Vignettes from the history of pediatric surgery

YJPSU-59360; No of Pages 37 Journal of Pediatric Surgery xxx (xxxx) xxx

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Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg

Review Article

Vignettes from the History of Pediatric Surgery Don K. Nakayama ⁎ Division of Pediatric Surgery, Department of Surgery, University of North Carolina at Chapel Hill

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Article history: Received 25 July 2019 Accepted 19 September 2019 Available online xxxx Key words: Pediatric surgery History of pediatric surgery American Pediatric Surgical Association

a b s t r a c t A series of historical vignettes were shared with the membership of the American Pediatric Surgical Association (APSA) in the months leading up to its 50th anniversary meeting in May, 2019. Some stories were less-known episodes from the lives of such prominent figures as William Ladd and C. Everett Koop. Others highlighted were surgeons who made significant contributions but with time have been overlooked. Examples included Herbert Coe and Oswald Wyatt, the first surgeons to devote their practices entirely to infants and children; Helen Noblett, a pediatric surgeon in Melbourne who invented a now standard device perfectly suited to sample the rectal mucosa of infants suspected of having Hirschsprung Disease; and Barbara Barlow, who fed baby rats in her Manhattan apartment to show the protective effect of breast milk on the development of experimental necrotizing enterocolitis. Great achievements were commemorated, including Morio Kasai’s operation for biliary atresia, Judah Folkman’s discoveries, and Lester Martin’s quest for a suitable operation for teenagers with ulcerative colitis. The golden anniversary of the founding of APSA made it appropriate to recount some of the backstories behind the effort to establish a board of pediatric surgery with certification authority and the organization of APSA itself. A few anecdotes were whimsical: the story behind the first central venous cannula; how the specialty came to be called pediatric surgery; and why Robert Gross’ textbook was exactly 1,000 pages long and was published with one critical chapter missing. Taken together, the vignettes of the field’s surgeons, both notable and lesser-known, and their achievements show the richness of the specialty’s heritage. © 2019 Elsevier Inc. All rights reserved.

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The Founders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. William Ladd and James Stone . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Herbert Coe, the first pediatric surgeon. . . . . . . . . . . . . . . . . . . . . . . . 1.3. Oswald Wyatt, the second fulltime pediatric surgeon . . . . . . . . . . . . . . . . . 1.4. C. Everett Koop, the fifth choice to be surgeon-in-chief at CHOP. . . . . . . . . . . . . 1.5. Surgical patients belong on a surgical service . . . . . . . . . . . . . . . . . . . . . 1.6. Willis Potts and the vascular clamp . . . . . . . . . . . . . . . . . . . . . . . . . 1.7. The part-time pediatric surgeons the field needed to get its start . . . . . . . . . . . . The Early Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. How pediatric surgery got its name . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. ‘No language but a cry’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. The changing names of children’s hospitals . . . . . . . . . . . . . . . . . . . . . . 2.4. Frédet, Ramstedt, and Nicholl and their operations for pyloric stenosis . . . . . . . . . 2.5. Sir Lancelot of Paediatric Surgery and the aphorism, “a child is not a little adult” . . . . . 2.6. Charles Mixter and his contribution to surgery for esophageal atresia . . . . . . . . . . Personalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Why there isn’t a Gross-Taussig shunt for tetralogy of Fallot . . . . . . . . . . . . . . 3.2. They put the word “collaboration” in the multidisciplinary care of childhood solid tumors. 3.3. The contributions of Helen Noblett to pediatric surgery . . . . . . . . . . . . . . . . 3.4. James Densler and Samuel Rosser, pioneering black pediatric surgeons . . . . . . . . . 3.5. Alberto Pena, the Australians, and Albinoni’s Adagio . . . . . . . . . . . . . . . . . . 3.6. The F2 generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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⁎ 170 Manning Drive, C.B. 7223, Chapel Hill, NC, 27599-7223. Fax: +1 919 843 2497. E-mail address: [email protected]. https://doi.org/10.1016/j.jpedsurg.2019.09.012 0022-3468/© 2019 Elsevier Inc. All rights reserved.

Please cite this article as: D.K. Nakayama, Vignettes from the History of Pediatric Surgery, Journal of Pediatric Surgery, https://doi.org/10.1016/j. jpedsurg.2019.09.012

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3.7. Pediatric surgeons in the military . . . . . . . . . . . . . . . . . . . . . . . . . . 3.8. Koop, Clatworthy, and the Ladd-Gross rapprochement . . . . . . . . . . . . . . . . 3.9. How George Holcomb, Jr., welcomed a new surgeon into town . . . . . . . . . . . . Achievements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Judah Folkman and sustained release of drugs from silicone rubber . . . . . . . . . . 4.2. The inspired afterthought that led to correcting the uncorrectable . . . . . . . . . . . 4.3. Scientific discovery from lambs on a Pennsylvania farm to rats in a Manhattan apartment 4.4. Lester Martin and the teen who died rather than have a stoma . . . . . . . . . . . . 4.5. Dale Johnson’s central line story . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6. Pediatric surgery’s non-surgical contribution to trauma surgery . . . . . . . . . . . . The Founding of APSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Two meetings that got it started . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. Advice from a Dutch uncle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3. The exclusive inclusivity of APSA . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4. “Gentlemen, you have your boards”. . . . . . . . . . . . . . . . . . . . . . . . . 5.5. APSA’s new logo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pediatric Surgical Miscellany . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1. The lost chapter, or why Gross’s 1953 textbook was ‘only’ 1,000 pages long. . . . . . . 6.2. It seemed like a good idea: the story of inversion appendectomy . . . . . . . . . . . 6.3. “You might not be able to make a living operating only on children” . . . . . . . . . . 6.4. The stoma story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.5. Pediatric surgery’s link to San Francisco and the summer of love, 1967 . . . . . . . . . 6.6. Memo from the chief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. The Founders 1.1. William Ladd and James Stone Most pediatric surgeons with a passing interest in the history of the field know William Ladd (1880–1967) as the “Father of Pediatric Surgery.” At one time, most surgeons could trace their surgical lineage to him [1]. It is reasonable to ask, “Who was Ladd’s mentor?” A good candidate is James Stone, surgeon-in-chief at The Children’s Hospital in Boston (now Boston Children’s Hospital) when Ladd was appointed to the visiting staff in 1910 (Fig. 1). Two years previously in 1908, when Ladd had just completed his residency at Boston City Hospital, Stone published a paper on intussusception [2]. Of eight cases admitted to the facility, only one survived, a 5-year-old with obstruction for 2 days. All the rest were 2 years or younger and had symptoms of 12 hours to 1 week in duration. The tone of the article reveals that Stone

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had had enough. “The results in The Children’s Hospital and in the Infant’s Hospital (then separate institutions) are bad,” he wrote, “but they represent the results in this community.” Ernest Codman, then at the Massachusetts General Hospital and his End Result Hospital still in the future, wrote, “[Stone] has shown us that the blame does not lie wholly with the surgeons,” Codman wrote, “but with the lack of the common knowledge among practitioners in general of the important early symptoms of intussuception [3].” So when Ladd came on staff, he helped Stone take the challenge. They, and only they, would care for infants with intussuception. Their goal was to duplicate the success of Dr. Charles P. B. Clubbe of Sydney, Australia who documented in 1907 an operative mortality of 13 percent over the course of treating 124 cases from 1893 to 1906 [4]. They adopted Clubbe’s principles: “Operate early and not after exhausting the patient by attempted palliation and delay, but as soon as the diagnosis is made; keep the infant warm by wrapping the extremities and body with bandages; use a right paramedian incision and remove the intestine to expose the lesion; and reduce the intussusceptum by pushing it from below, much as one would empty a flexible rubber tube of air.” By 1913, Ladd and Stone had reduced the mortality to 45 percent, a 50 percent reduction compared with just 5 years before [5]. In 1927 Ladd took over as surgeon-in-chief from Stone. Of all his achievements in pediatric surgery, his first was the treatment of intussusception at The Children’s Hospital, a project on which he and his chief worked together. References

Fig. 1. William E. Ladd in 1918, age 38, at the time of the Halifax Explosion. Boston Globe, December 8, 1917.

1. Glick PH, Azizkhan RG. A Genealogy of North American Pediatric Surgery from Ladd until Now. St Louis, Mo., Quality Medical Publishing, 1997. 2. Stone JS. Intussusception: a review of some recent literature, with a report of cases. Boston Med Surg. J 1908;158:435-9. 3. Codman EA. Remarks on intussusception, with a suggestion for a new method of operation upon cases in which reduction is not possible. Boston Med Surg. J 1908;158:439-46. 4. Clubbe CPB. The diagnosis and treatment of intussusception. Edinburgh: Young J. Pentland, 1907. 5. Ladd WE. Progress in the diagnosis and treatment of intussusception. Boston Med Surg. J 1913;168:542-4.

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The prevailing view of the ACS leadership was that surgical specialization only fragmented and weakened the field of surgery. The surgical establishment resisted legitimizing a purported specialty whose only distinction was the age of the patients and not the afflictions nor the therapy that characterized their diseases. “The College met Dr. Coe’s entreaties with an unyielding brick wall,” wrote Judson Randolph, longtime Surgeon-in-Chief at the Washington (D.C.) Children’s Hospital (now the Children’s National Medical Center) and past president of APSA [3]. 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 [3].” In 1947 Coe was given 2 hours before the general assembly 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, the first such specialty section in the organization. The Surgical Section was thus born in Atlantic City on November 21, 1948. The photograph of the 12 surgeons who gathered at the landmark meeting is a historical icon of Pediatric Surgery (Fig. 3). Off to the side, but at its spiritual center, was the Kris Kringle-like Figure who had been responsible for its creation [2]. A winsome anecdote, recounted by Randolph, illustrated Coe’s devotion to the care of children. [A] young hospitalized patient …was asked by the evening nurse if he wanted to say his prayers. The answer was a firm, “No.” “But don’t you say your prayers at home?” “Yes, every night,” the boy said. “Then why not here?” asked the nurse. “Dr Coe looks after me here [2].” References Fig. 2. Herbert Coe.

1. Bill AH. Herbert E. Coe, 1881-1968. J Pediatr Surg. 1969;4:1-2. 1.2. Herbert Coe, the first pediatric surgeon The honor of the first surgeon to devote his entire practice to children belongs to Herbert Coe (1881–1968) of Seattle (Fig. 2), whose appearance and demeanor resembled actor Edmund Gwenn in his role as Kris Kringle in the Christmas movie, Miracle on 34th Street (George Seaton, 20th Century Fox, 1947). Coe’s enthusiasm for the surgical care of children led to the formation of the first professional organization in pediatric surgery in America, the Section on Surgery of the American Academy of Pediatrics (AAP), familiarly known as the Surgical Section. Coe arrived in Seattle when the town was not far removed from having orchards on its outskirts. After medical school at the University of Michigan and training on Pittsburgh’s North Side in its sister town of Allegheny, he caught a ship around Cape Horn in 1908 to spend the rest of his career in Seattle. His first position was at the Children’s Orthopedic Hospital, a newly opened seven-bed facility in a Seattle cottage [1]. After his military service during World War I, Coe spent several months observing Ladd in Boston in 1919. As cases at Children’s Orthopedic Hospital absorbed more of his attention, he decided to devote his entire practice to children’s surgery. This made Coe the first full-time pediatric surgeon in the U.S. since Ladd was continuing to care for both adults and children in his private practice [2]. With his only colleagues in pediatric surgery being a continent away in Boston and despite being a member of several professional societies, the gregarious Coe felt isolated in his chosen specialty. As the field started to grow, he sought a place for pediatric surgery within the organizational framework of the American College of Surgeons (ACS), as the ACS had accommodated ophthalmology, otorhinolaryngology, orthopaedics, urology, and plastic surgery. During the late 1930s and the war years Coe made a number of formal requests to the ACS leadership and busily lobbied his friends and contacts in its hierarchy, thereby acquiring the deserved nickname, “The Politician.”

2. Randolph J. First of the best. J Pediatr Surg. 1985;20:580-91. 3. Randolph JG. History of the Section on Surgery, the American Academy of Pediatrics: the first 25 years (1948-1973). J Pediatr Surg. 1999;34(5 Suppl 1):3-18. 1.3. Oswald Wyatt, the second fulltime pediatric surgeon Oswald Wyatt (1896–1957) has the distinction of being the second surgeon to devote his entire practice to pediatric surgery. To use a phrase made popular by televised poker tournaments, he went “all in” for a practice devoted to pediatric surgery in 1928. And like all poker players, he almost went bust when the financial world crashed on Black Friday 1929. “[Wyatt] nearly starved to death!” wrote H. William Clatworthy, a leading figure in the history of pediatric surgery and longtime chief at the Children’s Hospital of Columbus [1]. Wyatt, a graduate of the University of Minnesota both as an undergrad and medical student, had just started a practice in general surgery in Minneapolis in 1920 after training as the first resident in surgery at the Hennepin County General Hospital and service in World War I. Despite his lack of formal training in children’s surgery Wyatt knew enough from his practice that, according to Clatworthy, “he became thoroughly dissatisfied with the quality of care rendered to infants and children in that city [1].” He thus became an ideal target for Herbert Coe, the first surgeon to have devoted himself to the fulltime practice of children’s surgery and always on the lookout for others who might be convinced to do the same [2]. Wyatt took the leap. In 1927 he closed his office and went to Washington University in St Louis and Children’s Memorial Hospital in Chicago for additional training in clinical pediatrics and children’s surgery [2]. When he returned in 1928, he restricted his practice to children, just the year before the Crash of 1929. Yet another challenge came when he was refused privileges at the university medical center by Owen Wangensteen, legendary Chair of Surgery at the University

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Fig. 3. First meeting, Section on Surgery, American Academy of Pediatrics, Atlantic City, November 21, 1948. Standing left to right: Henry Swan, Robert Bowman, Willis Potts, Jesus LozoyaSolis, C. Everett Koop, Professor Fontana of Uruguay (guest); Seated: William Ladd, Herbert Coe, Franc Ingraham, Oswald Wyatt, Thomas Lanman, Clifford Sweet (representing the AAP). National Library of Medicine.

Fig. 4. Oswald Wyatt (right) with associates Bernie Spencer (left) and Tague Chisholm. Photo courtesy of David Schmeling, Minneapolis, MN.

Please cite this article as: D.K. Nakayama, Vignettes from the History of Pediatric Surgery, Journal of Pediatric Surgery, https://doi.org/10.1016/j. jpedsurg.2019.09.012

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of Minnesota. Wangensteen’s view was that a surgeon trained at the University of Minnesota residency had the surgical expertise to practice on patients of all ages, including infants and children [3]. In a theme that would repeat in dozens of pediatric surgical practices, Wyatt’s private practice became a success because pediatricians, both in community offices and academic departments, sent their patients to him. They preferred his specialized training and his fulltime focus on children’s surgery over the general surgeons at the university hospital. With Tague Chisholm (Fig. 4), a Boston-trained pediatric surgeon who joined him in 1946, Wyatt’s practice grew to become the largest private practice in pediatric surgery the U.S., with extensive experience with such varied and complex conditions as exstrophy of the bladder and myelomeningocele [3]. References 1. Clatworthy HW Jr. Ladd’s vision. J Pediatr Surg. 1999;34(5 Suppl 1):32-7. 2. Randolph J. First of the best. J Pediatr Surg. 1985;20:580-91. 3. Randolph JG. History of the Section on Surgery, the American Academy of Pediatrics: the first 25 years (1948-1973). J Pediatr Surg. 1999;34(5 Suppl 1):3-18. 1.4. C. Everett Koop, the fifth choice to be surgeon-in-chief at CHOP Just 30 years old in 1946, C. Everett Koop (1916–2013) (Fig. 5) was near the end of his senior resident year at the Hospital of the University of Pennsylvania (HUP) when he had to be an inpatient there himself. He was in bed with pharyngitis with an intravenous needle in his arm when Isidor Ravdin, chair of surgery at Penn, burst into his room at 5 a.m. and appointed him surgeon-in-chief at the Children’s Hospital of Philadelphia (CHOP) [1].

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Koop had only a few short months of pediatric surgery experience during his residency and yet knew “that children did not get a fair shake in surgery [1].” He remembered that after a presentation Ladd made before the Boston Surgical Society, a respected Boston surgeon commented, “Anyone who can operate on a bunny rabbit can be a child surgeon [2].” Surgery at CHOP was performed by four surgeons who otherwise operated elsewhere on adult patients. With his characteristic candor Koop said, “[They] had not done it particularly well and certainly had no abiding interest [1].” Anesthesia was so unreliable that the fulltime staff at the University of Pennsylvania hated to come to CHOP, then located in South Philadelphia a few miles away from HUP on the Penn campus. The incident that brought Ravdin to Koop’s bedside was an infant with intussusception who died waiting for the arrival of a surgeon. Frances Clyde, who had worked with Ladd and Gross in Boston and was now the head nurse at CHOP, was furious. Koop described what happened next in an oral history interview with Moritz Ziegler: [She] went to the physician-in-chief of the children’s hospital, … Joseph Stokes, Jr., … and she said, “This is an absolute tragedy, and it’s a travesty that it would happen in a major children’s hospital and in a major university[.]… I give you, Dr. Stokes, and the University of Pennsylvania, one year to rectify this situation, and unless you are on the way to building a surgical service with the safety that Dr. Ladd and Dr. Gross have in Boston, my staff and I will quit. And when I say, ‘my staff,’ I mean every nurse on that staff [2].” His back against the wall, Ravdin asked each of the four surgeons on the visiting staff to take the fulltime position as chief of surgery at CHOP. Each of them declined the offer, which brought the chief to Koop’s hospital room with the offer he couldn’t refuse [2]. References 1. Koop CE. A perspective on the early days of Pediatric Surgery. J Pediatr Surg. 1999;34(5 Suppl 1):38-45. 2. C. Everett Koop, MD, ScD. Interviewed by Moritz Zeigler, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, May 8, 2006. Available from: https://www.aap.org/en-us/about-the-aap/Pediatric-HistoryCenter/Documents/Koop.pdf. Accessed September 13, 2017. 1.5. Surgical patients belong on a surgical service

Fig. 5. C. Everett Koop. National Library of Medicine.

