Pediatric Surgery: The Long Road to Recognition

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PEDIATRIC

HISTORY

Pediatric

Surgery:

The

Long

Road

to Recognition

C. Everett Koop, MD, ScD

Before 1946, when I completed my training in gen-eral surgery, I knew very little about the field that eventually became known as pediatric surgery. I knew that children did not get a fair shake in surgery; that was amply proved during my internship and residency. Surgical patients came from the adult world, and children had a difficult time competing with them. Surgeons in general were frightened of children, and they distrusted the ability of anesthe-tists to wake children up after putting them to sleep, a position not far from that of many anesthetists. The younger and smaller the patient, the more significant the hazard. I knew, also, that in the United States and in Europe, where some surgery of children was more successfully carried out, it fell usually into one of the specialties, especially orthopedics. In those days there was a need for such specialization in the treat-ment of diseases that are no longer problems: tuber-culosis of the bone, osteomyelitis, and polio.

I wish I could say that my knowledge of the sad state of child surgery as I saw it in Philadelphia made me determined to bring about changes for the better. Actually, during the last year of my general surgery training at the Hospital of the University of Pennsyl-vania, I was invited to become surgeon in chief of the Children’s Hospital of Philadelphia. Pediatric sur-gery was thrust upon me. Nevertheless, I was excited about the chance to make surgery safer for children, and I entered my career with that goal.

I was asked to spend 3 months at the Children’s Hospital of Philadelphia preparing for a year of ob-servation at the Boston Children’s Hospital and then to establish at the Children’s Hospital of Philadel-phia, under the aegis of the department of surgery of the University of Pennsylvania, the best possible aca-demic surgical program for children. Even during the 3 months before my departure for Boston, I had a foretaste of the hostility that would greet me upon my return. On the first day, I was given two unmis-takable messages: (1) “You’re not wanted here. You’re not needed here. Why don’t you go back where you came from?” and (2) “All patients who come to this hospital are admitted on my service; when I think they’re ready for operation, I will call you; and I will take over the care of the patient im-mediately after he or she comes from the operating room.”

The Boston Children’s Hospital-founded in 1869, 4 years after the Children’s Hospital of

Philadel-Received for publication Mar 8, 1993; accepted Apr 30. 1993.

phia-had a better surgical legacy than most chil-dren’s institutions. The names of several surgeons, as well as orthopedists, appeared here and there in its history until William E. Ladd appeared on the scene. Today, many will tell you that Ladd became inter-ested in the surgery of children when he went to care for injuries and burns of children after the tragic explosion of a munitions ship in Halifax harbor. Actually, his interest in children and their surgical problems began much earlier, at the Boston Chil-dren’s Hospital in 1910. Ladd had established a joint surgical internship between the Peter Bent Brigham and the Children’s Hospitals, and out of that train-ing there arose Robert E. Cross, whom Ladd took under his wing until Gross-without notifying his mentor-operated on the first patent ductus arterio-sus while Dr Ladd was out of town. Thereby began an estrangement that probably damaged the devel-opment of child surgery more than we will ever know.

Even though Ladd had published a number of papers on his own experiences, very little had been written about the surgery of infancy and childhood, which was done in most places by general surgeons or by anatomical specialists, such as urologists, in what seems retrospectively to have been a most hap-hazard way. Mortality was high, and morbidity was even higher.

Despite their personal relationship, Ladd and Gross published in 1941 the first American modern textbook on child surgery, Abdominal Surgery of Infancy and Childhood. They enunciated a principle that guided child surgeons through the first decade or so: infants and children who are surgical patients cannot be treated as though they were diminutive adult patients.

My time at the Boston Children’s Hospital went

slowly. I learned a few surgical techniques and a great deal about surgical pathology, but inasmuch as I had had more surgical training than any of the housestaff, I was somewhat disappointed in my role as an observer. My most valuable experience was the 6 weeks I substituted as the “pup,” the lowest man on the totem pole of the medical pediatric housestaff. Because of that grueling experience, I never had to ask anybody to do something to a baby that I did not

know how to do myself.

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PEDIATRIC HISTORY 619 chair of child surgery-but I began to call my new

specialty pediatric surgery. I do not claim to be the inventor of that term, but I did not find many people using it until I began to talk about it as such. It was a lonely specialty. Only Boston, Minneapolis, Seattle, and Philadelphia had embryonic pediatric surgery.

