Notes on the early development of pediatric surgery in the United States
Article Outline
Abstract
This lecture addresses the leadership roles in American surgery.
Key words: Leadership roles, American surgery
Dr William E. Ladd (Fig. 1) is generally acknowledged as the wellspring and founder of pediatric surgery in the United States of America. A graduate of Harvard College in 1903 and of its medical school in 1906, those who knew Dr Ladd well remarked that hanging plaques and awards on his walls was not his habit. However, in his bedroom hung a crimson painted oar. Because of all his achievements, Dr Ladd's greatest affection rested on his time spent as a member of the crew team of Harvard University [1].
Fig. 1.
Dr William E. Ladd.
Most of us are familiar with the Halifax disaster in 1917, when a ship laden with TNT exploded in Halifax Harbor. In 1916 and 1917, convoys of ships were customarily assembled in Halifax Harbor to brave the waters of the North Atlantic carrying supplies and soldiers from the North American continent to England. These ships were vulnerable to German submarines. In the spring of 1917, as a convoy was being assembled, a ship full of TNT with airplane fuel lashed to its decks broke loose from its moorings and drifted precariously closer to the Halifax side of the basin in which the ships were gathered. According to historians, the disaster occurred when children were home from school. People rushed to the windows as the Benzene caught fire and claimed their attention. Then the enormous explosion came as the TNT exploded, flattening a significant portion of Halifax, causing 10,000 deaths and twice that many injuries among children and adults. News of this extraordinary disaster spread throughout North America [2].
A response team was put together in Boston composed of many nurses, a number of doctors, and large amounts of medical equipment and supplies traveled by rail to the disaster area. This effort was placed in the charge of a young surgeon named Dr William E. Ladd. When the train reached Halifax, the enormity of medical need absorbed all of the equipment and personnel for a month. There are some who have claimed that the many injured children sparked a special interest in Dr Ladd for the direction of his future career in surgery. Although Dr Ladd disavowed this years later, he began to spend more and more time at the Children's Hospital and exhibited a growing fascination with the surgical needs of children. In 1927, Dr Ladd was named Surgeon-in-Chief of the Children's Hospital. Thereafter, he spent most of his time managing the surgical problems of infants and children but continued to practice gynecology and surgery in other hospitals in Boston [3].
In 1919, a surgeon from Seattle, Dr Herbert Coe, came to Boston to learn about surgery being practiced at Boston Children's Hospital. He spent several months observing Ladd and others who were there at the time (Fig. 2). Dr Coe then returned to Seattle toward the end of 1919 and announced that he intended to limit his practice to the surgery of infants and children, thereby becoming the first surgeon in the United States to practice pediatric surgery exclusively. Dr Coe subsequently made a major contribution to children's surgery. He fervently believed that there should be a national forum for those practicing pediatric surgery. After being rebuffed by the American College of Surgeons, he was influential in developing the surgical section of the American Academy of Pediatrics in 1948 [4].
Fig. 2.
Dr Herbert Coe of Seattle.
Dr Robert E. Gross graduated AOA from the Harvard Medical School in 1931. His record would have qualified him for a surgical internship at Massachusetts General Hospital or the Brigham Hospital in Boston, but he chose to apply only to Dr Owen Wangensteen's service at the University of Minnesota (Fig. 3). He was attracted to Minnesota because he had been a camp counselor in Minnesota and had returned to Minnesota to attend Carleton College as an undergraduate [5].
Fig. 3.
Dr Robert Gross as Resident in Pathology, 1933.
Unaccountably, Dr Wangensteen turned down Gross's application for surgical internship. Hurt by the refusal at Minnesota, young Dr Gross chose to abandon surgery temporarily and sought a pathology internship and residency with Dr Burt Wohlbach, Chairman of Pathology at the Brigham Hospital. Dr Gross approached this new endeavor with characteristic enthusiasm and diligence. During his internship and residency in pathology, he noted that children repeatedly came to autopsy having died of subacute bacterial endocarditis which originated in a persistent ductus arteriosus. An idea came to him for a surgical method which would allow one to close this persistent opening. Gross completed his pathology residency and became an assistant resident in surgery at the Peter Bent Brigham Hospital. It was in these years, 1935-1937, that he took to the surgical research laboratory ideas for closing the ductus arteriosus. Originally, he simply ligated the ductus.