The assignment of patients to a medical or surgical service, a toofamiliar controversy at many hospitals today, was an issue from pediatric surgery’s earliest days. In an era when most children were treated in the home, pediatricians supervised care when inpatient care was required, including surgery. They did the workups, made the diagnosis, and spoke with the family. When a child needed an operation, the pediatrician might sometimes assist at surgery or provide anesthesia. The surgeons at The Children’s Hospital visiting staff in Boston were all part-time and served only as consultants and technicians, including William Ladd, who kept his adult practice in a separate office downtown. But when he was named surgeon-in-chief in 1927 he began to reorganize the surgical services. When he was named onto the fulltime staff ten years later, he required that a patient was on an inpatient surgical service before and after their operation. With surgeons in control of the patient, a comprehensive approach of care could develop, especially in complex cases and surgical conditions of the newborn [1]. CHOP also had a part-time surgical staff. With his characteristic candor C. Everett Koop said, “Children did not get a fair shake in surgery. … [Surgeons there] had not done it particularly well and certainly had no abiding interest [2].” Pediatricians, protective then as now of their patients, were extremely cautious in recommending an operation. Each

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had a restricted range of ages where they felt an operation would be safe and a very short roster of surgeons and anesthetists permitted to perform operations on their patients. When Koop was about to begin work as surgeon-in-chief at CHOP in 1947, Joseph Stokes, professor of pediatrics at Penn, made sure that the young surgeon knew how things were run at his hospital. “All patients that come to this hospital are admitted on my service,” the pediatrician said. “When I think they’re ready for operation, I will call you and take over the care of the patient immediately after it comes from the operating room [1].” Koop stood firm. “That’s the way it was up until today, Dr Stokes,” he said. “That’s what I’m here for. I am going to run a surgical service, and I will be responsible for the patients, for their diagnosis, … treatment, … postoperative care, … and for their follow-up [3].” “We’ll see about that,” said Stokes, who reached for his phone to call Isidore Ravdin, chair of surgery at Penn. Ravdin had personally chosen Koop for the position at CHOP and had given his former chief resident his full support. Koop could tell from the pediatrician’s silence and the muffled but audibly raised tone of Ravdin’s voice from the receiver that it was Stokes who was being lectured. It took some time for Koop and Stokes’s relationship to smooth [3]. As early as 1948, his second year as chief, Koop saw progress. Anesthesia was safer, postoperative care was improving, and mortality was decreasing. With his devotion to his patients, mastery and improvement of the operations, and attention to the details of pre- and postoperative care, Koop proved the value of a specialist in the care of infants and children. His patients survived with conditions that previously had been fatal. The attending staff at CHOP soon recognized his talent. “Pediatricians…[came] to me, the surgeon, to help them out of their tighter spots,” he said [2]. Koop thus proved his worth by demonstrating he could take superlative care of infants and children on a surgical service, an ethic worth remembering whenever there’s a debate as to which service a patient belongs. Koop’s insistence on caring for his own patients reminded Charles Stolar, former surgeon-in-chief at Babies Hospital in Manhattan (today the Morgan Stanley Children’s Hospital of New York) of something Judson Randolph said to his fellows at the Children’s National Medical Center in Washington, D.C. “Children are transferred to the surgical service,” Randolph said, “not from the surgical service.” References 1. Clatworthy HW Jr. Ladd’s vision. J Pediatr Surg. 1999;34(5 Suppl 1):32-7. 2. Koop CE. A perspective on the early days of Pediatric Surgery. J Pediatr Surg. 1999;34(5 Suppl 1):38-45 3. C. Everett Koop, MD, ScD. Interviewed by Moritz Ziegler, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, May 8, 2006. Available from: https://www.aap.org/en-us/about-the-aap/Gartner-PediatricHistory-Center/DocLib/Koop.pdf. Accessed January 21, 2019. 1.6. Willis Potts and the vascular clamp Willis Potts (Fig. 6) invented the vascular clamp, a locking forcep that occluded large blood vessels without slipping or crushing the vessel wall [1]. The specifications were of particular importance in the original cardiovascular operation, the ligation of a patent ductus arteriosus (PDA), first performed by Robert Gross in 1938. The short length of a PDA, often broader than it is long, gives precious little space for it to be doubly clamped, divided, and oversewn. Gross employed standard surgical clamps with the jaws filed smooth and parallel when engaged. To prevent excessive pressure, he secured the handles with rubber bands instead of ratchets. Blalock used small bulldog clamps (invented by Alexis Carrel in 1906) with rubber tubing fitted over the jaws and Vivian Thomas’s special vertically-oriented

Fig. 6. Willis Potts. National Library Medicine.

clamp designed specifically for the pulmonary artery. Such jury-rigged modifications reflected the unique technical problems in operations on large blood vessels. Clearly surgeons needed clamps specially designed for vascular surgery [1]. Potts, a Sheboygan, WI, native, settled in Chicago after service in WWI for medical school and surgical training, and started a practice in general surgery in the city. When America entered WWII, he enlisted as a colonel and was assigned command of the 25th Evacuation Hospital in the Pacific Theater for the duration of the conflict. In his off-hours, he read Ladd and Gross’s textbook, Abdominal Surgery of Infancy and Childhood, just published in 1941. In the words of his associate at the Children’s Memorial Hospital in Chicago, Thomas Baffes, “He returned to devote his full time to pediatric surgery [2].” At war’s end, he went to The Children’s Hospital in Boston to spend 3 months observing Gross and its surgical staff, then returned to Chicago as surgeon-inchief at Memorial Hospital. (He was 50 when he did his fellowship, demonstrating that age need not be a barrier to ambition.) In Boston, he soon became familiar with the technical problem of vascular control, especially when dealing with the delicate PDA. Potts happened to see a device used by a colleague in plastic surgery that used an array of pins to keep a skin graft stretched to its full width without damaging the edges. He saw that the same principle could be used to the occluding surfaces of a vascular clamp: Fine serrations on each jaw to hold the vessel without crushing it. Potts’ neighbor in the Chicago suburb of Oak Park was Bruno Richter, a craftsman whose small shop specialized in the manufacture of surgical instruments. The surgeon described to Richter how he saw the problem and its solution. The hub of the clamp had to be constructed so that the jaws did not completely close, another precaution to prevent injudicious pressure on the vessel wall. Thus it allowed suture closure of openings too large for simple ligature and anastomosis without undue damage to either vessel. Angles and curves along the length of the jaws and handles accommodated deep exposures and contours of the

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field. From then the Potts vascular clamp, which he described in 1948, has been standard in all open vascular and cardiac operations [1]. While most surgeons familiar with the history of surgery recognize the operations of Robert Gross (first closure of a PDA in 1938) and Alfred Blalock (Blalock-Taussig shunt for tetralogy of Fallot in 1944) as landmark events, in the words of Martin Dalton and Will Sealy, cardiac surgeons and historians, “cardiac and vascular surgery could not have progressed without the atraumatic clamp designed and introduced by Willis Potts [1].” References 1. Dalton ML, Connally SR, Sealy WC. The original vascular clamp. Ann Vasc Surg. 1993;7:391-3. 2. Baffes TG. Willis J. Potts: His contributions to cardiovascular surgery. Ann Thorac Surg. 1987;44:92-6. 1.7. The part-time pediatric surgeons the field needed to get its start No matter how devoted he was to pediatric surgery, even William Ladd needed paying adult patients to make ends meet. He maintained a private office in downtown Boston until 1937 when the Children’s Hospital named him to its fulltime staff – and he took a financial loss in accepting the position. In the first generation of pediatric surgeons, there were many who maintained adult practices while making significant advancements in children’s surgery. Mark Ravitch (1910–1989; Fig. 7) was one of the foremost surgeons of his generation. He devised the mucosal proctectomy, colectomy, and ileoanal anastomosis operation in dogs in 1947 [1] that was later adapted in humans in 1952 by Asa Yancey for Hirschprung Disease (HD) in an adult [2]; Franco Soave in infants in 1964 [3]; and in 1977 for ulcerative colitis by Lester Martin (past president of APSA) [4]. Ravitch also standardized a safe approach to radiological reduction of intussusception using barium enema (1948) [5] and devised the standard operation for open correction of pectus excavatum (1949) [6]. As if all this were not enough, he introduced modern stapling devices to America after a 1958 U.S. State Department visit to Russia [7]. He was

Fig. 7. Mark Ravitch. National Library of Medicine.

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a leader in surgery on a national level, highly involved in professional organizations at the highest levels, including a term as chair of the Surgical Section (1967–1968). Serving as surgeon-in-chief of the Detroit Children’s Hospital from 1920–1950, Grover Penberthy (1886–1959; Fig. 8) made fundamental contributions to the treatment of osteomyelitis and empyema, and an early effort to define the role of splenectomy in hematological disease in children [8]. His protégé was Clifford Benson (1902–1995; Fig. 9), who also had a storied career as a pediatric surgeon while maintaining a busy adult practice. Known today for his eponymous pylorus spreader, he initiated one of the twelve training programs in pediatric surgery that were first approved in 1970 by the AAP Surgical Section. Benson also was one of the original editors of the multi-authored text, Pediatric Surgery, that became the standard text in the field. William Snyder, Jr. (1904–1974; Fig. 10), did general surgery across the street at the Hollywood Presbyterian Hospital to make a living while devoting much of his time at the Children’s Hospital of Los Angeles. Eventually, Snyder dropped his adult practice completely when he was named fulltime chief of surgery in 1964. Like Benson, he started one of the original training programs and was one of the editors of the two-volume text. Ravitch, Penberthy, Benson, and Snyder contributed significantly to the field, proof that there is much more to the history of pediatric surgery beyond Ladd, Gross, and Boston. References 1. Ravitch MM, Sabiston DC Jr. Anal ileostomy with preservation of the sphincter: a proposed operation in patients requiring total colectomy for benign lesions. Surg Gynecol Obstet. 1947;84:1095-9. 2. Yancey AG, Cromartie JE Jr, Ford JR, et al. A modification of the Swenson technique for congenital megacolon. J Natl Med Assoc. 1952;44:356-63.

Fig. 8. Grover Penberthy.

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Fig. 9. Clifford Benson.

3. Soave F. Hirschsprung’s disease: a new surgical technique. Arch Dis Childh. 1964;39:116-24. 4. Martin LW, LeCoultre C, Schubert WK. Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg. 1977;186:477-9. 5. Ravitch MM, McCune RM Jr. Reduction of intussusception by barium enema: a clinical and experimental study. Ann Surg. 1948;128:904-17. 6. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg. 1949;129:429-44. 7. Ravitch MM, Brown IW, Daviglus GF. Experimental and clinical use of the Soviet bronchus stapling instrument. Surgery. 1959;46:97-108. 8. Penberthy GC, Cooley TB. Results of splenectomy in childhood. Ann Surg. 1935;102:645-55. 2. The Early Years 2.1. How pediatric surgery got its name Names have determined destiny since Abram became Abraham in the Old Testament, and “pediatric surgery” was no different. In that context, it’s appropriate that C. Everett Koop established “pediatric surgery” as the specialty that “pediatric surgeons” practice, and the name of the American Pediatric Surgical Association (APSA). Clues of the derivation of the term, “pediatric surgery,” came from the early textbooks of the discipline, before specialization and surgeons were simply, “surgeons.” The title of the first textbook of the field was The Surgical Diseases of Children, published in 1860 by J. Cooper Forster of London [1]. Edmund Owen, surgeon to Great Ormond Street, adopted the same title for his textbook that was published a quarter century later in 1885 [2]. In the first half of the 20th century, the more widely used term was “children’s surgery,” a phrase used in 1869 by Timothy Holmes, who succeeded Henry Gray as editor of Gray’s Anatomy (the anatomy reference, not the popular television show) [3]. In 1895, Sir D’Arcy Power

Fig. 10. William Snyder, Jr.

called its practitioners “children’s surgeons,” a sign that a separate class of practitioners devoted to children’s care was beginning to emerge [4]. With an endowment of $6,000, in 1941 William Ladd was named to his eponymous chair of children’s surgery at Harvard [5]. In his organizational correspondence with the AAP to set up the Surgical Section, Herbert Coe used the term “children’s surgery” [6]. “Pediatric Surgery” first appeared on the title page of the first American textbook on the subject by Samuel Kelley of Cleveland in 1909, when he used the phrase as a subhead to the main title of his book, yet another Surgical Diseases of Children [7]. In 1910, the first academic chair of orthopaedic surgery in the United States (U.S.), DeForest Willard of the University of Pennsylvania, used the term “paediatric surgeon,” the British spelling a manner of habit for American orthopaedists, who pay homage to the British roots of the discipline. His bias is reflected by the content of his textbook, where he devotes nearly three-fourths of its pages to orthopedic topics [8]. Alex Haller, longtime professor at Johns Hopkins Hospital, remembered Alfred Blalock objecting to the term “pediatric surgery” because it made it seem it was an arm of pediatrics, and not a division of surgery. When a facility devoted to pediatrics at Hopkins was constructed during his tenure, Blalock made sure that it was named the Children’s Medical and Surgical Center [9]. The words acquired political significance when Koop tried to win approval for board certification under the aegis of the Advisory Board for Medical Specialties (ABMS) and the American Board of Surgery (ABS) in 1956. In his words, “unbelievably vehement opposition” came swift and hard from the Boards of Urology and Orthopaedics. Among their objections was the term, “pediatric surgery,” which they saw as misleading. They wanted “pediatric general surgery,” a more restrictive title that made a clear boundary between the disciplines. Even though the application was dismissed, Koop, and later Mark Ravitch, used the “pediatric surgery” in two more unsuccessful attempts in 1961 and 1967. As the field matured with the establishment of the Journal of Pediatric Surgery (1966), and the formation of the APSA (1970), the ABMS

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formalized the Certification of Special Competence in Pediatric Surgery by the American Board of Surgery (1973) [10]. Which brings us back to Koop. Koop, in leading the original two failed attempts at Board recognition, chose the term “pediatric surgery” for the field that he represented. He resisted changing it to “pediatric general surgery” when it might have been a politically expedient ploy to placate opponents in other specialties. When the field got final approval from the ABMS and the ABS for board certification status, “pediatric surgery” has been on every diploma ever since. And finally, he became the inaugural editor-in-chief of the Journal of Pediatric Surgery, the publication that he and its founder, Stephen Gans, no doubt had a role in naming. So yes, we have Koop to thank for naming our field. The present author has noted that the term “pediatric general surgery” and “pediatric general and thoracic surgery” appear here and there in academic practices in the U.S. Call it old-fashioned, but it’s “pediatric surgery,” period. It was the name that our proudest forebears used to get recognition for the discipline. Guard it and preserve it. It means something. References 1. Forster JC. The surgical diseases of children. London: John W. Parker and Son, 1860. 2. Owen E. The surgical diseases of children. Philadelphia: Lea Brothers, 1885. 3. Holmes T. The surgical treatment of the diseases of infancy and childhood. Philadelphia: Lindsay and Blakiston, 1869, p. vii. 4. Power D’A. The surgical diseases of children and their treatment by modern methods. Phladelphia: P. Blakiston, Son, and Co., 1898, p. 1. 5. Clatworthy HW Jr. Ladd’s vision. J Pediatr Surg. 1999;34(5 Suppl 1):32-7. 6. Randolph JG. History of the Section on Surgery, the American Academy of Pediatrics: the first 25 years (1948-1973). J Pediatr Surg. 1999;34(5 Suppl 1):3-16. 7. Kelley SW. Surgical diseases of children: a modern treatise on pediatric surgery. New York: E.B. Treat, 1909. 8. Willard DP. The surgery of childhood including orthopaedic surgery. Philadelphia, J.B. Lippincott, 1910, p. 10. 9. J. Alex Haller, Jr., MD. Interviewed by Kurt Newman, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, April 3, 2008. Available from: https://www.aap.org/en-us/about-the-aap/Gartner-PediatricHistory-Center/DocLib/Haller.pdf. Accessed January 20, 2019. 10. Koop CE. A perspective on the early days of Pediatric Surgery. J Pediatr Surg. 1999;34(5 Suppl 1):38-45. 2.2. ‘No language but a cry’ Most textbooks of pediatric surgery include a paragraph or two on how to approach children with a surgical illness or condition. While it would seem that anyone associated with pediatric care would approach a sick child with gentleness, each author has a unique view that reflects how the profession viewed pediatric patients during that time and something of his own personality. The first textbooks of children’s surgery in the mid-1800s emphasized the need for a kindly nurse to attend to the fear and concerns of a sick child. In 1869, Timothy Holmes wrote, “Little children require the constant attendance of a gentle patient nurse for the first few days after any severe operation [1].” In the first textbook on pediatric surgery in the English language published in 1860, J. Cooper Forster gave his opinion as to the qualifications of such a caregiver. “A nurse to be fit to undertake the management of children,” he wrote, “must almost be born a nurse, so much seems to depend upon an instinctive tact and insight into their little ways [2].” Neither made a specific reference to how the surgeon should approach a sick child. Paul Louis Benoit Guersant, surgeon to the L’Hôpital

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des Enfants-Malades in Paris in the mid-19th century, did not think it necessary to prepare a child for surgery: Those … who are old enough to listen to reason should be brought to the operation by explanation of its necessity, and be made to understand, that if they suffer pain, it is with the view of curing them. But the majority of children should be operated on by surprise. In every case it is indispensable that the surgeon should be surrounded with assistants capable of exerting a firm hold on the patient, and of displaying a force proportioned to that of the child [3]. Short of holding a child down by force, after the turn of the century authors began to consider how best to approach a child who needed an operation. Charles West, the founder of Hospital for Sick Children on Great Ormond Street, noted infants yet unable to speak still had a language of signs that they revealed only to those whom they regarded as friends [4]. Edmund Owens, in his 1885 text on the surgical diseases of children, recommended that the surgeon should earn the child’s trust before performing a physical examination [5]. In 1909 Samuel Kelley wrote on the qualities of the child surgeon. [He] should possess in eminent degree, sympathy, tact, patience, firmness, and gentleness in dealing with his little patients. His observing and reasoning powers should be of the keenest, for often all depends upon the objective signs and symptoms, the patient lending no aid [6]. De Forest Willard in 1910 wrote, “The surgeon must have … an innate love of children that will at once inspire confidence and dispel fear [7].” William Ladd and Robert Gross in their landmark 1941 textbook on abdominal surgery in childhood did not address the topic of how a surgeon should approach a pediatric patient [8]. Gross, in his 1953 update, wrote on the necessity of speaking directly with the child, but with euphemisms like “fix up,” or “make well.” He avoided direct terms like “[anesthetic] gas,” and “operation,” thinking them too harsh for young sensibilities. He was effusive in his praise of an unnamed resident who cared deeply for his patients. “Fortunate is the staff which is able to attract individuals of such character,” he wrote [9]. One surgeon recently speculated that Gross was referring to H. William Scott, who spent 3 years as Gross’ resident before devoting himself to general surgery as chair of the department of surgery and surgeon-in-chief at Vanderbilt University Medical Center. Willis Potts had a particularly poetic style of writing, which equally reflected his kindly personality. What he wrote in his 1960 text became part of the lore of pediatric surgery. Sometimes it seems that the infant and child have been forgotten – not by the physician or pediatrician, but by the surgeon…The infant ‘with no language but a cry’…the child, with no words to express the desire to be well and normal, asks that we make available to them the benefits of increased knowledge of their surgical diseases [10]. Thus one of the icons of field wrote one of the iconic epigrams of pediatric surgery. “No language but a cry” is a reminder that the patient has a means of human communication that expresses both distress and a plea for help. It is up to the surgeon to interpret it and provide appropriate remedy. References 1. Holmes T. The surgical treatment of the diseases of infancy and childhood. Philadelphia: Lindsay and Blakiston, 1869, p. vii. 2. Forster JC. The surgical diseases of children. London: John W. Parker and Son, 1860. 3. Guersant MP. Surgical diseases of infants and children. Trans. R Dunglison. Philadelphia: Henry C. Lea, 1873).