Shortly after I left Boston, the Children’s Memorial Hospital in Chicago and institutions in Minneapolis, Columbus, and Seattle took steps to further strengthen pediatric surgery.

Back in Philadelphia, the provost of the university;

my chief, 1.5. Ravdin; and his associate, Jonathan E. Rhoads, were very supportive, but the rest of the University, the majority of the Children’s Hospital staff, and the city-especially its surgical fraternity-were hostile to the arrival of a specialist in child surgery. Before an office was found for me, patients with competent pediatricians caring for them died on the wards of that hospital with surgically correctable lesions without even a surgical consultation. After 9 months, the Children’s Hospital finally found me an office, a small fifth-floor cubicle; I shared a waiting room and a secretary with five pediatricians.

This hostility was understandable then, and it is more understandable in retrospect. First, World War II had produced a tremendous variety of surgical subspecialities, the two most spectacular being tho-racic surgery and plastic surgery. Old-line general surgeons were becoming apprehensive as they saw the log of general surgery being splintered more and more, and the arrival of pediatric surgery was the last straw. Second, pediatric surgery was not a tradi-tional, vertical, cradle-to-grave, anatomical specialty. We in pediatric surgery claimed that we could take care of infants and children better than the anatomi-cal specialists could because of our understanding of their physiologic differences from adults, their lim-ited reserve, and their special pharmacologic needs. Not a popular position.

In contrast to general surgery, child surgery at that time was surgery of the skin and its entire contents. For those of us trained in general surgery it was pure heaven. I would be operating on the skull and the neck in the morning, do a thoracic procedure in the early afternoon, spend the rest of the day in the ab-domen, and clean up with fractures and injuries of the extremity in the hours that were left before morn-ing. The first day that I scheduled 13 procedures, the operating room staff quit. When I admitted my first African-American patient to what was called the “private floor,” the head nurse resigned. Visiting hours at the Boston Children’s Hospital were I hour every other Sunday; when I returned to Philadelphia, ours were twice as liberal. It was not easy to move toward 24-hour access.

The technique of administering fluids in those days was abysmal. One of my own children, treated at the Boston Children’s Hospital with a clysis of saline injected all at once under the skin between his scapulae, had a “tumor” as big as a grapefruit on his back. To insert a needle into a scalp vein was not difficult, but to keep it in place required some genius. We had only detachable steel needles and huge glass syringes. It took mountains of gauze pads to secure

the needle and syringe on the baby’s head, which was then taped to the mattress. When veins ran out, we resorted to a “cut-down,” first on a branch of the saphenous vein either anterior or lateral to the me-dial malleolus of the tibia. We then went to the radial, to the antecubital, and sometimes even to the ce-phalic veins.

Rigid brass scopes were used to do laryngoscopy, esophagoscopy, and bronchoscopy because there were no flexible scopes. Patients were never anesthe-tized. The distance from the eye to the object in ques-tion could be the length of the baby’s thorax. Visibil-ity was hampered by poor lighting and by the constant explosive splattering of saliva and other Se-cretions over one’s face and glasses.

In my early days as surgeon-in-chief, I found that none of the correctable congenital defects incompat-ible with life had ever been successfully treated in Philadelphia except rarely and then by good luck more than good management. The mortality for a simple colostomy was in the range of 90%. My study also revealed that a patient with a Wilms’ tumor rarely survived and that patients with such tumors as rhabdomyosarcomas were biopsied and allowed to die, but patients with one malignant tumor-neuroblastoma-seemed to survive despite mad-equate treatment or no treatment at all. Thus began

my lifelong interest in the neuroblastoma and its management.

A large percentage of the patients who came to me privately or to my surgical clinic had neurosurgical problems-primarily spina bifida and hydrocepha-lus-or urologic problems associated with various anomalies of the genitourinary tract, usually accom-panied by infection. I realized that we needed sur-geons who would develop careers in pediatric neu-rosurgery and pediatric urology, and I proceeded immediately to find such persons. There began my drift, and that of the Children’s Hospital of Philadel-phia, away from the philosophy of the Boston Chil-dren’s Hospital and the mainstream of the develop-ing specialty of pediatric surgery: a surgeon of the

skin and all it contains. I thought that pediatric sur-gery, to do the best for children, would have to be patterned after general surgery, with pediatric spe-cialists in all the surgical fields. I set my mind to this task: to build the most comprehensive group of pe-diatric surgical subspecialists in sufficient depth so that no child who came to that oldest children’s hos-pital of the land would ever have to be sent else-where for a surgical procedure. I accomplished my goal after more than 30 years and announced it to the board of managers when I had 28 surgical subspe-cialists in nine divisions that included dentistry and oral surgery.

