made of vinyl or polyehtylene. One of the early materials we used was tygon and one of the first applications was running a tygon tube from the ventricle to the peritoneal cavity for the relief of hydro- cephalus. Exposure to spinal fluid changed that once flexible tube to the consistency of a piece of uncooked spaghetti. If a child fell downstairs. he might break his conduit in three or four places. Supportive services such as bronchoscopy. a monopoly of bronchoesophagologists were hard to come by. expen- sive, and did not produce great results. Those of you who have become used to flexible scopes with Hopkins optics will have difficulty appreciating the all-metal laryngo- scope. esophagoscope, and bronchoscopy made of rigid brass. The patients were never anesthetized. The distance from the eye to the object in question could be the length of the baby's thorax. and the visibility was not only hampered by poor lighting but constant explosive splatter- ing of saliva and other secretions over one's face and glasses, if we were fortunate enough to wear them. I have said that the children's hospital was hostile. They didn't even find me an office until I had been there about 9 months. I then had a small cubicle on the fifth floor and shared a waiting room and the services of one secretary with five pediatricians. My overhead was $70 per month and I never made that much money in one month until the 15th month that I was in practice. In the days when I sat in the library-in lieu of an office-patients with surgically correctable lesions died on the wards of that hospital in the hands of competent pediatricians without even the benefit of a surgical consultation. That is merely a measure of the lack of confidence that pediatricians in the late 1940s had in reference to the ability of anesthetists and surgeons to deliver a patient back to the family. One of the first things I did in my relatively leisure days in that institution was di, 0 out old records of patients with tumors. To my amazement, I found that a patient with a Wilms' tumor rarely survived. that patients with such tumors as rhabdomyosarcomas underwent biopsy and were allowed to die; but there was one malignant tumor-the neuroblastoma-which although inadequately, treated, patients seemed to survive in spite of the treatment or lack thereof. This began my lifelong interest in the neuroblustoma and led eventually to my very unpopular stand that this tumor required not the usual modalities of postoperati\,e therapy; indeed they might be detrimental to the health of the patient. My observations on young infants with a primary neuroblastomu. metastases to the liver or , of Pediatrics and saw the safe launching of the Jourr7rri of Pediatric Srtr,er?: The next thing seemed to be to brin_c some order out of the chaos of the trainin: programs. Bill Clatworthy took that under his aegis and began. with the Academy`s approval and that of the Surgical Section. a thorough investigation and site visit of the 25 programs then extant. Eleven of them were approved. It was inevitable that eventuali), some of us would want a purely surgical society separate from the Academ! of Pediatrics. In the fall of 1969. at an Atlantic City meetins of either the American College of Surgeons OI- the American Academy of Pediatrics. Tom Boles. Lucian Leape, Dale Johnson. and I met at a tish restaurant and talked over the possibility of an American Pediatric Surgical Association. We were all in favor of it to be sure. but we also didn't M ant the Acaclem! 01` Pediatric\ to think that we were looking a gih horae in the mouth aftt`l- the wonderful way that they had supported us since 1918. They _nraciously acknowledged that they understood our position and that the times called for such a surgical organization. It is interesting to note that. in spite of the fact that we had no recogution as a specialty from a sur$cal board, by the 19705 there were more than 50 departments or divisions of pediatric surgery in academic centers and teachins hospitals. Indeed. by 1969. the American Board of Surgery CABS) acknowledged that there was a body of knowledge concerning the surgical problems of children that should be the understanding of all surgeons and that those subjects would be included thereafter in the ABS exams. In 1970 the Advisory Board on Medical Specialties became the American Board of Medical Specialties. We tried once again for a crack at accreditation. and this time it was Har\,ey Beardmore of Montr-eal who carried the ball. Largely through his persuasiveness and the gracious understanding of Keith Reetsma. then on the ABS and 960 C. EVERETT KOOP who had been one of my proteges back in his surgical residency at the University of Pennsylvania. accommoda- tions were reached and eventually pediatric surgeons were granted, through an examination, a special "Certii: cate of Competence in Pediatric Surgery," under the American Board of Surgery; this was 1973. Although it took from 1955 when I first tried until 1973 for us to get certification, we had come the full length of general surgery in a period of less than 20 years. The Bible tells us that a prophet is not without honor save in his own land. When the British Association of Pediatric Surgeons sought recognition from the Royal College of Surgeons in the United Kingdom. they were also unsuccessful. I took up the cause for them. and after some persuasive meetings with the brass at the Royal College of Surgeons of London and the Royal College of Surgeons of Edinburgh, our British colleagues were afforded recognition in the National Health Service as consultants in pediatric surgery. A very much appreciated reward for me was an honorary doctorate of medicine from the University of Liverpool. It took an American to help the British and it took a Canadian. Harvey, Beard- more, to plead the cause for his American cousins so persuasively that we finally won the recognition we felt we well deserved. I will never forget the day at a meeting of the American Pediatric Surgical Association when Harvey Beardmore reported in detail his odyssey from start to finish. He ended it dramatically with words that still ring in my ear: "Gentlemen. you have your boards!`. It was a great day. The hairs on my arms stood on end, and I felt UY had achieved all we needed in our dynamic specialty. Although we have never rewarded Harvey Beardmorc as the British did me. I hope you young folks never forget what Harvey Beardmore did to secure us the recognition we now enjoy. We have never suitably honored 2nd thanked Harvey Beardmore for the tremendous favor he did us with his persuasive way in convincing former antagonists that we were indeed surgeons worthy of recognition.