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4. West C. Lectures on the diseases of infancy and childhood. 3rd Ed. London: Longman, Green, Longman, Roberts and Green, 1854. 5. Owen E. The surgical diseases of children. Philadelphia: Lea Brothers, 1885. 6. Kelley SW. Surgical diseases of children: a modern treatise on pediatric surgery. New York: E.B. Treat, 1909. 7. Willard DP. The surgery of childhood including orthopaedic surgery. Philadelphia: J.B. Lippincott, 1910, p. 10. 8. Ladd WE, Gross RE. Abdominal surgery of infancy and childhood. Philadelphia: W.B. Saunders, 1941. 9. Gross RE. The surgery of infancy and childhood. Philadelphia: W.B. Saunders, 1953. 10. Potts WJ. The surgeon and the child. Philadelphia: W.B. Saunders, 1959. 2.3. The changing names of children’s hospitals Today, it’s the “Boston Children’s Hospital,” but that’s actually the seventh iteration of the institution that started in a house on Rutland Street in the South End of Boston, and once kept cows at its later Longwood Avenue location so that its patients could get milk free of tuberculosis (Fig. 11). From Ladd to Folkman, Boston’s presence in the history of pediatric history is so pervasive that a timeline is needed to get the name of the facility correct. Other hospitals have made name changes for various reasons. The Children’s Orthopedic Hospital adopted the naming format used in Boston and renamed itself the Seattle Children’s Hospital. The D.C. Children’s Hospital broadened its identity to the entire country when it became the Children’s National Medical Center, appropriate to its location in the nation’s capital. Upon receiving a sizable donation from an insurance company, the Children’s Hospital of Columbus leveraged a fortunate coincidence to broaden its identity from a medium-sized city in the Midwest into the Nationwide Children’s Hospital. Alina Morris, archivist with the Boston Children’s Hospital, provided a timeline for the evolving identity of the hospital based on its publications (Table 1). Not much of a difference to an outsider, for sure, but facts have to be right. Appropriate to “The Hub” that has “The Country Club,” “The Commons,” “The Garden,” and where time stops for “The Game,” it started as “The Children’s Hospital.” Mostly it has been “Children’s Hospital” in various iterations, with “Boston” thrown in once

Table 1 The names of the Boston Children’s Hospital since 1869. Dates

Name

1869–1912 1913–1951 1952–1983 1984–1996 1997–1999 2000–2012 2012–present

The Children’s Hospital The Children’s Hospital (Boston) Children’s Hospital Medical Center Children’s Hospital Children’s Hospital, Boston Children’s Hospital Boston Boston Children’s Hospital

someone realized that there was an entire country outside Route 128 that had no idea to which of the many fine children’s hospitals (lower case “c,” lower case “h”) the name referred. There was also an Infants’ Hospital. It started as the West End Nursery in 1881 and went through its own series of name changes before settling on Infants’ Hospital in 1907. It leased a cottage ward from The Children’s Hospital (Boston) in 1923, then was located in the Farley building of the Children’s Hospital Medical Center (see how confusing it gets?) from 1956 to 1961. In a transaction that foretold today’s multibillion dollar hospital mergers, in 1961 the Infants’ merged with the Children’s and ceased to exist as a separate entity as the small fish got swallowed whole by the much bigger one. Something is lost when venerated names of children’s hospitals disappeared: Babies Hospital in New York became the Morgan Stanley Children’s Hospital; the Children’s Memorial Hospital is now the Ann & Robert H. Lurie Children’s Hospital of Chicago. The old names were identified with revered pediatric surgeons. Whatever the hospitals call themselves today, we remember them as the homes of Sandy Bill, Jud Randolph, Bill Clatworthy, Tom Santulli, and Willis Potts, and as the places where Kathy Anderson, Peter Altman, Rick Fonkalsrud, Jim O’Neill, and John Raffensperger got their start. 2.4. Frédet, Ramstedt, and Nicholl and their operations for pyloric stenosis The names most associated with operative correction of pyloric stenosis are Pierre Frédet (1870–1946) of Paris and Conrad Ramstedt (1867–1963) of Münster. Both are recognized for their insight that incision of the pyloric muscle, without entry into the lumen of the channel,

Fig. 11. Cows pastured across Longwood Avenue from the main Children’s Hospital building, 1914. Boston Children’s Hospital archives, Alina Morris, archivist.

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Fig. 12. Emaciated and dehydrated infant with visible peristalsis from pyloric stenosis. Photos from Nicholl’s personal collection, published by Rankin W. Lessons on the Surgical Diseases of Childhood. Glasgow: Alex MacDougal, 1934.

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was sufficient to relieve gastric outlet obstruction. Forgotten is James Nicholl of Glasgow (1864–1921) who also devised an extramucosal operation for pyloric stenosis before either of the surgeons on the continent. Even though infantile pyloric stenosis has a unique pathology, the first operations were devised for adult conditions: gastroenterostomy (used for obstructing gastric cancers) and the classic Heineke-Mikulicz pyloroplasty (acid-peptic strictures). Nearly all infants with pyloric stenosis died, either from dehydration and malnutrition (Fig. 12) [1], or infection when the surgeon entered the obstructed stomach and allowed the contents to spill into the peritoneal cavity. With the hypertrophic pylorus too thick for easy transverse closure once it had undergone a longitudinal incision, most surgeons opted for gastroenterostomy. Nicholl was the first to stay in the extramucosal plane with his version, a Y-V pyloroplasty described in 1906 [2]. He combined it with a gastrostomy that allowed the passage of a Hegar dilator (or his finger) to forcibly widen the channel (Fig. 13) [3]. One year later, in October 1907, Frédet performed his extramucosal pyloromyotomy, but closed the muscularis in a classic Heineke-Mikulicz transverse closure. In a 2009 article in the Journal of Pediatric Surgery, John Raffensperger wrote that Frédet was likely unable to complete the transverse closure so he added a gastrojejunostomy in 9 of the 11 cases of pyloromyotomy in his report [3]. Which brings us to Ramstedt. Anthony Shaw, in a 2012 article that also appeared in the Journal of Pediatric Surgery, gave a complete account of how Ramstedt discovered that all that was needed was a simple longitudinal incision of the pylorus down to the submucosa, the operation used today. Unaware of Frédet’s accomplishment, Ramstedt knew that Wilhelm Weber of Dresden reported in 1910 two cases in which he performed a submucosal pyloroplasty with transverse closure, the identical procedure as Frédet’s. Ramstedt planned to do Weber’s operation when he saw his first case of pyloric stenosis, a nobleman’s son, in August 1911. He did the longitudinal extramucosal

Fig. 13. Figure from Nicholl’s article in the Glasgow Medical Journal, 1906.

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myotomy as described, but predictably could not close it in the transverse direction. But Ramstedt saw that the pylorus gaped open and recognized that its lumen was wide enough to allow the stomach to empty. He did what any surgeon unsure of the integrity of the stomach and duodenum would do in that situation – he placed some omentum over the incision – and the baby did fine. After he did a second case several months later in June 1912 (this time a physician’s son, quite the carriage trade), he reported his accomplishment to the National Science Assembly in Münster that September [4]. Geopolitics and national chauvinism came into play when surgeons began to refer to the operation by an eponym because the operations were devised just before World War I. The operation was ascribed to Frédet in France, where he was a national hero for his many contributions to medicine, including the Legion of Honor for his work treating the injured on the Western Front. German surgeons naturally championed Ramstedt. Despite being on opposite sides during the conflict, American surgery saw Germany as being the leader for surgical advances, so Ramstedt’s name was favored. Frédet received his due on this side of the Atlantic in 1919 when Langley Porter and Lawson Tait acknowledged his contributions at a meeting of the American Medical Association [3]. In his article, Shaw noted that world politics aside, Willis Potts, an American who was in the medical corps of both World War I and II, succinctly described its success: “The most satisfactory procedure in the field of pediatric surgery [5].” As a postscript, Frédet was surgeon to the Hôpital de la Charité and the Hôpital universitaire Pitié-Salpêtrière in Paris, where he taught surgery. Those who know Raffensperger can easily imagine his delight when he found the following quote, attributed to Frédet. “There are two categories of interns,” he wrote, “the pests and the useless. Try to be only useless help [3].” References 1. Rankin W. Lessons on the Surgical Diseases of Childhood. Glasgow: Alex MacDougal, 1934. 2. Nicholl JH. Several patients from a further series of cases of congenital obstruction of the pylorus treated by operation. Glasgow Med J. 1906;65:253-7. 3. Raffensperger J. Pierre Fredet and pyloromyotomy. J Pediatr Surg. 2009;44:1842-5. 4. Shaw A. Historical vignette. Ramstedt and the centennial of pyloromyotomy. J Pediatr Surg. 2012;47:1433-5. 5. Potts W. The surgeon and the child. Philadelphia: WB Saunders, 1959, p. 153. 2.5. Sir Lancelot of Paediatric Surgery and the aphorism, “a child is not a little adult” Most students and residents new to pediatric surgery hear the central aphorism of the field, “a child is not a little adult,” on the first day on service, and certainly by the second. It comes from an English surgeon with one of the most colorful names in the field, Sir Lancelot Barrington-Ward (1884–1953), who with his colleague and equally wonderfully named Thomas Twistington Higgins (1887–1966), was on the staff at the Hospital for Sick Children at Great Ormond Street in London. While they maintained mainly adult practices, they were devoted to the institution. In 1928 they were joined by Sir Denis Browne of Australia (1892–1967), who was the first surgeon in the world to devote his entire practice to children’s surgery. Together they were the foremost pediatric – er, paediatric – surgeons in England for most of the first half of the 20th century. Higgins (Fig. 14) was a junior surgeon to Great Ormond Street in 1912 and was named to its staff in 1919. He was senior surgeon in 1944 until his retirement in 1952. He gave up his commitments to adult patients in 1930. Devoted to paediatric urology, his work led to the establishment of a separate department of urology at the hospital.

Fig. 14. Thomas Twistington Higgins.

Higgins, David Williams (who is today credited with founding the specialty of paediatric urology) and Denis Ellison Nash wrote one of the seminal texts in urology, The Urology of Childhood, in 1951 [1]. Barrington-Ward (Fig. 15) was appointed assistant surgeon to Great Ormond Street in 1914. Oxford and Edinburgh University educated, he was also a champion rugby player on the England national team in four international competitions. In addition to his responsibilities to Great Ormond Street, he was senior surgeon to the Royal Northern Hospital. In 1918, he performed an appendectomy on H.R.H. Prince Albert, later Duke of York and George VI. The operation started his life-long service to the House of Windsor, including the sister of George V, the Queen of Norway, and as extra surgeon to Her Majesty Elizabeth II on her accession in 1952 [2]. In his obituary, Barrington-Ward was described as “an ideal children’s surgeon [2].” In 1928, he wrote one of the first books on modern paediatric surgery, Abdominal Surgery of Children [3], which predated Ladd and Gross’s landmark text of 1941. In its preface, BarringtonWard made the famous quote, “The adult may be safely treated as a child, but the converse can lead to disaster.” William Ladd repeated the quote in the forward to Orvar Swenson’s 1958 textbook, Pediatric Surgery [4]. In its various iterations, we remember it today as, “a child is not a little adult,” one of the basic principles of the field. References 1. [No author, signed G.H.M.] In memoriam: T. Twistington Higgins, O.B.E., F.R.C.S. (1887-1966). Ann R Coll Surg. Engl 1966;39:260-2. 2. Royal College of Surgeons. Plarr’s Lives of the Fellows. Barrington-Ward, Sir Lancelot Edward (184-1953). Available at: https://livesonline. rcseng.ac.uk/client/en_GB/lives/search/detailnonmodal/ent:$002f $002fSD_ASSET$002f0$002f339398/one?qu=%22rcs%3A+E004885% 22&rt=false%7C%7C%7CIDENTIFIER%7C%7C%7CResource+Identifier. Accessed January 7, 2018. 3. Barrington-Ward LE. The abdominal surgery of children. London: Humphrey Milford, 1928. 2.6. Charles Mixter and his contribution to surgery for esophageal atresia In 1929, Charles Mixter (1882–1965; Fig. 16) attempted to divide a distal tracheoesophageal fistula (TEF) in association with esophageal atresia (EA) by approaching the posterior mediastinum without

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Fig. 15. Sir Lancelot Barrington-Ward. National Portrait Gallery.

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opening the chest, a significant barrier in an era where anesthesia was delivered using open drop ether and ventilation relied on spontaneous breathing [1]. The two patients he operated on both died, but his paraspinous approach was used by both Cameron Haight (1901–1970) of Ann Arbor [2] and Thomas Lanman (1891–1961) of Boston in their attempts at primary repair of EA. In 1913, Harry Richter in Chicago was the first to attempt a primary repair of EA [3]. He knew once he opened the chest, the infant’s respiratory efforts would be futile, so he would have precious little time to complete the operation. He jury-rigged a positive pressure apparatus using a catheter and a pump to force air into the lungs using a rheostat. Both of his two attempts ended in death shortly after the operation, an indication that techniques to sustain respiratory function were still inadequate for intrathoracic surgery. That the infants had survived their operation was a testament to his courage and skill. Like Ladd (1880–1967), Mixter was on the visiting staff at The Children’s Hospital in Boston. In a radical concept that reflected an understanding of the hazard of open thoracotomy and the necessity to reach the near midpoint of the posterior mediastinum, Mixter’s approach was from the back with the child prone, posterior to the pleural cavity. Yet another example of his understanding of the pathology, he made the crucial decision to come from the right side of the vertebral column so the aorta did not obscure the anatomy. Based on later descriptions by Lanman, Mixter resected the posterior segments of several ribs, probably the third, fourth, and fifth. Then he carefully pushed the tissue paper-thin parietal pleura forward to reach the area he wanted and ligated the TEF (behind the azygos vein, a landmark also noted by Richter). He brought the distal segment out the back as a dorsal esophagostomy. The first patient was dead at the completion of the operation, but his next (and his only other attempt) lived 2 1/2 days. Both patients received a gastrostomy. While Mixter’s operation addressed the TEF,

Fig. 16. Clockwise from top left: W. Jason Mixter (neurosurgeon, Massachusetts General Hospital), Charles Mixter (chief, Beth Israel), Samuel Mixter, Samuel Jason Mixter (the “Chief,” seated). Courtesy of Charles (Terry) Mixter, III, Scottsdale, AZ. Thomas V.N. (Tad) Ballantine, a pediatric surgeon from Hershey, PA, was also a descendant of the Mixter family.

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Lanman added a proximal esophagostomy to take care of the other source of pulmonary contamination. Division of the TEF, gastrostomy, and dorsal esophagostomy became the standard operation in Boston for almost a decade. Lanman used Mixer’s posterior approach to the mediastinum to make five attempts at primary repair of the anomaly from 1936 to 1939 [1]. Haight of Ann Arbor also used the posterior approach, but he did it with the baby in a lateral position. After three fatalities, he succeeded in 1941, the first long term survivor after primary repair. Unlike Mixter and Lanman who operated from the right side of the spine, however, Haight approached the anomaly from the left and thus had to contend with the aorta, subclavian artery, and intercostal vessels to reach the esophagus and the TEF. He finally began to approach it from the right side in 1944 [2]. Mixter also had an abiding interest in childhood pathology and published a series of articles on urinary cancers including Wilms’ tumor, neuroblastoma, and bladder sarcomas [4-6]. He listed his Children’s Hospital affiliation without mentioning his appointment at the Beth Israel Hospital, where he became its surgeon-in-chief. Mixter never co-authored a paper with Ladd even though they both practiced at The Children’s Hospital and maintained adult practices at other hospitals. But Ladd had the inside track for the position as surgeon-in-chief at The Children’s Hospital in 1927 and its fulltime staff in 1937. Also hired were Thomas Lanman, Franc Ingraham, and David MacCollum; Mixter was the odd man out. When Ladd published his own paper on Wilms’ tumor in 1938, only 6 years after Mixter’s presentation in 1932, Ladd mentioned Mixter in passing as his “former associate [7].” According to a PubMed search, there are no further publications by Mixter on topics on children’s surgery. No records exist as to the circumstances of his disappearance from the field to which he had devoted so much of his academic career. It is reasonable to surmise that despite his contributions to children’s surgery, Mixter was among the first victims of a modern phenomenon, a private surgeon being eased out of a hospital by one that is employed.

Vanderbilt. Famously he and his laboratory technician, Vivien Thomas, developed and performed the first subclavian-to-pulmonary artery anastomosis in November 1944. With Gross’s ligation of a patent ductus arteriosus in August 1938, the two landmark operations opened the field of cardiovascular surgery [1, 2]. Shortly after Gross’s achievement, Taussig went to Boston to hear him lecture on his bold operation. She knew that a child with tetralogy of Fallot often deteriorated when the ductus arteriosus closed in the days after birth. With intuitive brilliance, she wondered whether a ductus artificially created by a surgical operation might preserve enough blood flow through the lungs to maintain gas exchange. After Gross’s lecture, she went to him and asked whether such an operation could be done [3]. Yes, Gross said. He had constructed a dog model of ductus arteriosus so he could practice the procedure before he attempted it on an actual patient, so such an operation was technically possible. But he did not want to do the procedure on a human infant because he was afraid that the augmented pulmonary blood flow would flood the lungs. He was interested in closing ductuses, not creating them, Gross said [4], a cutting remark that would not surprise those who knew him in Boston. Undeterred, Taussig pitched her idea to Blalock after he arrived at Hopkins in 1941. The successful “blue baby” operation was a collaborative success that defied all racial and gender stereotypes: Blalock, a white patrician from the pre-Civil Rights South; Taussig, a woman physician who was a professional contradiction, a cardiologist who was nearly deaf; and Thomas, an African American denied opportunity because of Jim Crow-era segregation. Immortalized by Hollywood (Something the Lord Made: Joseph Sargent, HBO, 2004), the story is a part of popular American history. Perhaps it’s better that Gross passed on doing the operation.

References 1. Lanman TH. Congenital atresia of the esophagus: a study of thirtytwo cases. Arch Surg. 1940;41:1060–83. 2. Haight C, Towsley HA. Congenital atresia of the esophagus with tracheo-esophageal fistula. Extrapleural ligation of fistula and endto-end anastomosis of esophageal segments. Surg Gynecol Obstet. 1943;76:672-88. 3. Richter HM. Congenital atresia of the oesophagus; an operation designed for its cure. Surg Gynecol Obstet. 1913;17:397-401. 4. Mixter CG. Sarcoma of the bladder in a child. Ann Surg. 1917;65:628-32. 5. Mixter CG. Tumors of the kidney in infancy and childhood. Ann Surg. 1922;76:52-63. 6. Mixter CG. Malignant tumors of the kidney in infancy and childhood. Ann Surg. 1932;96:1017-27. 7. Ladd WE. Embryoma of the kidney (Wilms’ tumor). Ann Surg. 1938;108:885-902. 3. Personalities 3.1. Why there isn’t a Gross-Taussig shunt for tetralogy of Fallot In one of the great “what ifs” in the history of surgery, Robert Gross (1905–1988; Fig. 17) rejected Helen Taussig’s (1898–1968; Fig. 18) suggestion to create an “artificial ductus” to increase the pulmonary blood flow in children with pulmonary stenosis as part of tetralogy of Fallot. After his refusal, Taussig, the legendary pediatric cardiologist at the Johns Hopkins Hospital, then turned to Alfred Blalock, newly named professor chair of surgery at Hopkins, who had recently come from

Fig. 17. Robert Gross. National Library of Medicine.

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Fig. 19. Judson Randolph. Courtesy Judson Randolph papers.

Fig. 18. Helen Taussig. National Library of Medicine.

References 1. Gross RE, Hubbard JP. Surgical ligation of a patent ductus arteriosus: Report of first successful case. J Amer Med Assoc. 1939:112:729-31. 2. Blalock A, Taussig HB. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or atresia. J Amer Med Assoc. 1945;128:189-202. 3. Alexi-Meskishvili VV, Bottcher W. The first closure of the persistent ductus arteriosus. Ann Thorac Surg. 2010;90:349-56. 4. Murray L, Hendren WH, Mayer JE, et al. Historical vignette. “A thrill of extreme magnety”: Robert E. Gross and the beginnings of cardiac surgery. J Pediatr Surg. 2013;48:1822-5. 3.2. They put the word “collaboration” in the multidisciplinary care of childhood solid tumors Wilms’ tumor is heralded as the first success of multimodal care in the treatment of solid tumors, where care is delivered by an interdisciplinary team representing medical oncology, radiation therapy, pathology, and surgery. But the cooperative approach on which it depended had its start at The Children’s Hospital in Boston where a group of junior attendings worked well together, shared a common purpose, and thus combined their talents for the benefit of their patients with cancer. Judson Randolph (Fig. 19) and Giulio (Dan) D’Angio were associated with Robert Gross (surgery) and Edward Neuhauser (radiology), respectively. The senior pair reported a 47 percent survival when postoperative radiation therapy followed nephrectomy [1], an improvement from 32 percent achieved by William Ladd with surgery alone [2]. Audrey Evans was the clinical associate of Sidney Farber (pathology), who was the first to report a new antibiotic, actinomycin D, as an effective chemotherapeutic agent against solid tumors (1953) [3]. Children who received the drug were especially sensitive to skin toxicity from radiation therapy, an interesting augmentation of the tumor-killing effect

of radiation that D’Angio confirmed in the laboratory in 1960 [4]. Combining chemotherapy and radiation with surgery for Wilms’ tumor set the stage for the modern era of multimodal cancer care [5]. There was the practical matter of how such care was going to be delivered. At The Children’s Hospital, the big names at the top relied on junior colleagues to do the work. Randolph, during his chief resident year and 2 years as attending staff under Gross, did most of the tumor resections. Neuhauser was less interested in ongoing radiation therapy, so he left it to his associate Martin Wittenborg and D’Angio, the latter becoming the leader of the National Wilms’ Tumor Study group (NWTS). Evans, Farber’s clinical associate, often visited the operating room and looked over Randolph’s shoulder. “So here we were, three younger people, each with a distinguished chief who was less interested in tumor work than we were,” said Randolph. “We sort of banded together … We really got it going as a team … We really developed a strong tumor approach [6].” Daniel Hays had a different experience at the Children’s Hospital of Los Angeles. “It’s funny,” he said, “but the hematologists … who were treating leukemia … did not want to take over the treatment of metastatic solid tumors.” He had to start a clinic of his own to give chemotherapy to solid tumor patients with disseminated disease [7]. The hematologists in LA eventually came around, to the benefit of the patients and families in Southern California. The successive NWTS protocols formalized the multidisciplinary approach to cancer care and brought the advances to the rest of the world. But the spirit of collaboration began with Randolph, Evans, and D’Angio on the wards of the Children’s Hospital in Boston. References 1. Gross RE, Neuhauser EBD. Treatment of mixed tumors of the kidney in childhood. Pediatrics 1950;6:843-52. 2. Ladd WE, White RR. Embryoma of the kidney, [Wilms tumor]. J Am Med Assoc 1941; 112:1858–63. 3. Farber S. Chemotherapy in the treatment of leukemia and Wilms’ tumor. J Amer Med Assoc 1966;198:826. 4. D’Angio CJ, Farber S, Maddock CL. Potentiation of x-ray effects by actinomycin D. Radiology 1959;73:175-7.