It has to be said that pediatric surgery would never have gotten off the ground without the development of pediatric anesthesiology. Indeed, in my own expe-rience, I spent as much time in the first year-and-a-half working with Dr Margo Deming as she per-fected anesthesia techniques in small infants as I spent on surgery. There was no equipment to be bought; we made our own. The night before surgery, we would fashion endotracheal tubes out of red

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ber catheters, file the edges with emery boards to prevent injury to the tracheal mucosa, boil them over a bent wire-hoping that they would retain some curved memory-and then begin to experiment with anesthetic gases as well as preoperative medication.

I had been convinced early on that we needed a cadre of nurses to look after neonatal surgical pa-tients, but I found that need very difficult to sell to the hospital. Finally, after three attempts, a federal agency-the Children’s Bureau-gave me a grant to establish the first neonatal intensive care unit in the United States. It had three early-model Isolettes, a development at the Children’s Hospital that grew out of the original Chappell incubator. Even with the small number of beds, all surgical results improved. Eventually we combined medical and surgical pedi-atric neonatal intensive care at the old Children’s Hospital. The unit was expanded greatly when we moved to our new quarters on the campus of the University of Pennsylvania in 1974.

Over the years, pediatric surgery outcomes bbs-somed. Survivals of newborns with esophageal atre-sia, diaphragmatic hernia, malrotation of the colon, atresia of the small bowel, imperforate anus, and barge omphalocebes and gastroschisis began to occur; survivors then began to reach parity with losses; and, eventually, mortality statistics turned into survival statistics, except for diaphragmatic hernia.

As several of us surveyed the situation in 1948, we seemed to have everything going for us. We were improving techniques, anesthesiology was coming along, and survival was improving, but the hostility toward us persisted, we had no recognition, and we really had no organization behind us.

In Atlantic City in October of 1948 (Figure), some of us who were attending the fall meeting of the American Academy of Pediatrics (AAP) got together to talk about the situation. I, as the youngest, felt privileged to be present, and this discussion, in my opinion, was indeed the beginning of pediatric

sur-gery in America.

As early as 1941, Dr Ladd had expressed an inter-est in seeing some kind of recognition for child

sur-Figure. In October of 1948, at the fall

meeting of the American Academy of Pediatrics (AAP), some attendees met to talk about pediatric surgery. Front row (left to right): William E. Ladd, Herbert Coe, Franc D. Ingraham, Os-wald S. Wyatt, Thomas Lanman, and an unidentified representative of the AAP; back row: Henry Swan, Robert Bowman, Willis Potts, Jesus

Lozoya-Solis, C. Everett Koop, and an uniden-tified attendee.

gery as a specialty. After that meeting in Atlantic City, the AAP took us under their wing by establish-ing the Surgical Section within the Academy. Those who aspired to membership would have to certify that they devoted 90% of their surgical practices to the care of children.

The argument that pediatric surgeons could care for a urologic patient or a neurosurgical patient or a plastic surgical patient better than anatomical spe-cialists became less convincing as the patients grew older. No one doubted that we could do better with newborns, especially premature and small infants, but as we began to do those things well, pediatri-cians wanted us to do older children, who did seem to do better with us than they did with general sur-geons or with anatomical subspecialists. As pediat-rics expanded its own field to encompass those youngsters who frequently fell through the cracks-adolescents-the field of pediatric surgery even lengthened.

When I spoke about the hostility of the Univer-sity of Pennsylvania, the Children’s Hospital, and the city of Philadelphia, I did not include pediatricians, but pediatricians did not seek a specialty of child surgery. Nor did pediatricians jump on the band wagon early on; indeed, they let patients die in our hospital without a surgical consultation. But as they learned what we could do, their support grew, and after the AAP took us under their wing, pediatricians eventually, albeit slowly, became our very strong supporters.