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5. Nakayama DK, Bonasso PC. The history of multimodal treatment of Wilms’ tumor. Am Surg. 2016;82:487-92. 6. Judson Randolph, MD. Interviewed by Kurt Newman, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 26, 2007. Available from: https://www.aap.org/en-us/about-the-aap/GartnerPediatric-History-Center/DocLib/Randolph.pdf. Accessed January 17, 2019. 7. Daniel M. Hayes, MD. Interviewed by Kevin P. Lally, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, July 3, 2007. Available from: https://www.aap.org/en-us/about-the-aap/Gartner-PediatricHistory-Center/DocLib/HaysREV.pdf. Accessed January 17, 2019. 3.3. The contributions of Helen Noblett to pediatric surgery In two landmark publications in 1969, Helen Noblett (Fig. 20) made two lasting contributions to pediatric surgery, the use of water-soluble radiological contrast in newborn infants with meconium ileus and the description of a suction rectal biopsy tool for the diagnosis of HD. Despite her accomplishments, she is an almost forgotten personality, mentioned only in passing in surgical memoirs and lost entirely from the archives of the Royal Children’s Hospital in Melbourne and the Bristol Royal Hospital for Children in England, two institutions where she practiced for many years. Her clinical contributions, however, endure. In 1969, she reported the first use of Gastrograffin (diatrizoate meglumine and diatrioate sodium solution, Bracco Diagnostics, Monroe Township, NJ), a watersoluble radiological contrast solution, to relieve uncomplicated meconium ileus [1]. Except in the mildest cases, surgery was believed to be necessary to relieve intestinal obstruction from the mass of sticky meconium in the distal intestinal tract. Others had used enemas in attempts to treat the condition, including pancreatic enzymes, hydrogen peroxide, and the industrial solvent Tween 80 with some relief of obstruction. Noblett was able to achieve consistent success using Gastrografin, which was water-soluble and thus could be used in the diagnosis of distal intestinal obstruction without the risk of becoming an impaction itself, as was the case when barium was used. It was not without drawbacks. The formulation of Gastrografin was then hypertonic with the potential to draw excessive fluid into the colon and cause dehydration. It also had cytopathic effects on the colonic mucosa itself. Today’s isotonic contrast solutions avoid both drawbacks. But the principle to use a radiological contrast enema in the treatment of meconium ileus was first established by Noblett a half century ago. After her article on contrast enema appeared in April, she had a second one in August that described her modification of a catheter-based rectal biopsy device appropriate for use in the diagnosis of HD in infants. Noblett’s design, a shorter version of one designed for blind biopsies of the gastric mucosa in adults, was appropriate for the short distances of an infant’s anorectum. Her modified device attached the cable-blade system to a hinged handle so that a single person could use it one-handed at the baby’s cribside [2]. Her design is the one in widespread use today. There are scant records of her life in Australia and Bristol, England, where she moved later in her career. Her home institutions in Melbourne and Bristol have no records of her professional career. She had been noted in passing as having been on the thoracic unit under Russell Howard in Melbourne [3]. Other surgeons’ memoirs acknowledged her impact on their training in their memoirs, but sadly without adding to her personal history. Jim O’Neill and Kathryn Anderson both worked with Noblett. She was a research fellow from Melbourne at Columbus Children’s Hospital when O’Neill and Jay Grosfeld were in training there under program director H. William Clatworthy. “Helen was a delightful woman who was collaborative and helped with some of our work when we had trouble getting to the lab because of clinical duties,” O’Neill wrote. “The reason she started work on a biopsy tool was that she and Blanca Smith-Kent

Fig. 20. Helen Noblett. The Royal Children’s Hospital Melbourne.

were investigating the maturation of ganglion cells in rats, so she designed a tiny suction tool to obtain samples from the anorectum in fetal and immature animals.” Her instrument for clinical use was a larger version of her lab device. When he started clinical practice, O’Neill obtained an early version of her biopsy gun, one that he would use his entire career and still uses in his current overseas work in Africa. Anderson knew Noblett personally. “She was the most charming person, very scholarly,” Anderson wrote. “I learned an enormous amount from her.” At one point in her career, Noblett from Melbourne moved to Bristol, Anderson’s home town in England. Anderson and Noblett held a clinic in Bristol, where they saw esophageal atresia patients treated by Ronald Belsey, who used exclusively colon interposition for esophageal atresia. Both Anderson and Noblett favored a reverse gastric tube esophagoplasty, which proved an equivalent procedure for esophageal replacement. Both O’Neill and Anderson remembered her with admiration and fondness. “I mentioned her to my residents every time we used the [Noblett’s biopsy] instrument to give them an example of what a resident can contribute,” O’Neill wrote. “Toward the end of her life,” Anderson wrote, “Helen became rather reclusive. It is a shame that she has been forgotten, but sadly, there are many surgeons who are unknown, though they made sentinel contributions to the advancement of surgery in children.” “So, who was she?” O’Neill asked the rhetorical question implied by the title of the original vignette. He answered: “She was the real thing.” References 1. Noblett HR. Treatment of uncomplicated meconium ileus by Gastrograffin enema: a preliminary report. J Pediatr Surg. 1969;4:190-97. 2. Campbell PE, Noblett HR. Experience with rectal suction biopsy in the diagnosis of Hirschsprung’s disease. J Pediatr Surg. 1969;4:410-5. 3. Stephens FD. F. Douglas Stephens, MD. Interviewed by John M. Hutson, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, May 30, 2007. Available from: https://www.aap.org/en-

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us/about-the-aap/Pediatric-History-Center/Documents/Stephens. pdf. Accessed May 7 2018. 3.4. James Densler and Samuel Rosser, pioneering black pediatric surgeons The 50th anniversary of APSA coincided with a half-century of African Americans in the field, notably James Densler (Fig. 21), who started practice in Atlanta in 1969, and Samuel Rosser (Fig. 22), who became chief of pediatric surgery at Howard University in 1972. A Savannah native, Densler was the highest ranked graduate of the 1954 class of Savannah State College (now University), the oldest publicly supported historically black college and university (HBCU) in Georgia. Briefly a teacher in the Chatham County school system, he enlisted in the Army, where he was assigned medic training. The experience led him to settle on a career in medicine. After Meharry Medical College, where he was named first honor student upon his graduation in 1961 (no surprise), he did his internship and general surgery training at the U.S. Public Health Hospital in Staten Island (1961–1966) followed by a fellowship in pediatric surgery at the United Hospitals of Newark (1966–1968). He returned to Georgia in 1969 to start practice in Atlanta as the first African American pediatric surgeon in the U.S. With two associates, he started the first African American incorporated group practice in the state. He had many leadership roles in Atlanta area hospitals and medical societies, so in 1974 he had the political connections to invite the newly-organized Morehouse School of Medicine to use the Southwest Community Hospital as one of its clinical sites, where he served as chief of its medical staff. When he retired from clinical practice in 1999, he continued teaching in the Morehouse department of medical education and ran the pediatric surgery clinic at the Otis W. Smith/ Southwest Grady Healthcare Center in Atlanta [1]. “Dr. Densler was one of the group of Black physicians who helped start the school, especially financially,” wrote W. Lynn Weaver, past chair at Morehouse. “He is an amazing man. I was lucky to have him on faculty.” As a pediatric surgeon, he had the distinction of being the first African American in the Surgical Section (1971) and the second to receive board certification in pediatric surgery by the ABS (after Rosser; 1976) [2]. He was never a member of APSA, however. This oversight was rectified at the 50th annual meeting of APSA, where Densler received an honorary membership in the organization.

Fig. 22. Samuel Rossser

Samuel Rosser was the son of teachers and raised in Tallapoosa, GA, a segregated industrial town of 2,000 midway on the rail line between Atlanta and Birmingham. To give his children a better educational opportunity, Rosser’s father took a job at the Carroll County Training School in Carrollton, 20 miles away, where Samuel received a secondary school diploma in 1950. Four years later, he earned a baccalaureate from Clark College in Atlanta, another HBCU that started as a Methodist freedmen’s school. To earn money for school, Rosser worked summers

Fig. 21. James Densler (seated) with colleagues (from left) Tony Stallion, Edward Barksdale, Henri Ford, and James Gilbert.

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in Detroit at the Kirwood General Hospital, the only predominately black hospital in the Detroit inner city. After graduation, he took a master’s degree in parasitology from Wright State University in 1956 [3]. Guy Saulsberry, the founder and medical director at Kirwood and a Howard medical school graduate, encouraged Rosser to train in medicine. Rosser took his advice and graduated from Howard with a medical degree in 1960. After a rotating internship at Freedmen’s Hospital, he stayed for surgical training there, with full-year rotations at the Staten Island U.S. Public Health Service Hospital and the Memorial SloanKettering Cancer Center. After completion of his training, he stayed on faculty at Howard and started a private practice in general surgery. He was certified by the ABS in 1968. In 1970 he gave up his practice to train in pediatric surgery at the Children’s Hospital in Washington, D.C. (now the Children’s National Medical Center), under Judson Randolph. On completion of his fellowship in 1972, he returned to Howard as chief of pediatric surgery. Rosser was among the first group of surgeons to take the first board certifying examination at the fifth annual meeting of APSA in Puerto Rico in 1975, and thus became the first black surgeon with Board certification in pediatric surgery. He drew from his experience at Howard and the D.C. General Hospital to contribute to the pediatric surgical literature in the Journal of the National Medical Association and the Journal of Pediatric Surgery [3]. Rosser died in January 2018 at age 83. As African American pioneers in pediatric surgery, Densler and Rosser’s careers spanned an era of monumental social change in the country. From their upbringing in the segregated Jim Crow South, they made the most of the limited educational opportunities open to them. They

thus became the first representatives of a vital part of the specialty, African American pediatric surgeons. They lived to see black pediatric surgeons attain prominence in the specialty and become leaders in academic medical schools. Today, it is impossible to imagine the specialty and American medicine without Densler and Rosser’s surgical descendants. References 1. Morehouse School of Medicine. Dr James F. Densler, first AfricanAmerican pediatric surgeon to practice in U.S., retires from Morehouse School of Medicine. Available at: http://www.msm.edu/ RSSFeedArticles/May2016/DrJamesDenslerRetirement.php. Accessed February 5, 2019. 2. Wyckoff AS. First black member of Section on Surgery a pioneer. Did you know? AAP News. Available at: http://www.aappublications. org/news/2018/06/22/dyk062218. Accessed February 5, 2019. 3. Organ CH Jr, Kosiba MM. A century of black surgeons: the U.S.A. experience. Norman, OK: Transcript Press, 1987. 3.5. Alberto Pena, the Australians, and Albinoni’s Adagio Alberto Peña’s (Fig. 23) groundbreaking work on surgery for imperforate anus required radically new concepts of pathological anatomy of anorectal malformations that set him at odds with the foremost experts in the field, F. Douglas Stephens and E. Durham Smith of Melbourne. Stephens had been dissecting specimens of anorectal and genitourinary

Fig. 23. Alberto Peña and Robert Gross (right).

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malformations since his years in training at the Hospital for Sick Children at Great Ormond Street in the late 1940s. The project had consumed him for nearly a quarter-century, with three books published on the topic over 20 years [1-3]. From his research on twelve infants dying with the malformation, Stephens concluded that in the absence of an anorectum, the puborectalis coalesced behind the urethra. According to his studies, posterior and superficial to that level, there was little that existed in the way of muscular anatomy of surgical significance. Based on Stephens’ concepts, William Kiesewetter of Pittsburgh devised the sacral abdominoperineal pullthrough: identifying the urethra using a sound, then dissecting a space between the urinary tract and the puborectalis. The rectosigmoid then was pulled through the interval to a small incision in the perineum for a neoanus. Beyond the puborectalis, the perineal dissection was largely blind without regard to the muscular anatomy in the pelvis [4]. When Peña was named surgeon-in-chief at the National Institute of Pediatrics in Mexico City in 1972, he was only 34 years of age and fresh out of training at the Children’s Medical Center in Boston (today’s Boston Children’s Hospital) [5]. Now in practice on his own, Peña wanted to better define the muscular anatomy by stimulating the tissues of the perineum with an electrical stimulator. He saw contractions of a muscle that he attributed to be the puborectalis. He decided to present his findings at a meeting of the Pacific Association of Pediatric Surgeons in 1980. Smith, who was present, criticized his paper saying that what Peña saw wasn’t the puborectalis, which lay deeper in the pelvis and could not be observed from the perineum. He was right, of course, but Peña left the lectern irritated. “If nobody had seen the puborectalis,” he thought, “why are we talking about it?” Working with Pieter DeVries, his solution was to enlarge the perineal incision to get a better look, from the coccyx to the base of the scrotum, and use the stimulator to better define the pelvic muscular anatomy. Even in the absence of the anorectum, he recognized a complex muscular anatomy that extended down to the perineum. When stimulated, it caused a concentric contraction that caused a “wink” of anal skin. He reasoned that the musculature, which he termed the external sphincter complex, once reconstructed around the pulled-through anorectum, might once more confer voluntary control to the passage of stool. What’s more, the exposure was so good that he was able to find the fistula, mobilize the rectum, and reconstruct the sphincteric musculature down to the neoanus. Now the entire pullthrough procedure could be done from the perineum, whereas the previous operation had relied on an abdominal exposure to divide the fisula and mobilize the rectum. His eponymous procedure became the standard approach for the anomaly. His presentation two years later to APSA in 1982, with de Vries as co-author, became one of the most important articles ever published in the Journal of Pediatric Surgery [6]. Peña became a lecturer in demand at children’s hospitals and universities throughout the world. Despite the debate on the anatomy of anorectal malformations and techniques for their correction, Stephens and Smith invited him for a 2-week visit to the Land Down Under to present his work at the major medical centers of Australia, including Melbourne. “I cultivated an excellent friendship with Dr. Douglas Stephens until his passing,” Peña recently wrote. “Dr. Durham Smith is a gentleman and excellent pediatric surgeon. Our differences concerning the anatomy of anorectal malformations did not interfere with our professional relationship.” As an epilogue to the story, Peña’s video of the operation at the landmark meeting of 1982 had a distinctive classical piece as background music, a quirk to some and irritating to others. “I believe that we could select a different type of music for every operation,” Peña recently wrote. When he asked Kathryn Anderson for an appropriate piece, she came up with one of her favorites, Samuel Barber’s Adagio for Strings, a 1936 piece that had a gravity appropriate for the war years and played at the announcements of the deaths of FDR, JFK, and Princess Diana, and the funerals of Einstein and Princess Grace.

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Peña chose instead a piece titled Abinoni’s Adagio, a piece that at times is also referred to as Adagio for Strings, the same name as the Barber composition. Its similarly somber passages made it a Hollywood favorite as background music for scenes that required pathos: Rollerball (1975), Gallipoli (1981), Flashdance (1983), and most recently, the Oscar-winning movie Manchester by the Sea (2016). Purportedly recovered from a fragment of a manuscript uncovered by a 20th century musicologist from Italy named Remo Giazotto, it turns out that the piece was composed by Giazotto himself and its provenance linking it to the 18th century Baroque composer Tomaso Giovanni Albinoni was a hoax [7]. The music struck those who viewed it in different ways. Hardy Hendren was irritated by the soundtrack, thinking that it distracted the viewer. (One imagines that Hardy was not one to allow music in the OR.) Jack Templeton at the Children’s Hospital of Philadelphia was so inspired by Peña’s presentation and his operation that he played the Adagio whenever he had a case. I was impressed that the music seemed to have dramatic crescendos that coincided with the contraction of the anus each time Peña touched the sphincter with his stimulator. Marina Petrulla, administrative director of APSA, said that in any other context my observation would deserve a reprimand from the Human Resources department. References 1. Stephens FD. Congenital malformations of the rectum, anus, and genitourinary tracts. Edinburgh: Livingstone, 1963. 2. Stephens FD, Smith ED. Anorectal malformations in children. Chicago: Year Book, 1971. 3. Stephens FD. Congenital malformations of the urinary tract. New York: Praeger, 1983. 4. Kiesewetter WB. Imperforate anus. II. The rationale and technic of the sacroabdominoperineal operation. J Pediatr Surg. 1967;2:106-10. 5. Alberto Peña, MD. Interviewed by Richard G. Azizkhan, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, May 22 2008. Available from: https://www.aap.org/en-us/about-the-aap/GartnerPediatric-History-Center/DocLib/Pena.pdf. Accessed January 21, 2019. 6. Peña A, DeVries PA: Posterior sagittal anorectoplasty: Important technical considerations and new applications. J Pediatr Surg. 17:796-811, 1982. 7. Dekel J. Is Albinoni’s Adagio the biggest fraud in music history? https://www.cbcmusic.ca/posts/18137/albinoni-adagio-g-minorbiggest-fraud. Accessed December 4 2018. 3.6. The F2 generation The first generation of surgeons with formal training in pediatric surgery who came of age in the 1950s and 1960s faced challenges in establishing a specialty that straddled two ingrained disciplines, pediatrics and surgery. Their mentors were skeptical that they were making the correct choices of careers. Pediatricians had to be convinced that the new arrival brought tangible benefits to their patients. General surgeons who treated children in addition to their adult practices scoffed at the suggestion that the care they gave was somehow inferior to a specialist whose only distinction was the age of the patient. Then as now, most children came from young families unable to pay for costly operations and hospitalizations without insurance or public assistance, so it was uncertain whether a practitioner could make a living performing exclusively children’s surgery. Pediatricians soon saw the advantage of a pediatric surgeon and began to use their services exclusively [1]. Academic departments of surgery, sometimes at the insistence of their pediatric colleagues, created separate divisions of pediatric surgery. The discipline, a chancy financial proposition when left to support itself, thus found a stable

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financial home within university medical centers and children’s hospitals. James O’Neill (Fig. 24), long identified with Vanderbilt University and Nashville, was in medical school at Yale University when he first encountered pediatric surgery. He was on his junior clerkship in pediatrics when an infant arrived with “fainting spells” from an intussusception. The condition, at first obscure, was diagnosed on physical examination by a general surgeon who took call for pediatric emergencies at the facility. The surgeon allowed him to scrub in and he was hooked. “That’s the kind of doctor I want to be,” he said. When it came time to decide on surgical training, he announced his career intention to Gustaf Lindskog, his chair at Yale. “Well, I can’t understand why you’d want to do pediatric surgery,” Lindskog said. “Who needs pediatric surgeons?” The chair sent him to Vanderbilt where the curriculum included a rotation on pediatric surgery for his intern year in 1959–1960 to “get it out of your system [2].” Working in Nashville with H. William Scott, who had spent 3 years under Robert Gross at The Children’s Hospital in Boston, his time at Vanderbilt only solidified his choice. Decades later O’Neill became surgeon-in-chief at the Children’s Hospital of Philadelphia, chair of the Section of Surgical Sciences at Vanderbilt, and president of APSA (1988–1989). Judson Randolph (see Fig. 19) had a secure position with Gross at The Children’s Hospital when Robert Parrott, chair of pediatrics at Georgetown University in Washington, D.C., came to Boston specifically to recruit him to become chief of surgery at the Children’s Hospital of the District of Columbia (now the Children’s National Medical Center). When he arrived in 1964, the surgeons who had been covering the facility were not as welcoming. “I had a hard time at first,” he said, “because [they] did not want a pediatric [surgeon] – particularly some guy that was young, that was from Boston, …[and] that thought he knew something that they didn’t know [3].” Among his first cases was a baby who died of complications following surgery for esophageal atresia. The adult surgeons used a strategy

often used to push rivals out of an institution: They got the hospital to initiate a formal investigation into the death. All Randolph needed to clear his name was to review the outcome of cases operated on by the same surgeons who were accusing him of negligence and incompetence. All had died [3]. His position secure, he went on to create one of the most successful academic services in pediatric surgery. Like O’Neill, he was elected president of APSA (1984–1985). It took some time for pediatricians to feel comfortable for Thomas Holder (Fig. 25) to care for their patients at the Children’s Mercy Hospital in Kansas City upon his arrival in 1960. Another who had trained in Boston with Gross, he had been recruited by Herbert Miller, Chair of Pediatrics at the University of Kansas, the academic affiliate of the facility at the time. “There were a lot of turf battles at home in those days,” Holder said. “There was concern about patients that had not been properly cared for. … Over time, … people realized that surgeons with pediatric surgical training could do a better job. … These were educational years for all of us and for the pediatricians as well [4].” With his associate Keith Ashcraft, Holder built a thriving clinical service and highly soughtafter training program. He also served as president of APSA (1975–1976). Pediatric surgeons faced unique challenges to establish the specialty as part of both surgery and pediatrics. Using Mendelian terminology, Ladd, of the P generation, defined the specialty. The F1 generation that trained in the Boston School, such as Gross, Clatworthy, Koop, and Potts, established it as a discipline that required formal instruction and training. It was left to O’Neill, Randolph, Holder, and others of the F2 generation to bring the discipline into the academic centers and the nation’s largest children’s hospitals as an integral part of modern surgical and pediatric practice.

Fig. 24. James O’Neill, Jr.

Fig. 25. Thomas Holder.

References 1. Randolph JG. History of the Section on Surgery, the American Academy of Pediatrics: the first 25 years (1948-1973). J Pediatr Surg. 1999;34(5 Suppl 1):3-18

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2. James A. O’Neill, Jr., MD. Interviewed by George W. Holcomb, III, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, May 1, 2008. Available from: https://www.aap.org/en-us/about-the-aap/GartnerPediatric-History-Center/DocLib/ONeill.pdf. Accessed January 21, 2019. 3. Judson Randolph, MD. Interviewed by Kurt Newman, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 26, 2007. Available from: https://www.aap.org/en-us/about-the-aap/GartnerPediatric-History-Center/DocLib/Randolph.pdf. Accessed January 21, 2019. 4. Thomas M. Holder, MD. Interviewed by George W. Holcomb, III, MD, MBA. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 5, 2006. Available from: https://www.aap.org/en-us/about-the-aap/ Gartner-Pediatric-History-Center/DocLib/Holder.pdf. Accessed January 21, 2019. 3.7. Pediatric surgeons in the military In late November 1944, Lieutenant Junior Grade Luke Able, Medical Officer of the U.S.S. Aulick in the Leyte Gulf, suffered open fractures of both legs and multiple other wounds during a Japanese kamikaze attack on the destroyer that left 32 men killed or missing and another 64 wounded. Stubbornly he refused aid for himself and directed lifesaving efforts on others more grievously injured until he passed out, for which he received the Silver Star and Purple Heart [1]. After a twoyear hospitalization, Able trained in pediatric surgery at The Children’s Hospital in Boston and practiced for more than 3 decades at the Texas Children’s Hospital in Houston [2]. Lieutenant Able was a part of a proud tradition in pediatric surgery of military service to the nation that started with Herbert Coe, part of the American Expeditionary Force during World War I. In a survey of members of APSA conducted by Kenneth Azarow in 2010, 11.5 percent of the membership served in the U.S. military in some capacity, a rate 60 percent higher than the 7.5 percent of the citizenry at large [3]. In 1965 Robert Filler, Arvin Philippart, and Albert Dibbins were members of one of the first medical units sent to Vietnam. “Bob got the first case,” Dibbins wrote, “a door gunner in a chopper who had a severed femoral artery. He repaired the artery with 4-0 silks on French eye needles because we had no arterial sutures.” Colonel Frederick “Fritz” Karrer of the US Army Reserves continues the tradition of service with six deployments to the Middle East. He wasn’t at APSA’s 50th anniversary meeting in Boston: He was deployed for a seventh time to Afghanistan. Ethicists point out the conflict between medicine, dedicated to the prevention of death and suffering, and the military, the defenders of society by wounding and killing others. “Going to the Vietnam Wall (Vietnam Veterans Memorial in Washington, D.C.) is difficult for me,” Dibbins wrote. “There are 58,000 names that should not be there.” Retired Colonel Rick Pearl (Fig. 26) sees that surgeons and officers share an essential obligation to soldiers in battle, a perspective from his experience as an infantry officer and helicopter pilot in Vietnam (three Bronze Stars and Legion of Merit), and surgeon in the Middle East: Family members of soldiers in your command won’t remember if you took “X” hill on “X” day in a battle. They will remember if their son came home [4]. Between battles, pediatric surgeons helped children affected by the war. In Vietnam, Filler, Philippart, and Dibbins bypassed Army regulations to repair cleft lips and palates. During recent conflicts in the Middle East, humanitarian care became an accepted part of military medical duty. Chris Coppola and Lucas Neff routinely treated seriously wounded children in combat environments, the latter using his experience to perfect massive transfusion protocols in pediatric trauma. “Kids are the

Fig. 26. Rick Pearl in Vietnam.

same everywhere,” Karrer says. “They want to be well. They fight hard to be better. And they are amazingly resilient.” References 1. The Hall of Valor Project. Luke Able. Available at: https://valor. militarytimes.com/hero/55167. Accessed January 7 2018. 2. Abram L. Houston Chronicle. Deaths: Dr Luke Able, 93, saved lives on and off the battlefield. March 30, 2006. Available at: https://www. chron.com/news/houston-deaths/article/Deaths-Dr-Luke-Able-93saved-lives-on-and-off-1846798.php. Accessed January 7 2018. 3. Azarow K. Personal communication, November 10, 2018. 4. Madden W, Carter BS. Physician-soldier: a moral profession. Chapter 10 in. Military Medical Ethics (2 volumes), Beam TE and Sparacino LR (editors). Washington, D.C.: Office of the Surgeon General, 2003, pp. 267-291.

3.8. Koop, Clatworthy, and the Ladd-Gross rapprochement During his training from April through November 1946 at The Children’s Hospital in Boston, C. Everett Koop, his lifelong nickname “Chick” a reminder of playmates’ playful teasing of his last name [1], was an eyewitness to the famous feud between William Ladd and Robert Gross. Sent by Isidore Ravdin, his chief at Penn, to gain additional experience in children’s surgery before taking the position as the first fulltime surgeon-in-chief at CHOP, he experienced the contentious atmosphere that climaxed in the interval between Ladd’s retirement in 1945 and Gross’s formal appointment to succeed him in 1947. Koop recounted the episode in an oral history conducted by Mory Ziegler in 2006, a trove of information on the early history of pediatric surgery and available on the AAP website [2]. In retirement, Ladd’s daily schedule started with chores as a gentleman farmer in Natick, then a village near Framingham some 20 miles outside of Boston, lunch at the Harvard Club, then hanging around The Children’s Hospital “where he would sit on an empty crib, his long

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legs dangling, hoping a member of the house staff would come along for a chat,” Koop said. “I tried to meet with him as often as I could [2].” His relationship with Gross evolved differently. Koop was only an observer during the interregnum after Ladd stepped down. Franc Ingraham, a neurosurgeon, was acting surgeon-in-chief until the succession issue could be resolved. Gross was still the dominant clinical presence, but those close to him could tell he was troubled. “A warm greeting from [Gross] in the morning would be, ‘[grunts],’” said Koop. “It was Orvar Swenson and the residents who taught me what I went to learn [3].” Intending to spend a year in Boston, after 8 months, he cut short his experience and returned to Philadelphia in December. Koop gave Gross the benefit of the doubt and attributed his rudeness to the stress of the hostility that grew between them, which included Ladd actively lobbying against his candidacy to succeed him as surgeon-in-chief at The Children’s Hospital [2]. The bitterness of the feud, in Koop’s words, a deep “estrangement that probably damaged the development of child surgery more than we will ever know [4].” In the first years after his return to Philadelphia, Koop soon established a national prominence in pediatric surgery. When he made his first return visit to Boston, Gross welcomed him “like a longlost son” and cleared his schedule for the rest of the day so they could talk. As Koop remembered, Gross “unloaded to me about his difficulties with Ladd. … from that time on, we were very fast friends [2].” Koop became someone to whom Gross could confide. One sticking point between Ladd and Gross was the update of their textbook, Abdominal Surgery of Infancy and Childhood, which was printed in 1941. Planning an expanded version that was scheduled to appear in 1953, Gross needed material that was in the earlier edition. And Ladd still held the copyright. Koop agreed to help convince Ladd to sign the rights over to Gross. He enlisted the help of H. William Clatworthy, whose time in Boston as a trainee also spanned a period when both Ladd and Gross were active. They visited Ladd in Natick. As they sat and chatted, Koop steered the conversation toward an appreciation over what Ladd had contributed to children’s surgery. “But there was one more thing he could do,” Koop said, “and that was to give Gross the copyright to the first book, so that pediatric surgery could be made available to more people [2].” Ladd hesitated. Koop had an ace and played it. The Surgical Section was establishing an award in his honor, the William E. Ladd Medal. It was only right that he, William E. Ladd, would be there at its inception in Chicago. Ladd could meet Gross on the train from Boston and sign the necessary papers. No one would be the wiser. “It wouldn’t take more than about 2 minutes,” Koop said. “So that’s what happened.” Koop was already in Chicago, so Clatworthy took Ladd to the dining car at breakfast and the deed was done. “This [was] one of the first political things I ever got deeply involved in medicine,” Koop said [2]. It wasn’t quite Nixon in China, but Koop’s diplomacy between two intractable adversaries foreshadowed an aptitude for politics that he demonstrated so ably decades later as U.S. Surgeon General. References 1. Cooper A. Personal communication, May 4, 2019. 2. C. Everett Koop, MD, ScD. Interviewed by Moritz Zeigler, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, May 8, 2006. Available from: https://www.aap.org/en-us/about-the-aap/Pediatric-HistoryCenter/Documents/Koop.pdf. Accessed September 13, 2017. 3. Koop CE. A perspective on the early days of Pediatric Surgery. J Pediatr Surg. 1999;34(5 Suppl 1):38-45. 4. Koop CE. Pediatric surgery: the long road to recognition. Pediatrics 1993;92:618-21.

3.9. How George Holcomb, Jr., welcomed a new surgeon into town George Holcomb, Jr., a pioneer of pediatric surgery and a trainee of Robert Gross at The Children’s Hospital in Boston, was a familiar Figure in the first decades of the Surgical Section and APSA. He also was one of the founding members of the Lilliputian Surgical Society. While today few in the pediatric surgery community knew him, the depth of his character is revealed through his relationship with his colleague in Nashville, Jim O’Neill. When the latter was hired onto the faculty of Vanderbilt University, the two became fast friends and avoided a town-gown rivalry that created havoc in so many other places. They forged the first university-community partnership in the U.S., a model of collegiality that represents the best of professionalism in our field. After his time in Boston, and 2 years in Osaka as chief of Thoracic Surgery at the U.S. Army Hospital there during the Korean war, Holcomb settled in Nashville in 1954. But there was no room for him at the Vanderbilt University Hospital under its chair of surgery and surgeon-inchief, H. William Scott. With 3 years of training under Gross, Scott did both general and cardiac cases in children and infants. He enjoyed it so much that later in his career he told O’Neill that he regretted not restricting his practice solely to pediatric surgery. Other Vanderbilt surgeons also did children’s surgery and made fundamental contributions to the field. Rollin Daniel, Jr., chief of thoracic surgery, was among the first to have a survivor of primary repair of EA/TEF (1943), just 2 years after Cameron Haight’s success. James Kirtley, Jr., had the first long term jaundice-free survivor after hepatic portoenterostomy for biliary atresia (1951), 4 years before Morio Kasai’s first report of his eponymous operation in Japanese (1955) and more than a decade-and-ahalf before the latter made his first report in the English literature (1968). Scott, occupied in his position as chair and the developing field of congenital heart surgery, groomed another surgeon, Samuel Stephenson, Jr., to take over his general pediatric cases. Despite Scott’s presence in Vanderbilt, Holcomb took the risk of establishing a practice in the community in the shadow of a big university hospital. He devoted the time and effort required to win the confidence of cautious pediatricians, doing general surgery in adults to make ends meet until he could confine his practice to pediatrics. Judson Randolph later wrote He was embraced by the entire pediatric community, including the fulltime department of pediatrics of the Vanderbilt University Medical Center. … All complicated children’s surgery and all, absolutely all, babies requiring any kind of surgical diagnosis and treatment were immediately forwarded to Dr Holcomb’s care. Rather than bringing Holcomb onto his staff, Scott wanted a fulltime pediatric surgeon under him in his academic department. When Stephenson left Vanderbilt and Randolph decided to stay in his position as surgeon-in-chief at the Children’s Hospital in Washington, D.C. (today the Children’s National Medical Center), Scott reached out to O’Neill to take the job. The latter had trained as a resident in general surgery at Vanderbilt and worked with Holcomb at the Nashville General Hospital during his training. Holcomb knew of the young resident’s interest in pediatric surgery. “He was kind to me and let me do cases as time came along,” O’Neill later said in an interview conducted by Holcomb’s son, Whit, part of an oral history project of the AAP. Instead of resentment, Holcomb welcomed O’Neill with friendship. They began to cover each other’s practice, then combined their practices and shared the work. The catalyst for the merger was the organization of the Vanderbilt Children’s Hospital. In O’Neill’s words So we said, we should do something together and just share the work. Then the pediatricians won’t have to worry about referring to one or the other. We liked each other, and we respected each other. Rivalry, inevitable when the talented and ambitious meet, is a theme in the history of pediatric surgery. The Ladd-Gross feud is only the most

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famous one. Equally bitter conflicts arose throughout the country and continue today. At its best, competition fuels scientific and clinical advancement. Too often it devolves into turf battles between hostile competing groups and RVU-grabbing within a single practice. Holcomb made sure that his former resident’s transition into the Nashville community went smoothly. Knowing their shared dedication to children and pediatric surgery, Holcomb and O’Neill recognized that working together they could build their practices into something greater than they could separately. The present success of the department of pediatric surgery at Vanderbilt and its children’s hospital is the legacy of the spirit of teamwork at the inception of a partnership between a senior clinician and a junior academician. As a postscript to this memorial, pediatric surgeons recognize the Holcomb name in his son, George W. Holcomb, III (Whit), who did the interview of O’Neill quoted above and who now serves as the editor-in-chief of the Journal of Pediatric Surgery. The father had the pleasure of seeing his son take up his profession and become one of its foremost experts in minimally invasive surgery, transforming the field in a manner that his own generation would scarcely imagine.

4. Achievements 4.1. Judah Folkman and sustained release of drugs from silicone rubber Before his landmark research on angiogenesis, Judah Folkman (Fig. 27) found that oil-based dyes dissolved in silicone rubber, and then diffused back out of it. His observation formed the basis of sustained release of drugs from implanted capsules, such as the contraceptive Norplant. He later used his discovery in his groundbreaking research into angiogenesis. Folkman told this story to a rapt audience as part of his APSA presidential address in May 2006, which was later published in the Journal of Pediatric Surgery as its lead article for January 2007 [1]. A resident in surgery at the Massachusetts General Hospital, Folkman was drafted and assigned to the Naval Medical Research Institute. His task was to test the ability of blood substitutes to sustain tissue viability. His test was the growth of mouse melanoma implants in isolated thyroid glands, which he then reimplanted into the mouse as an added test of viability. He saw that the tumors only had limited growth to 1–2 mm in the thyroid set-up, but 1,000 times greater in size back in the mouse. It was the original observation that led to his breakthroughs in angiogenesis in human disease processes. His research mate was David Long, a resident in surgery from the University of Minnesota. Long studied turbulence created by silicone rubber heart valves. Folkman’s set-up used silicone rubber tubing to perfuse the dog thyroids. They used vital dyes in their work: Long, to better visualize the action of the valves; Folkman, to perfuse the tissues to verify vessel patency. Oil-based dyes like Sudan IV dissolved into the rubber, but the water-based ones like chlorazol black did not. When they filled silicone tubes with dry powder of each dye and sealed both ends, Sudan IV diffused out of the tubing for months, where cholazol black did not [2]. “The result,” Folkman said, “initiated the field of sustained release of drugs [1].” The Navy took out a patent on their discovery, then reassigned it to Long and Folkman upon their discharge. They in turn turned it over royalty-free to the Population Council of the Rockefeller Foundation, which it used to develop implantable devices for the sustained release of progesterone as a means of birth control. On completion of training and now on the Harvard faculty, Folkman opened a laboratory at the Boston City Hospital. He impregnated test substances into bits of silicone rubber as one of his bioassays of angiogenesis, drawing on the principle that he discovered as a surgery resident working with rubber tubes attached to thyroid glands from dogs.

Fig. 27. Judah Folkman, ca. 1957, as a resident with Airplane, the dog in which he had implanted the first external cardiac pacemaker, another of his fundamental innovations in surgery. From the Harvard Medical Library in the Francis A. Countway Library of Medicine. Airplane was named the Dog of the Year by the National Society for Medical Research.

References 1. Folkman J. Is angiogenesis an organizing principle in biology and medicine? J Pediatr Surg. 2007;42:1-11. 2. Folkman J, Long DM. The use of silicone rubber as a carrier for prolonged drug therapy. J Surg. Res 1964;4:139-42. 4.2. The inspired afterthought that led to correcting the uncorrectable Operating on a 10-week-old girl for jaundice in 1955, Shigetsu Katsura, professor of surgery at Tohoku University in Sendai, searched beneath the hepatic hilum for a remnant of the major bile ducts, a cyst or nubbin large enough to create an anastomosis with a loop of bowel. It was the standard last step before declaring the pathology as the “uncorrectable” and thus incurable form of biliary atresia. Katsura found none. In an operative afterthought that sometimes occurs in surgery, he made an opening in the duodenum and sutured it to area that he had incised. To his surprise, as the baby recovered, bile began to appear in the stool, and the infant’s jaundice began to clear. When another jaundiced infant came to surgery, Katsura decided to simply suture the duodenum unopened to the cut surface of the fibrous plate. Excretion of bile was slower in coming, but the child was passing bile-tinged stool at the time of discharge. Jaundice never cleared, however, and the patient died [1]. His junior associate and eventual successor as chief of surgery at Sendai, Morio Kasai (1922–2008; Fig. 28), performed the autopsy. A fistula had formed from intrahepatic bile ducts into the lumen of the intestine. In a style associated with Japanese understatement and reserve, Ryoji Ohi, who would take his turn as chief upon Kasai’s retirement, wrote:

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He was very much impressed by the natural course of the bile from the liver to force its way through the duodenal wall … spontaneously. The establishment of the biliary fistula in this case provided an important hint [1]. In further pathological studies, Kasai, Ohi, and their pathologist Tohru Takahashi described the microscopic pathology of biliary atresia: ductules of microscopic size, hundreds of microns in diameter, within the fibrous plate at the bifurcation of the portal vessels [2]. When the next infant came to surgery, Kasai took the bold step of deliberately transecting the fibrous tissue in the hilum where Katsura had unintentionally created the bile fistula. Instead of suturing the fibrous tissue to the duodenum, Kasai made an anastomosis with a blind loop of jejunum in a Roux-en-Y jejunojejunostomy. The infant became his first long-term survivor, one of his successes in his first English language report in the Journal of Pediatric Surgery 13 years later in 1968. The article was arguably the first major surgical advance reported in the fledgling publication since its inception in 1966 [3]. In work that would consume decades, Kasai and Ohi made modifications to the operation and postoperative care that steadily improved their results: the benefit of early surgery; dissection to preserve critical areas where the ductules were consistently more numerous; and aggressive antibiotic treatment of bouts of cholangitis that were especially damaging to bile flow. Jaundice-free survival reached 55 percent among those operated on in the mid 1980s [1], a vast improvement for a condition that was uniformly fatal in infancy, progress that began when Kasai took the inspired step beyond his boss’s surgical afterthought and thus corrected the “uncorrectable.” References 1. Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12:871-4. 2. Ohi R, Kasai M. Intrahepatic biliary obstruction in congenital bile duct atresia. Tohoku J Exp Med. 1969;99:129-49.