Sometimes an enthusiastic individual pediatrician or a specific surgical advance pushed pediatric sur-gery forward by leaps and bounds. One such ad-vance much appreciated by pediatricians was ambu-latory surgery for inguinal hernias; this procedure allowed patients to be discharged to full activity with no sutures and no bandages.

By the mid-1950s, I thought that the time was right to ask for specialty recognition for those of us who practiced pediatric surgery because we had the sup-port of many individual pediatricians and of the

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PEDIATRIC HISTORY 621 a specialty that could demonstrate success.

Accord-ingly, I made the first proposal on behalf of the Sur-gical Section of the AAP to the American Board of Surgery in 1956. It was not accepted with enthusi-asm, but the Board did make a proposal on our be-half to the Advisory Board on Medical Specialties. Who knows how far it might have gone in a pedes-trian way up the bureaucratic ladder had it not been for the unbelievably vehement opposition of the So-ciety of University Surgeons and the American Board of Urology. Because of their opposition, the American Board of Surgery withdrew their proposal to the Ad-visory Board of Medical Specialties in 1957.

The American Board of Surgery itself kindly sug-gested that we make the Surgical Section of the AAP

big enough to take the place of certification. This was easier said than done, but my principal concern-and it was shared by others-was this: we were in-deed very pediatrically oriented, but we were sur-geons, and we deserved to have recognition among surgical specialists.

In 1967, a second attempt through the American Board of Surgery to the Advisory Committee on Medical Specialties was rejected within 6 months. This rejection was discouraging, but by that time an important enhancement to the future of pediatric surgery was well under way-the Journal of Pediatric Surgery. The journal was the brain child of Stephen Cans, who shared with me the role of editor-in-chief for 25 years. The first issue of the Journal of Pediatric

Surgery

was published in February 1966, and shortly thereafter this journal was adopted as the official publication of the Surgical Section of the AAP. Within the next year, the British Association of Pediatric Sur-geons and then the Canadian Association of Pediatric Surgeons afforded us the same honor. We had be-come an international journal.

By the 1970s, we had tried twice for certification, we were under the wing of the AAP, and we had seen the safe launching of the Journal of Pediatric Surgery.

The next task was to bring some order out of the chaos of the training programs. With the approval of the AAP and of its Surgical Section, a thorough in-vestigation and site visit of the 25 programs then extant was undertaken; 11 of them were approved. Inevitably, some of us would want eventually a purely surgical society free from the ties with the AAP. In the fall of 1969, at an Atlantic City meeting of

either the American College of Surgeons or the American Academy of Pediatrics, several of us met at a fish restaurant to talk over the possibility of an American Pediatric Surgical Association. We were all in favor of it, to be sure, but we did not want the AAP to think that we were ungrateful for the wonderful way that they had supported us since 1949. They graciously acknowledged our need and agreed that the times called for such a surgical organization. Although we had no recognition as a specialty from a surgical board, by the 1970s there were more than 50 departments or divisions of pediatric surgery in academic centers. Indeed, the American Board of Surgery acknowledged in 1969 that there was a body of knowledge concerning the surgical problems of children that should be understood by all surgeons taking the examinations of the American Board of Surgery; pediatric surgery was included in the exams thereafter. In 1970, the Advisory Board on Medical Specialties became the American Board of Medical Specialties. We tried once again for accreditation, and this time we succeeded. By 1973, pediatric surgeons would be granted, through an examination, a special certificate of competence in pediatric surgery under the American Board of Surgery. Although it took a!-most 20 years-from 1955 when I first tried until 1973-for us to get certification, we had become a microcosm of general surgery in fewer than 40 years. When the British Association of Pediatric Surgeons sought recognition from the Royal Colleges of Sur-geons in the United Kingdom, they were also unsuc-cessful. It took an American to persuade the Royal College of Surgeons of London and the Royal College of Surgeons of Edinburgh to give our British cob-leagues recognition as National Health Service con-sultants in pediatric surgery. Similarly, it took a Ca-nadian 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 when members of the American Pediatric Surgical Association heard this: “Gentlemen, you have your Boards!” It was a great day. We had achieved all we needed at the time, in our dynamic specialty.

Editor’s Note. Rather than excluding important con-tributors to the development of pediatric surgery, we have omitted most names.

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1993;92;618

Pediatrics

C. Everett Koop