3. Kasai M, Kimura S, Asakura Y, et al. Surgical treatment of biliary atresia. J Pediatr Surg. 1968;3:865-75.

4.3. Scientific discovery from lambs on a Pennsylvania farm to rats in a Manhattan apartment Before she became nationally known for her efforts in injury prevention in inner city children, Barbara Barlow’s upbringing in the central Pennsylvania farm country around her hometown of Lancaster led to a fundamental discovery in the prevention of necrotizing enterocolitis (NEC): breast milk prevented newborn infants from getting the disease. She showed that baby rats fed breast milk survived experimental NEC, whereas those fed formula did not. Published as the lead article in the October 1974 issue of the Journal of Pediatric Surgery, her paper became one of the most cited articles in the still-young publication’s first decade [1]. During her fellowship in pediatric surgery at Babies Hospital in New York, Barlow saw firsthand the epidemic of NEC that was afflicting prematurely born infants kept alive with aggressive life support. The babies were being fed formula. “I thought about how at home in Lancaster on the farm, sheep got bloats and calves got sick if they didn’t have mother’s milk,” she said. “So I looked at this and said, ‘I think this disease is because they’re not being breastfed [2].’” Barlow tested her hypothesis on an experimental model of NEC: baby rats that developed NEC brought on by hypoxia and contamination of the gastrointestinal tract with Klebsiella. She then fed the rats every 4 hours, day and night by gavage, with either a formula based on rat milk or breast milk extracted from nursing rat mothers. Because the experiment required feedings during off-hours and weekends, she fashioned a makeshift rat nursery in her apartment, surely one of the most unique of the 8 million stories in the Naked City. Despite Barlow’s bond with her chief, Thomas Santulli, her discovery sparked a feud between the two. Her presentation at the annual APSA meeting in April 1974 won a lot of attention for the department of surgical services at Babies Hospital. Santulli published a review of Barlow’s research in a throwaway journal and failed to give her credit. Worse, the article made it appear that it was his idea to send her to the laboratory to research the project. “He had no knowledge of what I was doing until I had the results,” Barlow said. “He never set foot in the lab. He just said, ‘Go to the lab and do a project because you have to write a paper.’” “I was furious,” Barlow said. “’What do you mean by saying it was your idea?’” she said to him. “I took the journal [Santuli’s throwaway] in the middle of a conference and threw it at him.” They were not on speaking terms for a month. “I loved him,” she said. “But I was so furious [2].” References 1. Barlow B, Santulli TV, Heird WC, et al. An experimental study of acute neonatal enterocolitis – the importance of breast milk. J Pediatr Surg. 1974;9:587-95. 2. Barbara Barlow, MD. Interviewed by Suzanne Boulter, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, April 10, 2008. Available from: https://www.aap.org/en-us/about-the-aap/PediatricHistory-Center/Documents/Barlow.pdf. Accessed January 13, 2019. 4.4. Lester Martin and the teen who died rather than have a stoma

Fig. 28. Morio Kasai.

A tragedy involving a Cincinnati teenager convinced Lester Martin (Fig. 29) to devise an operation to address ulcerative colitis (UC). The procedure – mucosal protectomy, total colectomy, and ileo-anal pouch anastomosis – became the standard sphincter-sparing operation for UC to the vast improvement in the quality of life for thousands of patients with the disabling condition.

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It had only been about a year after Martin had taken the job as the sole pediatric surgeon at the Cincinnati Children’s Hospital in 1957 when a colleague approached him at lunch in the hospital cafeteria. “There’s a patient upstairs with UC,” he said. “I think he needs an ileostomy or something. He’s in pretty bad shape.” He added, “You have time to finish your lunch.” “Oh, golly,” Martin said to himself. By the time he made it to the ward, the patient, a teenaged boy, had died. Although he had suffered through his disease for 3 years, he had refused a colectomy, even when it would have been lifesaving, because it meant living with an ileostomy for the rest of his life [1]. “It really bothered me,” he said. At the time, surgery was too often deferred until the course of the disease was overtaken by lifethreatening emergencies such as toxic megacolon and perforation. Teenagers, especially sensitive to body image, resisted permanent stomas, which they saw as disfiguring. Martin searched for a surgical alternative that would restore intestinal continuity to the anus and preserve continence [1]. Mark Ravitch and David Sabiston had described resection of the mucosa of the anorectum and anastomosis of the ileum to the anus after proctocolectomy in dogs in 1947 [2] but a limited trial of two patients revealed the difficulty with uncontrollable diarrhea and perianal skin excoriation that would prevent widespread application of the operation [3]. In 1949, Orvar Swenson showed that it was possible to preserve the anorectal sphincters even after removal of the rectum to the level of the levator ani in HD [4]. Martin spoke with Franco Soave of Genoa, who had published his sphincter-saving procedure for HD in the English literature in 1964 [5]. Martin learned that contraction of the internal sphincter relied on a reflex arc that started with the perception of distention that lay in the columns of Morgagni, so he resolved to preserve the transitional mucosa that covered this structure. He tried out the procedure on dogs, in which the dissection of the mucosa off the muscularis was “disarmingly easy.” Doing the same on his patient, a 12-year-old boy, was another matter.

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“Overwhelming” mucosal inflammation contributed to 8 hours of operating and the transfusion of four pints of blood. Despite regret that he had undertaken the case, Martin got the child through the operation, which throug was a success. Years later, Martin caught up with him, and found out he was an engineering graduate who was married with two children [1]. When the effluent from a straight ileoanal anastomosis irritated the perineal skin, Martin created an ileal reservoir by adapting the “J” shaped jejunal loop that was used to construct a new stomach after total gastrectomy for gastric cancer. In contrast to Ravitch’s failed attempt in human patients in the late 1940s, 30 years later in the mid 1970s, Martin had the advantage of nutritional support, steroid therapy to control mucosal inflammation, and broad-spectrum antibiotic coverage. He developed a routine to control mucosal inflammation with a regimen that included nothing by mouth, total parenteral nutrition, intravenous and topical steroid therapy, and systemic antibiotics. He reported his success with his first 17 patients in 1977 before the American Surgical Association (ASA) with publication in the Annals of Surgery [6]. He began to show adult surgeons in Cincinnati how to do the procedure. When Josef Fischer arrived as the newly named professor and chair of the department of surgery at the University of Cincinnati, he and Martin began a partnership to manage patients with UC that continued until Martin’s retirement. Martin’s dedication to the sensitivities of an adolescent led to a new operation in the treatment of UC. Even though the patient was essentially an adult in size and physiology, it was his sympathy to the psychology of a uniquely pediatric situation that led to a fundamental contribution in the treatment of inflammatory bowel disease. References 1. Lester W. Martin, MD. Interviewed by Brad W. Warner, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 5, 2007. Available from: https://www.aap.org/en-us/about-the-aap/Gartner-PediatricHistory-Center/DocLib/Martin.pdf. Accessed January 23, 2019. 2. Ravitch MM, Sabiston DC Jr. Anal ileostomy with preservation of the sphincter: a proposed operation in patients requiring total colectomy for benign conditions. Surg Gynecol Obstet. 1947;84:1095-9. 3. Ravitch MM. Anal ileostomy with sphincter preservation in patients requiring total colectomy for benign conditions. Surgery 1948;24:170-87. 4. Swenson O, Bill AH. Resection of rectum and rectosigmoid with preservation of sphincter for benign spastic lesions producing megacolon. Surgery 1948;24:212-20. 5. Soave F. La colon-ano-stomia senza sutura dopo mobilizzazione ed abbassamento extramucoso del retto-sigma. Una nuova tecnica chirurgica per la terpia della malattia di Hirschsprung. Osped Ital Chir 1963;8:285. 6. Martin LW, LeCoultre C, Schubert WK. Total colectomy and mucosal proctectomy with preservation of continence in ulcerative colitis. Ann Surg. 1977;186:477-9. 4.5. Dale Johnson’s central line story

Fig. 29. Lester Martin.

The year 2018 was the 50th anniversary of Douglas Wilmore and Stanley Dudrick's landmark 1968 publication reporting the first patient sustained completely by TPN, a newborn infant with near-total atresia of the small bowel who was slowly dying of malnutrition and dehydration [1]. TPN had been used in adults with short bowel syndrome as a result of massive resections, trauma, and as a nutritional adjunct in cachectic cancer patients, but never before to completely replace digested nutrients absorbed through the gut [2]. Having an integral role in the care of the baby was Dale Johnson, past president of APSA and longtime chief of pediatric surgery at the Primary Children's Hospital in Salt Lake City. A brand-new attending at CHOP

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who had just completed his training there, Johnson was on call alone; all his partners were away on vacation or out of town. It soon became apparent that the baby, a girl, was going to die on his watch. He and the baby's parents seemed to be out of options [3]. Before his training, Johnson had to wait a year before starting his fellowship, so he spent a year at the Harrison Department of Surgical Research at Penn. His office was just down the hall from Dudrick's lab, who was working on TPN under two other legendary Penn surgeons, Isidore Ravdin and Jonathan Rhoads. Johnson knew that Dudrick had been giving adults his 'puppy formula' of intravenous nutrients that he had developed in beagles. Now an attending caring for an infant in desperate need of fluid and nutritional support, he contacted Dudrick and explained the situation. Here was a chance to save a child's life, he explained, and an opportunity to prove the concept that intravenous nutrition could sustain life over a prolonged period [3]. Dudrick agreed to give it a try, and the baby became the first human whose nutrition was supported completely by intravenous solutions. Johnson cared for the child and dealt with the many complications she suffered, nearly all of them were unique to the new technology. When each appeared, it was for the first time. Johnson had to recognize something was wrong, figure out the cause, and devise an intervention. He assigned the resident rotating on his service to take the infant on as his only patient. The trainee, Douglas Wilmore, would continue his interest in surgical nutrition, and would go on as one of the most prominent clinicians in the field at the Peter Bent Brigham Hospital. Willmore and Dudrick left Johnson off as a co-author on their landmark paper of 1968, although they gave him an acknowledgement at the end of the manuscript for his pains. Johnson's lasting contribution from the episode was the first central line placed in a newborn infant. Flexible cannulas were still far in the future. Among the many tasks of the pediatric surgical fellow was to place stainless steel needles for intravenous access and secure them so they wouldn't be displaced. During his year in the lab, he had to do the same, only using a vein in the tail of lab rats. In typical fashion, young Johnson searched for a better way. His project required periodic visits to the Merck research labs across the Delaware River in New Jersey. He and the white coats at Merck came up with an alternative to trying to keep a rigid steel needle secured onto a rat tail. They took insulated copper wiring, removed the metal wire, and placed the hollow insulation into the tail vein, a situation that allowed the rat more mobility than a rigid steel needle. When it came time to place a catheter in a human patient, that is what Johnson used – the polyvinyl insulation from a copper wire [4]. It was the first time a pediatric surgeon was called for a central line for a newborn, a scenario that would be repeated countless times since, especially at 4 p.m. on a Friday afternoon before a holiday weekend. Generations of pediatric surgeons have Dale Johnson to thank. References 1. Wilmore DW, Dudrick SJ. Growth and development of an infant receiving all nutrients exclusively by vein. JAMA. 1968;203:860-4. 2. Dudrick SJ. A three and one-half decade nutritional and metabolic Iliad. J Amer Coll Surg. 2007;205:S59-S64. 3. Johnson DG. Oral interview conducted by Rebecka Myers, 2018. 4. Personal communication, Dale Johnson, May 5 2017, Hollywood, FL, May 5, 2017 4.6. Pediatric surgery’s non-surgical contribution to trauma surgery It also has been 50 years since Purushottam Upadhyaya and Jones Simpson of the Hospital for Sick Children in Toronto published their seminal paper of 1968 where they described selective management of injuries to the spleen in Surgery, Gynecology and Obstetrics [1]. When it appeared, the article sparked controversy because it departed radically from surgical dogma ascribed by such surgical icons as Kocher and

Mayo. “Injuries of the spleen demand excision of the gland,” wrote Theodor Kocher in 1911 in his widely read textbook. “No evil effects follow its removal, while the danger of hemorrhage is effectively stopped [2].” In an era before the development of hematology and immunology, no one knew what the organ did, much less why it was there. But even in Kocher’s time, in 1903 Nicholas Senn of Chicago, a member of the founding editorial board of Surgery, Gynecology, and Obstetrics, warned against unwarranted removal of the spleen: The spleen has its important functions to perform, and although in its absence other organs appear to assume its role in the organism and compensate for its loss, we are as yet not warranted in assuming that its removal is a matter of so little consequence that it is not necessary to limit it to cases in which no other alternative is left [3]. Investigators suspected that splenectomy left the host susceptible to infection. In 1919, Dudley Morris and Frederick Bullock injected rats that had undergone splenectomy with plague bacillus. Animals that had lost their spleens had a mortality rate – 81 percent – much higher than the 39 percent in controls that still had the organ. In a landmark bacteriological article published in a surgical journal, the Annals of Surgery, the researchers warned surgeons that the spleen might be similarly important in human immune defenses: It is not improbable that the human body deprived of its spleen shows a similar increased susceptibility to infection. Bearing this in mind, some of the fatalities following splenectomy, especially where death was attributed to infection, may find a ready explanation and tend to increase our caution in the removal of this organ [4]. In 1952, in Indianapolis Harold King and Harris Schumaker, Jr., made a disturbing finding in their review of approximately 100 cases at the Indiana University Hospitals. Five infants with hereditary spherocytosis suffered severe bacterial infections 2 1/2 to 3 years after surgery, four with meningitis. Two died. Splenectomy had left the infants vulnerable to overwhelming infection [5]. It was a difficult concept: An operation that was supposedly beneficial was putting patients’ lives at risk. But all surgeons dealt with trauma and removed spleens to save lives. Were they also putting patients at risk for serious infections? In 1973, Don Singer of Houston, in an extensive review of 2,795 patients with splenectomy since Harris and Schumaker’s report, found a 1.45 percent rate of severe infections with a 0.58 percent mortality among 688 trauma splenectomies, rates that were low, but still more than 50 times the rates of the general population. Older children and adults were not spared from the risk of post-splenectomy sepsis and were still susceptible [6]. Recently Sherif Emil of Montreal pointed out that the article by Upadhyaya and Simpson reported a practice that actually started at the hospital under Robert “Tim” Wansbrough, chief of surgery at the Hospital for Sick Children in Toronto from 1945 to 1956. Upadhyaya and Simpson’s paper included Wansbrough’s series of 32 patients with splenic injury, which began in 1948. Emil says that Wansbrough learned the potential success of non-operative management of the spleen from Herbert Owen, a pediatric surgeon at McGill University and Montreal Children’s Hospital, and recipient of the Military Cross for his service in the Canadian military during World War II. As word began to spread about Owen’s radical departure from surgical dogma, he was called into the office of the chair of surgery and told to knock it off or he would lose his job [7]. Of patients undergoing an operation for a ruptured spleen in Upadhyaya and Simpson’s paper, nearly half (19 of 40, 47.5%) had no active bleeding from the organ at the time of laparotomy. In another 12 patients, they made the clinical diagnosis of splenic injury on the basis of history and examination and were able to avoid operation. In all, nearly 60 percent of their patients (31 of 52, 59.6 percent) with the clinical diagnosis of splenic injury did not require an operation [1].

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They were cautious in their recommendation of a completely nonoperative approach, however, because of the difficulty in making the diagnosis of splenic injury. Symptoms often were vague and non-specific, especially in a frightened child with other injuries. A left-sided rib fracture or a shadow on a plain film of the abdomen might suggest the presence of a ruptured spleen but other signs were required to make this diagnosis. Advances in imaging technology provided more precision in the diagnosis of splenic injury, first with nuclear scans in the 1970s, then computed tomography (CT) in the 1980s. Now surgeons could carefully monitor a stable patient without fear that a significant injury had been missed. In 1988, Richard Pearl updated the experience at the Hospital for Sick Children where surgeons routinely used nuclear scans and began to apply CT. He reported an overall salvage rate of 95.9 percent (70 of 73), 65 (86.7 percent) not undergoing laparotomy and another 5 undergoing repair or a partial splenectomy [8]. Over the next decade, a non-operative approach was adopted for adult trauma victims and expanded to patients with hepatic injuries. Pediatric surgeons, with the benefit of advances in hematology, immunology, and radiology, established a radically new approach to trauma management, to the benefit of patients of all ages. References 1. Upadhyaya P, Simpson JS. Splenic trauma in children. Surg Gynecol Obstet. 1968; 126:781-90. 2. Kocher ET. Textbook of Operative Surgery, trans by Stiles HJ, Paul CB. London, A & C Black, 1911, p.565-6. 3. Senn N. Hemorrhage of the spleen. J Amer Med Assoc 1903;41:12415. 4. Morris DH, Bullock FD. The importance of the spleen in resistance to infection. Ann Surg. 1919;70:513-21. 5. King H, Shumacker HB. Splenic studies. I. Susceptibility to infection after splenectomy performed in infancy. Ann Surg. 1952;136:239-42. 6. Singer DB. Postsplenectomy sepsis. Perspect Pediatr Pathol 1973;1:285-311. 7. Emil S. Personal communication, April 10, 2019. 8. Pearl RH, Wesson DE, Spence LJ, et al. Splenic injury: a 5-year update with improved results and changing criteria for conservative management. J Pediatr Surg. 1989;24:428-31. 5. The Founding of APSA 5.1. Two meetings that got it started The glitzy banquet and multimedia scientific presentations of the annual meeting of APSA belie the two decidedly informal gatherings that got the organization started: one in an Atlantic City boardwalk café and an all-nighter in a shared room at an overbooked burn conference. The creation of APSA came from a cohort of pediatric surgeons that trained in the 1950s and 1960s. In contrast to their predecessors, most of whom were taught by Robert Gross and his staff at The Children’s Hospital in Boston, many of the new generation of pediatric surgeons came from children’s hospitals outside of the Hub, trained by the next generation of leaders in the field that included C. Everett Koop (Philadelphia), Willis Potts (Chicago), and H. William Clatworthy (Columbus). Many had appointments in academic departments of surgery as heads of single-surgeon sections. As the sole fulltime surgeons in children’s specialty hospitals, each held the title of surgeon-in-chief by default. Yet none had board certification in their specialty because such a distinction didn’t exist. In 1967, the ABS and the ABMS refused to grant board certification authority in the field of pediatric surgery. As the sole professional society representing the specialty, the Surgical Section appeared no closer to achieving board certification status than their prior rejections in 1957 and 1961 [1].

Fig. 30. Lucien Leape.

Frustration with the Surgical Section and the inability of the specialty to win Board certification status underlaid an ad hoc gathering of pediatric surgeons in a café off the Atlantic City boardwalk during the annual meeting of the American College of Surgeons in October 1968. In the words of Dale Johnson, they “rehashed identity problems.” Lucian Leape (Fig. 30), one of those present, believed that the ABS refused its support because pediatric surgeons were too closely aligned with pediatricians. “Pediatric surgery is never going to get anywhere until we stand alone as surgeons,” he said. “We have to have our own organization [1].” Not part of the Surgical Section hierarchy, Leape had an inkling of the political blowback that would accompany an attempt to establish a surgical organization independent of the Surgical Section. But Koop knew. The youngest at the inception of the Surgical Section 20 years previously at age 32, Koop was now the oldest among the gathering at the bistro. He recognized the difference in ages between the two groups and the inherent resistance between generations. “It is not going to happen, Lucien,” he said, “unless you younger people do it [1].” Leape let the concept gestate and thus he was ready for the second key meeting that actually created APSA. Serendipity brought Leape and E. Thomas Boles together in March 1969 at the unlikely venue of the inaugural meeting of the American Burn Association in Atlanta. The excitement of a conference devoted to burn research and treatment attracted an overflow crowd and the conference hotel was beyond its capacity. Leape was lucky to find Boles with a room and a spare bed. Boles, like Leape, was convinced that an independent professional organization with an unambiguously surgical identity was necessary for the specialty to develop. As Leape unpacked, they started an all-night conversation that became the nidus of the largest organization of pediatric surgeons in the world [2]. By dawn they resolved to call a more conventional meeting to lay the groundwork for what would become APSA. They invited 24 pediatric surgeons, like themselves outside the inner circle of the Surgical Section, for a meeting at the O’Hare airport hotel in May. Sixteen showed up and began the hard work of building a tangible organization. But it was two ad hoc gatherings in a bistro off the Atlantic City

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Boardwalk and a shared room in an overbooked hotel that sparked the creation of APSA. References 1. Johnson DG. Excellence in search of recognition. J Pediatr Surg. 1986;21:1019-31. 2. Leape LL. A brief account of the founding of the American Pediatric Surgical Association. J Pediatr Surg. 1996;31:12-8. 5.2. Advice from a Dutch uncle To win board certification status, the issue that catalyzed the creation of APSA, pediatric surgery needed the candid assessments of where their previous applications fell short. Its advocates were pursuing an endeavor where powerful Figures wanted them to fail. They needed the insights of an insider who would be blunt with hard advice; in short, a Dutch uncle who gave his opinion but no more. It was up to the listener to follow through. For pediatric surgery, the Dutch uncle was William Holden, chair of surgery at Case Western Reserve University (Fig. 31). Holden was chair of the board of directors of the ABS in 1967–1968, a crucial period after Mark Ravitch led yet another failed attempt in 1967 and just before

Harvey Beardmore initiated the final successful push in 1969 and formalization of the Certification of Special Competence in Pediatric Surgery by the ABS and ABMS in 1973 [1]. A major reason why the Surgical Section was unable to win board recognition was that the leaders of the ABS and the major surgical societies saw specialization as fragmentation of the main body of surgery and a trend to be resisted. 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 [2]. In retrospect, it was no surprise that applications for Board recognition by Koop and the Surgical Section were rejected in 1957 and 1961. He shared the terse summary of the deficits of the field in a later conversation with James O’Neill, Jr., who succeeded him as surgeon-in-chief at the Children’s Hospital of Philadelphia: “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 conclusion that was shorter but as direct: “You ain’t got nothin’ [3].’” In 1966 the field responded by establishing criteria for training through the education and training committee of the Surgical Section,

Fig. 31. William Holden (left), with Robert Zollinger (center) and William Altemeier.

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better known as the “Clatworthy committee” after its chair, H. William Clatworthy of Columbus [4]. To help establish a body of knowledge Stephen Gans organized the Journal of Pediatric Surgery, which published its first issue in 1966, with Koop as its first editor-in-chief [5]. Despite these accomplishments, another run at board certification led by Mark Ravitch, the epitome of the surgical establishment, was rejected yet again in 1967. After the experience, Ravitch’s advice was to “lay low,” and avoid any attempts anytime soon [1]. Robert Izant (Fig. 32), a Gross trainee, was among a burgeoning generation of pediatric surgeons fresh from training programs and eager for a board of pediatric surgery. The Surgical Section assigned him to act as its emissary to meet with Holden, his boss at Case. 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. 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

Fig. 32. Robert Izant.

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overemphasized [1]. Holden gave clear advice: as a surgical specialty, pediatric surgery had to establish itself as an unambiguously surgical specialty if certification authority was to be granted under the aegis of the ABS. It wasn’t going to happen as long as the major professional society of the field was part of a pediatric society. An independent organization of pediatric surgeons became an unofficial prerequisite for board recognition. The concept became the philosophical justification for the founding of APSA. References 1. Johnson DG. Excellence in search of recognition. J Pediatr Surg. 1986;21:1019-31. 2. Koop CE. A perspective on the early days of Pediatric Surgery. J Pediatr Surg. 1999;34(5 Suppl 1):38-45. 3. O’Neill JA Jr. Comments made at the editorial board meeting, Journal of Pediatric Surgery, Hollywood, Fla., May 5, 2017. 4. Ziegler MM. Pediatric surgical training: An historic perspective, a formula for change. J Pediatr Surg. 2004;39:1159-72 5. Grosfeld JL. 30th Anniverary issue: Journal of Pediatric Surgery, 19661996. J Pediatr Surg. 1996;31:1-2. 5.3. The exclusive inclusivity of APSA Among the reasons why the APSA arose independently of the Surgical Section was that the latter’s membership included surgeons who were self-taught, had graduated from programs with substandard educational rigor and clinical exposure, and were not engaged in the fulltime practice of children’s surgery. Lucien Leape and E. Thomas Boles conceived a society of pediatric surgeons that had unquestioned education and training in the field and had fulltime practices in infants and children’s surgery. The devil, of course, was in the detail of how specific membership criteria were defined, which would determine the character and direction of the organization. Leape gave a first-person account of the origin of the association, the source of the details that follow [1]. In the first organizational meeting at the airport hotel in Chicago on May 23 and 24, 1969, Leape and Boles outlined their concept for the society: in the former’s words, an inclusive organization of “all qualified pediatric surgeons who confined their surgical practice to children.” When residency accreditation and board certification mechanisms in the specialty became official, only graduates of approved programs that had their boards would be accepted. Their view won the support of most of the surgeons in the founding group. The next step was to win converts in the wider community of those in the practice of children’s surgery. After the May meeting adjourned, the organizing group identified about 100 surgeons to contact and solicit support for the proposed association. All would qualify under any criteria: training in recognized programs, in the fulltime practice of children’s surgery, and with established clinical reputations. They met again in July. Also attending was the three past chairs of the Surgical Section, which naturally became known as “the old guard.” To the surprise of Leape, Boles, and their organizing group, the old guard agreed that a new, entirely surgical organization was needed. But they preferred a small body of elite specialists with standing in the broader community of organized surgery, who might better represent the goals of pediatric surgery as a whole, especially on the issue of recognition as a specialty with board certification status. 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. A compromise was reached – a restricted group of about 100 fulltime pediatric surgeons who had made significant contributions to the field. What a “significant contribution,” wrote Leape, “was purposefully left vague.” At a third organizing meeting in October, the evening after the Saturday session of the Surgical Section meeting, various lists

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of potential members were proposed. In the selection process, the arbitrariness of whom to include in the 100 – they could really agree on only about half the names – became clear. “It was a disaster,” wrote Leape of his candid assessment of the meeting. As soon as they returned home, Leape and Boles scrambled to get the organization back on track, calling all the members of the original organizing group and getting general agreement on their original conception of an open membership. On the basis of a second mail poll, they agreed on a new set of criteria: U.S. or Canadian citizenship; practice confined to the surgery of infants and children; certification by the ABS or Fellowship in the Royal College of Surgeons of Canada; and at least 2 years in practice after completion of residency. Rather than soliciting applications, the membership committee identified candidates, verified their qualifications, then forwarded their names to the organizing group. “This turned out to be a formidable task,” Leape wrote, “but in the end, very few who were qualified were overlooked.” In January 1970, invitations were sent to 210 candidates to apply for charter membership; 191 joined. Ninety-six attended the inaugural meeting at the Pheasant Run Resort outside Chicago on April 17, 1970. At the founding meeting, chaired by Boles and Leape acting as secretary, the general membership went over the bylaws point by point, the discussion often spirited. The membership criteria were made stricter with regard to the practice of pediatric surgery. One’s practice had to be devoted entirely to pediatric surgery; new members could not be elected to membership until 2 years after residency training; and membership credentials would be reviewed every 4 years to assure compliance. “It was clear,” Leape wrote, “that membership in this society would be limited to those who are fully committed to pediatric surgery.” The foundational concept of APSA was in the definition of its membership: inclusive of all surgeons entirely devoted to infants and children, exclusive in terms of training and certification. All were fundamental issues during the maturation of the specialty and became embodied in the founding organization of APSA. References 1. Leape LL. A brief account of the founding of the American Pediatric Surgical Association. J Pediatr Surg. 1996;31:12-8 5.4. “Gentlemen, you have your boards” The Surgical Section appeared to have a congenital inability to win board certification status under the ABS and the ABMS. The issue was one of the primary reasons for the creation of APSA in 1969. In his APSA presidential address of 1986, Dale Johnson chronicled the series of attempts by advocates of pediatric surgery to gain board certification status. Most of the events that follow come from his manuscript [1]. Many surgeons saw the formation of specialty boards as fragmenting and thus weakening the discipline. At first the specialties made sense: ophthalmology (the first specialty board, founded in 1916), then otorhinolaryngology (1924), obstetrics and gynecology (1927), orthopedics (1935), urology (1935), and neurosurgery (1940). The ASA led the creation of a board of surgery (1937) but alarm grew as specialties once integral to its corpus began to break away: plastic surgery (1941), colon and rectal surgery (1949), and thoracic surgery (1971). Thus, pediatric surgeons faced stiff resistance from the surgical establishment when they decided to seek formal board recognition. 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 [2]. In 1956, Koop’s first proposal to the ABS on the behalf of the Surgical Section was actually approved, only to be rejected by the ABMS in 1957.

He tried again in 1960, this time with the support of the AAP and the endorsement of the ACS. When the ABS rejected the application in 1961, it archly suggested that pediatric surgeons might find a more appropriate organizational context among pediatricians. Pediatric surgery addressed the deficiencies by establishing standards for training by the education committee of the Surgical Section (1966–1970), familiarly known as the “Clatworthy Committee,” and the creation of the Journal of Pediatric Surgery (1966). After a third rejection in 1967, a group of upstarts not connected with the inner circle of the Surgical Section founded APSA in 1969 to establish a surgical organization independent of the AAP to claim a surgical identity. That year, the ACS named pediatric surgery as one of its component members, giving the discipline a measure of legitimacy. In 1969, Harvey Beardmore of Montreal (Fig. 33), who had succeeded Ravitch as chair of the Surgical Section, took another run at the ABS only 2 years after the 1967 failed attempt. Beardmore’s approach, in Jud Randolph’s words, was “a unique brand of diplomacy, humor, and purpose [3].” He crisscrossed the country to build support. In addition to backing from the AAP and the ACS, he had key allies within the ABS hierarchy. David Sabiston, newly appointed chair of the ABS for 1971–1972, had been 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 3 years in training with Ladd in Boston. While his practice at Vanderbilt had drifted away from pediatric surgery, Scott was a member of the ABS and a strong advocate for the field. In March 1971, Keith Reemtsma, then chair of the department of surgery at the University of Utah, was assigned to chair an ad hoc committee of the ABS to study Beardmore’s petition. When Reemtsma was a medical student at Penn, he was a Koop protégé. He had just recruited Johnson away from Philadelphia to join his department as the first pediatric surgeon in the state. Reemtsma’s committee recommended approval of Beardmore’s petition. In June 1972, the ABS approved Beardmore’s proposal 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 [1]. 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 the application at their April 1973 meeting. 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 1974, Beardmore, Randolph, and Rowe took the inaugural board examination in Philadelphia. In Randolph’s words, they “fortunately passed [3].” Beardmore won diploma number 3; Randolph, 4; and Rowe, 5. 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. 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 [3]. Just before the 6th APSA meeting in April 1975, more than 250 surgeons settled in a resort ballroom in Puerto Rico to take the 3-hour test. Nearly all (238) passed and achieved certification [6]. 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 [4]!”

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“Some people think my being Canadian was an advantage,” said Beardmore in a 2005 interview with Jay Grosfeld. “It was the presence of a Canadian who had no real axe to grind who pulled it off [5].” References 1. Johnson DG. Excellence in search of recognition. J Pediatr Surg. 1986;21:1019-31. 2. O’Neill JA Jr. Comments made at the editorial board meeting, Journal of Pediatric Surgery, Hollywood, Fla., May 5, 2017. 3. Randolph JG. History of the Section on Surgery, the American Academy of Pediatrics: the first 25 years (1948-1973). J Pediatr Surg. 1999;34(5 Suppl 1):3-18. 4. Koop CE. A perspective on the early days of Pediatric Surgery. J Pediatr Surg. 1999;34(5 Suppl 1):38-45. 5. Beardmore HE. Interview by Grosfeld JL. Pediatric History Center, American Academy of Pediatrics oral history project. Harvey E. Beardmore, MD. Elk Grove, IL, American Academy of Pediatrics, December 2–3, 2005. Available from: https://www.aap.org/en-us/ about-the-aap/Gartner-Pediatric-History-Center/DocLib/ Beardmore.pdf. Accessed February 3, 2019. 6. Amoury RA. “Matchmaker – matchmaker” – The evolution of pediatric surgical training programs and the selection of candidates for pediatric surgical training through the first quarter-century of the American Pediatric Surgical Association. J Pediatr Surg. 1995;30:143-57. 5.5. APSA’s new logo

Fig. 33. Harvey Beardmore.

“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 [4].” 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 [4].

In 2018, APSA unveiled its new logo (Fig. 34), a gender-neutral version of a surgeon holding an infant. It still has the triangle design of its predecessor (Fig. 35), with a contemporary touch button look that places it in the 21th century. It loses the hard-to-read text on its border, and uses instead a two-word slogan, ‘Saving Lifetimes,’ a derivation from a quote from H. William Clatworthy, who said when describing the progress of pediatric surgery during his career, “We were saving whole lifetimes that had never been saved before [1].” The two words are an inspired choice, and certainly better for the task than other aphorisms from the field’s past (e.g., “a child is not a little adult [2, 3],” and “pediatric surgery exists as a specialty, not as a monopoly, but to establish a standard,” which has already been claimed by our British brethren [4]). In an article that is required reading for anyone interested in the history of organized pediatric surgery, Lucien Leape in 1996 recounted the backstory of the creation of the original logo in his memoir of the founding of APSA in the Journal of Pediatric Surgery [5]. As one of his final tasks as secretary before the first meeting of the association at

Fig. 34. The new APSA logo (2018).

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design that the majority of the charter members voted for at the meeting [5]. It worked for 50 years. Ashcraft, the impromptu model, became the very model of a modern major pediatric surgeon: program director at Children’s Mercy Hospital in Kansas City, editor of one of the major textbooks in the field, and president of APSA. APSA’s updated logo reflects changes in artistic tastes and social sensitivities, just as the organization has changed over the past halfcentury. Significantly, it kept the overall triangular format and a Figure that recalls Ashcraft’s profile. In the midst of change, the design reassures a fidelity to the enduring tripartite principles of patient care, education, and research. References 1. Randolph J. First of the best. J Pediatr Surg. 1985;20:580-91.

Fig. 35. The old APSA logo (1969).

the Pheasant Run resort outside Chicago in April 1970, he asked a medical illustrator at the University of Kansas for mock-ups that might serve as an emblem for the new organization. Most were variations on what one might expect for a pediatric society, such as an infant in swaddling in a circular or oval design. One Figure caught Leape’s eye; in his words, “a surgeon in operating dress looking in a benign but determined way at an infant he was holding in his hands.” But the surgeon just didn’t look authentic. “She couldn’t seem to get [the surgeon] right. [He] looked wooden and unrealistic.” Leape decided the artist needed a real surgeon as a model, and he knew someone who would be perfect for the task. He wrote So, one day I recruited our resident, Keith Ashcraft, to don his greens, cap, and mask, and pose for the illustrator so she could get a better idea of what it really looked like. It worked, and that became the

2. Barrington-Ward LE. The abdominal surgery of children. London: Humphrey Milford, 1928. 3. Swenson O. Foreward by WE Ladd. Pediatric surgery. New York: Appleton-Century-Crofts, 1958. 4. Williams DI. Denis Browne and the specialization of paediatric surgery. J Med Biogr 1999;7:145-50. 5. Leape LL. A brief account of the founding of the American Pediatric Surgical Association. J Pediatr Surg. 1996;31:12-8. 6. Pediatric Surgical Miscellany 6.1. The lost chapter, or why Gross’s 1953 textbook was ‘only’ 1,000 pages long Robert Gross’s (1905–1988) 1953 single-authored text, The Surgery of Infancy and Childhood (Philadelphia, W.B. Saunders), has two anecdotes appropriate to its legendary status in the history of pediatric surgery. The first is that it was 1,000 pages in length, including the index section (Fig. 36), because of the obsessive nature of the author [1]. Tom Holder, past president of APSA and a Boston trainee under Gross,

Fig. 36. Last page of Gross’ textbook.

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remembers that his chief was always perfectly groomed, every hair in place even when he was driving a tractor on his farm near Framingham, MA [2]. According to the late Judson Randolph, like Holder a Boston trainee and past president of APSA, it was no surprise to those who knew his fastidious nature that his textbook would have a set number of pages [1]. The second was that the textbook lacked a key subject, sacrococcygeal teratoma [1], an omission that somehow was overlooked by his editors but was no doubt noted by his contemporaries but who kept their silence [3]. One of Gross’s trainees in Portland, ME, had a case of sacrococcygeal teratoma in an infant whose parents were rural folk not willing to journey into Boston. They insisted on having surgery in Maine. He called his former chief for advice. “I need to operate on this sacrococcygeal teratoma,” he said. “I just wanted to walk over the steps with you, if you would give me a few minutes here on the phone.” “Well, do you have a copy of my book?” Gross asked.“Oh, yes, sir,” the former resident replied. “I’ve looked at it from page one to page one thousand, and there’s nothing on sacrococcygeal teratoma in the book.” After walking him through the steps of the procedure, Gross picked up a copy of his book. “Sure enough, there was no chapter of sacrococcygeal teratoma,” said Randolph. At his office in Framingham that night, Gross rummaged around and found that the draft of the chapter had slipped behind the old-fashioned steam radiator in his office. “It had never made it into the book,” Randolph laughed. [3] It was also a good way to keep the book within the thousand-page limit. After the story above was recently shared with the membership of APSA on its electronic newsletter, Albert Dibbins took issue with the assertion that Gross’s search for the errant chapter was sparked by a former resident in Portland, ME. Dibbins, who spent his entire multidecade career in the state, knew everything surgical in Portland. “No one who practiced in Portland trained at the Brigham or would have had contact with Children’s,” he wrote. “The surgeons in Portland who were trained in Boston were trained at the Massachusetts General Hospital (MGH). No one at the MGH would have sent a patient to Children’s.” However good the story, it seems, this one ran against one of the immutable laws of surgery in New England. Some taboos cannot be broken. References 1. Randolph J. First of the best. J Pediatr Surg. 1985;20:580-91. 2. Thomas M. Holder, MD. Interviewed by George W. Holcomb, III, MD MBA. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 5, 2006. Available from: https://www.aap.org/en-us/about-the-aap/ Pediatric-History-Center/Documents/Holder.pdf. Accessed September 13, 2017. 3. Judson Randolph, MD. Interviewed by Kurt Newman, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 26, 2007. Available from: https://www.aap.org/en-us/about-the-aap/PediatricHistory-Center/Documents/Randolph.pdf. Accessed September 14, 2017. 6.2. It seemed like a good idea: the story of inversion appendectomy Inversion of the appendix was used as a means of performing an incidental appendectomy in infants and children but created a lead point for intussusception, a complication that led to its abandonment just years later. In theory, the operation made sense: appendicitis is a disease of childhood and adolescents, so eliminating the appendix by inverting it into the cecum seemed to be a nifty maneuver that

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dispensed with the structure as a future cause of problems for the rest of the patient’s life. Technically, it did not further soil a dirty case and kept a clean operation from contamination. John Lilly and Judson Randolph resurrected the procedure and reported their experience in the Journal of Pediatric Surgery in 1968. They stripped the mesoappendix along the length of the appendix to make it non-viable as it was inverted into the cecum with a steel probe. At the time of their report, they did more than 100 cases using the technique at the Children’s Hospital of the District of Columbia, including operations for esophageal reflux and intussusception [1]. It made the most sense in patients coming to surgery for malrotation, where traditionally the appendix was removed as it could wind up anywhere in the peritoneal cavity and confuse diagnosis by causing pain in an unexpected location. Trouble arose when patients began to have intussusception from the procedure, the first report in 1969 in adults just one year after Lilly and Randolph’s article. The inverted appendix, still viable, was a lead point that drew the cecum into the ascending colon as an intussusceptum. While Lilly and Randolph did not have the complication among their cases, they heard of four pediatric cases of post-inversion intussusception. In an admirable example of academic candor, in 1973 they withdrew their recommendation of inversion as a method for incidental appendectomy in a commentary published in the Journal of Pediatric Surgery. “We believe any procedure, which requires for its success performance by selected surgeons or institutions, is probably not worth its salt,” they wrote [2]. In the same issue of the Journal, Harry Bishop and Howard Filston at CHOP came up with a solution. They inverted the structure to where there was about a 3–4 mm nubbin left protruding, then ligated it as an additional means of cutting off its blood supply before a final inversion of the stump. They had more than 200 cases using their modification without complications, including intussusception [3] Decades later, reports of intussusception after inversion appendectomy continued to appear. In 1995 Jeff Hoehner, now a pediatric surgeon in Arizona, reported three cases including one that extended to the child’s anus and presented as a rectal prolapse [4]. In 2008, 4 decades after Lilly and Randolph’s original article, Amit Arora, now a thoracic surgeon in Ohio, reported a case of intussusception that followed inversion appendectomy with ligation of the base as described by Bishop and Filston [5]. That it took 40 years to report a case of intussusception using the CHOP technique may be proof of its effectiveness. It is probably more likely that in the modern era of minimally invasive surgery most pediatric surgeons today don’t bother with inverting the appendix. When they perform an incidental appendectomy, they simply ligate the structure and throw it away. Carol Scott-Conner, former chair of surgery at the University of Iowa, read this vignette and wrote, “I often tell the residents that people write about how good operations are,” she wrote. “They rarely go back and drive a stake through the heart of an operation that hasn't panned out.” References 1. Lilly JR, Randolph JG. Total inversion of the appendix: experience with incidental appendectomy in children. J Pediatr Surg. 1968;3:357-63. 2. Lilly JR, Randolph JG. On the inversion technique of incidental appendectomy. J Pediatr Surg. 1973;8:887. 3. Bishop HC, Filston HC. An inversion-ligation technique for incidental appendectomy. J Pediatr Surg. 1973;8:889-92. 4. Hoehner JC, Kimura K, Soper RT. Postoperative intussusception as a consequence of inversion appendectomy. Pediatr Surg. Int. 1995,10:51-53. 5. Arora A, Caniano DA, Hammond S, et al. Inversion appendectomy acting as a lead point in intussusception. Pediatr Surg. Int. 2008;24:1261-4.

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6.3. “You might not be able to make a living operating only on children” When he began to consider his options for a career in surgery, Alex Haller, who would become children’s surgeon-in-charge at the Johns Hopkins Hospital, asked Mark Ravitch for his advice. The only surgeon performing non-cardiac pediatric surgery at Hopkins in 1951, Ravitch seemed to be a good person to ask. But his response surprised the young surgeon. “You might not be able to make a living operating only on children,” his mentor said. “[Be] a well-trained general surgeon first and let pediatric surgery be your hobby. It is a great field! But there may be no future for the specialty [1].” It was a problem inherent to the field. In Great Britain, surgeons who were interested in children’s surgery also faced the same problem. “There was no livelihood in caring for the young,” wrote David Williams, the dean of British pediatric urology. “Physicians were dependent both for their income and for their professional advancement upon adult practice [2].” When William Ladd was named to the fulltime staff at The Children’s Hospital in Boston in 1937, the position came at a financial sacrifice: he had to close his downtown private practice that he had maintained for almost 2 decades [3]. His family’s wealth probably allowed him to bear the financial sacrifice. Sir Denis Browne, the father of modern British pediatric surgery, was the first surgeon in London to confine his practice to the field. He was able to do so because his wife, Helen Simpson, was a successful writer. When she died in 1940, he married Lady Moyra Ponsonby, another woman of means [2]. Oswald Wyatt of Minneapolis had to have faith that his decision to devote himself entirely to pediatric surgery would ultimately work out. Convinced to take the leap by Herbert Coe of Seattle, the first U.S. surgeon to maintain a practice exclusively to children, Wyatt closed his practice in 1927 to obtain additional experience in clinical pediatrics and children’s surgery at Washington University in St. Louis and Children’s Memorial Hospital in Chicago [4]. When he returned in 1928, he was refused privileges at the university medical center by Owen Wangensteen, legendary chair of surgery at the University of Minnesota [5]. Faced the double challenge of exclusion from the university hospital and the Depression of the 1930s, “[Wyatt] nearly starved to death!” H. William Clatworthy later wrote [3]. With time, Wyatt’s practice became a success because pediatricians, both in community offices and academic departments, embraced Wyatt’s specialized training and expertise [5]. Lester Martin faced similar odds after he completed his training in Boston in 1957. There was a sudden vacancy in the position of surgeon-in-chief at the Cincinnati Children’s Hospital. With more than 80 pediatricians on staff and no fulltime specialists in children’s surgery, it was an excellent opportunity. Marshall Lee, a general surgeon who had held the position before him, had relocated to Boston as a medical director with the John Hancock Life Insurance Company. Thus, Martin was able to stop by his office to find out why he had left. To Lee, children’s surgery was “a hobby” that took too much time from his private practice. “You can’t make a living in pediatric surgery,” Lee said, reprising the advice that had become one of the characteristics of the field. Another Cincinnati surgeon described the financial facts of life to Martin. Two young people get together, and they’re going to get married and have a baby, sometimes not exactly in that order, and they don’t have any money. The young man gets himself a job somewhere, a minimum-wage type job, and they save up enough money to pay the obstetrician. The pediatrician—they can put that on time, by so much a month. And if the baby has to have surgery, there just is nothing left for it. It’s all for free [6]. Nonetheless, Martin decided to pursue the opportunity, and one of the legendary careers in American pediatric surgery began. Today the financial picture for pediatric surgeons, even those fresh out of training, is far different [7]. It is good to remember that

today’s premium salaries arose from surgeons who took a chance on a field that others said they couldn’t make enough money to earn a living. References 1. Haller JA Jr. Why pediatric surgery? A personal journey through the first 50 years. Ann Surg. 2003;237:597-606. 2. Williams DI. Denis Browne and the specialization of paediatric surgery. J Med Biogr 1999;7:145-50. 3. Clatworthy HW Jr. Ladd’s vision. J Pediatr Surg. 1999;34(5 Suppl 1):32-7. 4. Randolph J. First of the best. J Pediatr Surg. 1985;20:580-91. 5. Randolph JG. History of the Section on Surgery, the American Academy of Pediatrics: the first 25 years (1948-1973). J Pediatr Surg. 1999;34(5 Suppl 1):3-18. 6. Lester W. Martin, MD. Interviewed by Brad W. Warner, MD. Pediatric History Center, American Academy of Pediatrics oral history project. Elk Grove, IL, American Academy of Pediatrics, June 26, 2007. Available from: https://www.aap.org/en-us/about-the-aap/GartnerPediatric-History-Center/DocLib/Martin.pdf. Accessed January 20, 2019. 7. Stolar CJ, Aspelund G. First employment characteristics for the 2011 pediatric surgery fellowship graduates. J Pediatr Surg. 2013;48:99-103.

6.4. The stoma story In the early history of pediatric surgery, surgeons operating on infants and children soon found that procedures routinely used in adults were often inappropriate in the treatment of the unique intestinal anomalies and conditions of infants and children. Each condition had its own challenges, such as the size disparity between the proximal and distal ends of small bowel atresia, neglected cases of atresia where the intestine was ischemic or necrotic, and meconium ileus where sticky concretions still obstructed the distal ileum and colon after diversion. Once created, a stoma also had to be closed expeditiously to restore bowel continuity so enteral feedings could resume as soon as possible, an urgent priority in an era before parenteral nutritional support. William Ladd struggled with intestinal atresia when he and Robert Gross published their historic 1941 textbook, Abdominal Surgery in Infancy and Childhood. In the chapter on congenital atresias of the intestine and colon, they reported 40 cases involving the jejunum and ileum, with only six survivors. “To one inexperienced in this field, it would appear that ileostomy would be the procedure of choice in order to relieve the obstruction,” they wrote at the time. “However, there is adequate proof that ileostomy alone is a poor surgical procedure.” The procedure they advocated was a long side-to-side anastomosis, which in nearly all cases failed to function before the infant succumbed to dehydration and starvation [1]. In his single-authored textbook of 1953, Robert Gross in Boston advocated a Mikulicz enterostomy for any intestinal operation other than a straightforward primary anastomosis. His was a classic approach: exteriorization of the problem segment, then closure of the wound around the intestine. The segment, once safely outside the body, could then be resected where its contents could spill without soiling the peritoneal cavity. After recovery from the first operation, a clamp specific for the task was applied between the two loops to crush the tissue and leave a common opening below the level of the fascia. Closing the stoma was then a simple matter of oversewing the two loops, and closing fascia and skin over it. It was a safe approach appropriate in an era before antibiotics, and where infants often arrived in physiologically desperate shape. Survival at the Children’s Hospital improved; of 51 infants operated on since the Ladd and Gross textbook of 1941, Gross had 26 survive [2].

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When meconium ileus began to be recognized as a distinct pathological entity in the 1940s, understandably there was no uniformity of approach to the condition. Gross used his favored operation for intestinal obstruction, the Mikulicz enterostomy. A truly inspired stoma (full disclosure: the author trained in Philadelphia) was reported in 1957 by Harry Bishop and C. Everett Koop, former editorin-chief of the Journal of Pediatric Surgery, for meconium ileus [3]. They took the proximal loop and sewed it to the side of the distal loop, which was then exteriorized as an end stoma. Thus the free end of the distal loop could decompress the bowel if there was residual obstruction farther down the intestine and colon, as was sometimes the case in meconium ileus. It gave access for the passage of a catheter to irrigate the distal limb with mucolytic solutions. The direction of peristalsis carried intestinal contents downstream once the distal loop was clear and the child was on appropriate enzyme replacement. At that point, the enterostomy was simply closed, the anastomosis already present and functioning. In 1961, Thomas Santulli in New York created a hybrid operation that combined features from the Boston and Philadelphia approaches for meconium ileus. Relief of intestinal obstruction remained the immediate priority, so he kept Gross’s proximal enterostomy. But rather than make a side-to-side double-barreled stoma, Santulli preferred Bishop and Koop’s approach of a formal anastomosis at the first operation and plugged the distal loop to the side of the proximal enterostomy. The arrangement also allowed irrigation of the distal intestine though a catheter manipulated from the stoma into the distal loop. To drive intestinal contents past the anastomosis, he gradually occluded the stoma with a bulldog clamp [4]. Enterostomy for jejunoileal atresia and meconium ileus gradually fell into disuse as resection and primary anastomosis became preferred for most cases of jejunoileal atresia, first described by Orvar Swenson in 1954 and confirmed the next year by surgeons in all

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corners of the world (Clifford Benson, Detroit; Harold Nixon, London; and Jan Louw, Cape Town) [5-8]. Helen Noblett (Melbourne) showed that water-soluble contrast enema was a therapeutic option for meconium ileus in 1969 and thus avoided surgery altogether [9], giving further proof of the international reach of pediatric surgery. The variants of pediatric enterostomy, still a valuable surgical alternative in complicated cases where an infant’s condition demanded expeditious surgery, became a historic artifact in old textbooks (Fig. 37). References 1. Ladd WE, Gross RE. Abdominal surgery of infancy and childhood . Philadelphia: W.B. Saunders, 1941. 2. Gross RE. The surgery of infancy and childhood. Philadelphia, W.B. Saunders, 1953. 3. Bishop HC, Koop CE. Management of meconium ileus: resection, anastomosis and ileostomy irrigation with pancreatic enzymes. Ann Surg. 1957;145:410-4. 4. Santulli TV, Blanc WA. Congenital atresia of the intestine: pathogenesis and treatment. Ann Surg. 1961;154:934-48. 5. Swenson O. End-to-end aseptic intestinal anastomosis in infants and children. Surgery 36(2):192-7. 6. Benson CD. Resection and primary anastomosis of the jejunum and ileum in the newborn. Ann Surg. 1955;142:478-85. 7. Louw JH, Barnard CN. Congenital intestinal atresia. Observations on its origin. Lancet 1955;266(6899):1065-7. 8. Nixon HH. Intestinal obstruction in the newborn. Arch Dis Child. 1955;30(149):13-22. 9. Noblett HR. Treatment of uncomplicated meconium ileus by gastrograffin enema: a preliminary report. J Pediatr Surg. 1969;4:190-7.

Fig. 37. Stomas used in the management of intestinal atresia.

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6.5. Pediatric surgery’s link to San Francisco and the summer of love, 1967 Cameron Haight, honored in pediatric surgery for one of the signal achievements in the field, the first survivor after primary repair of EA/ TEF, had a family connection with one of the major American cultural phenomena of the 20th century, the “Summer of Love” of 1967. The event had its geographical epicenter in the Haight-Ashbury district of San Francisco, named after the two cross streets in its modest business area. There are no records whether any Haight family descendants partook of the hippie lifestyle or dress, but the iconic neighborhood was named for one of the three Haight brothers and a Haight male cousin who settled in the city during the California Gold Rush era of the 1850s. While there is no consensus which of the Haight men the street was named for – and one writer suggests the street was named for a Haight wife – the famous intersection bears the name of one of the prominent Figures in pediatric surgical history. The Haight family’s roots were in upstate New York, but in the mid19th century several of its male members moved to the Golden State. Henry Haight (1820–1869), started as a teller in the St. Louis banking

house of Page, Bacon, and Co., and rose to be firm’s California branch manager. The dissolution of the home office scarcely affected his wealth and standing in the city’s social and philanthropic circles. The Museum of the City of San Francisco ascribes the street name to him [1]. Henry’s much-older brother Fletcher (1799–1866) [2], had a son, also named Henry (middle name Huntley, 1825–1878). The younger Henry was a lawyer in Rochester, NY, in his father’s firm when the lure of gold took hold and he moved his family west to San Francisco. In 1867, he was elected Governor as a Democrat, without having previously held public office. His administration was eventful, with the completion of the transcontinental railroad and the foundation of the University of California [3]. Despite his advanced age, older brother Fletcher would also move west to Southern California, where he was appointed circuit court judge [4]. Governor Henry Haight and his wife Elizabeth Stuart (nee McLachlan) had eight children, but only four survived infancy, including a son named Cameron Haight (1860–1866) that lived to only age 6. The first son to survive childhood was Henry Huntley II (1864–1919), who joined the family law firm. Another son Louis Montrose Haight

Fig. 38. Memorandum, Judson Randolph papers. Courtesy Mary Fallat.

Please cite this article as: D.K. Nakayama, Vignettes from the History of Pediatric Surgery, Journal of Pediatric Surgery, https://doi.org/10.1016/j. jpedsurg.2019.09.012

D.K. Nakayama / Journal of Pediatric Surgery xxx (xxxx) xxx

(1868–1942), was also the youngest sibling [5]. Details are scant, but from a number of internet sources, genealogies, and graduation records, there is evidence that he was a rebel in the family, not attending Yale until his late 20s and becoming a doctor rather than entering the bar like his older brother. After Louis graduated from the Cooper Medical College in San Francisco in 1903 (the Cooper Medical College would be transferred to the Stanford University in 1908), he moved away from the family’s home in the East Bay town of Alameda to set up practice in Stockton. During medical school in San Francisco, Louis Haight and Minnie Amelia (nee Schuler) had their first child in 1901, whose first name was Louis after the father and middle name Cameron after the father’s long-deceased older brother who died in early childhood. The first name was dropped as the son entered his majority, but he adopted the father’s profession rather than entering the bar like so many of the other male members of the family. Like his father, he moved from the family’s roots in California and settled in far-off Ann Arbor at the University of Michigan. The transcontinental railroad and the University of California notwithstanding, the individual achievements of Cameron Haight outweighed those of his forebears. The University of Michigan is justifiably proud of the achievements of its adopted son, with an endowed professorship in his name. San Francisco honors the Haight family in one of its most colorful neighborhoods, and certainly one of its most pilfered street signs. References 1. Virtual Museum of the City of San Francisco. Available at: http:// www.sfmuseum.org/street/stnames4.html. Accessed January 27, 2019. 2. San Francisco Genealogy. Obituaries and death notices. Available at: http://www.sfgenealogy.org/sf/vitals/sfobiha.htm. Accessed January 27, 2019. 3. Alameda (city) – biography. Henry Huntley Haight (5-20-1825 – 92-1878). Available at: https://renamehaight.files.wordpress.com/ 2018/02/henry-haight-biographical-materials.pdf. Accessed January 27, 2019.

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4. Federal Judicial Center. Haight, Fletcher Mathews. Available at: https://www.fjc.gov/history/judges/haight-fletcher-mathews. Accessed January 27, 2019. 5. Oakland Wiki. Henry H. Haight. Available at: https://localwiki.org/ oakland/Henry_H._Haight. Accessed January 27, 2019. 6.6. Memo from the chief When he was a junior resident at The Children’s Hospital in Boston, Judson Randolph (1927–2015) received a memo from Robert Gross (1905–1988), his chief and one of the most prominent figures in pediatric surgery. The memo was just eight words, but Gross’ intent was to shape the conduct of his young trainee. It revealed something of the personality of its author and the whimsy of the one who chose to save and frame it. After Randolph died, his papers were given to Mary Fallat, his former trainee and past president of APSA: boxes of clippings, correspondence, copies, reprints, drafts of articles that were published and unpublished, and stacks of photos both framed and unframed. Some were true gems: the Ladd medal, heavy and thick, the father of the specialty in bas relief. Just holding it is akin to deigning to put on a Super Bowl ring or hoist the Stanley Cup. One just doesn’t do it, who hasn’t earned it. And amid the welter of memorabilia was a scrap of paper in a brittle wooden frame in glass that, by some miracle, had escaped the years without a crack (Fig. 38). It read: “To ‘Dr Randolph’ from ‘Dr Gross’: ‘Judd – in the dining room– coats should be worn. REG.’” The scrawl revealed the author’s prickly nature and perfectionism. To frame the memo showed the recipient’s irreverence. One can sense the irritation of Gross when he spies across the room one of his residents in shirt sleeves sitting down to lunch. One can also see Randolph’s face, eyes bright, barely able to contain his laughter when he shows the prized memento on the wall to a visitor to his office. The heft of the Ladd Medal is evidence of its importance in pediatric surgery. Equally profound are the moistness in the eyes and the catch in the throat when one holds a small piece of paper in a cheap frame that reveals so much about our cherished field.

Please cite this article as: D.K. Nakayama, Vignettes from the History of Pediatric Surgery, Journal of Pediatric Surgery, https://doi.org/10.1016/j. jpedsurg.2019.09.012