In the summer of 1938, Dr Gross, while still a surgical resident, having convinced himself of the efficacy and in fact the necessity of closing the ductus arteriosus, embarked on a campaign of selecting children with a patent ductus with the aid of his friend in cardiology, Dr John Hubbard. In August of 1938, Dr Ladd went on his usual one month vacation and told Dr Gross that he was not to perform this complicated operation while he was gone. In fact, Dr Gross lined up 2 patients for the operation and proceeded in the early days of August to operate on the first candidate. Things went extremely well, and he subsequently performed the operation on the second candidate. News of this surgical feat spread promptly and widely and may have been responsible for the well-known rift in the Ladd and Gross personal relationship. In spite of this, Ladd brought Gross onto the surgical staff of Children's Hospital in 1939. Thereafter, as a junior member of the faculty, Dr Gross worked in the laboratory on other vascular problems, such as coarctation of the aorta and vascular rings. During 1940, Dr Gross began a methodical compilation of the surgical department's achievements, and he and Ladd published the semi-annual surgical volume titled “The Abdominal Surgery of Infants and Children” in 1941 [6].
The decade of the 1940's was an extraordinarily active and productive period of time at the Boston Children's Hospital Department of Surgery and its laboratories. Dr Gross was at work in the laboratory, having electrified the world with the division of the ductus arteriosus. Dr Gross was a mechanic and not a physiologist. As he was working in the pathology laboratory with patients who had succumbed to a variety of disorders, he recognized the impact of coarctation of the aorta and its early impact on children's’ hearts. Once again, his mechanical insights focused on this narrow segment of the descending aorta. In 1940, it was not known if cross clamping the aorta while removing a narrow segment would have any deleterious impact on the spinal cord. Thus, Dr Gross undertook a series of animal experiments to show that even with animal models which had not undergone narrowing of the aorta, the aorta could be cross clamped for a period of time. In 1946, shortly after Crafoord of Sweden, Gross reported surgical excision of coarctation of the aorta [7].
In some patients the segment of coarctation was so long as to preclude reanastomosis. Working with Drs Bill and Pierce in the laboratory, segments of aorta were harvested, then irradiated and freeze-dried for storage. These aortic sleeves were subsequently reconstituted, inserted in aortas of laboratory animals, and studied for periods up to a year. This work was reported in 1948, along with 9 clinical patients in whom human aortic homografts had been inserted. This achievement proved to be the foundation stone for modern vascular surgery [8].
Another young surgeon from the Brigham and Children's surgical training program, Orvar Swenson, began to do more and more of his work at Children's Hospital and was put on the staff in the early 1940s. Dr Swenson had graduated from the Harvard Medical School in 1933 (Fig. 4). Of interest is the fact that he and his brother, who had gone to Liberty Jewell College in Missouri, had both applied to the Harvard Medical School, and his older brother, Al, was admitted on the first round. Orvar was placed on the waiting list. Al wrote to the Dean and said that they were 2 poor farm boys from Missouri who had to go to the same medical school because of financial problems. The Dean wrote back to Al, “Bring your little brother” [9].
Fig. 4.
Dr Ovar Swenson, Surgeon-in-Chief, Children's Memorial Hospital, Chicago, 1960-1971.
Working with another Harvard/Children's Hospital product, Dr Alexander Bill, Swenson marshaled the information from other sources that the cause of congenital megacolon was not in the enlarged dilated segment of colon, but rather in the narrow rectal segment above the anus. He then went to work to devise an operation which would allow excision of the non-functioning aganglionic recto-sigmoid colon and permit union of the normal colon to the anorectum [10].
This work proved to be the foundation stone for the modern surgical treatment of Hirschsprung's Disease. Dr Swenson's first report was given at the Society of the University Surgeons in 1948. It is of interest that at the same meeting, a report from Baltimore by Dr David Sabiston and Dr Mark Ravitch detailed a new approach for the treatment of multiple polyposis of the colon. In their operation, these surgeons recommended excision of the mucosa of the rectosigmoid mucosa, bringing the ileum down within the confines of the muscular sleeve of the rectosigmoid. It is such a coincidence that Sabiston and Ravitch suggested the operation for multiple polyposis and were actually describing the operation that Franco Soave would introduce as a method of dealing with Hirschsprung's Disease in the 1960s [11].
Dr Ladd served as Surgeon-in-Chief and Director of the Surgical Services at Children's Hospital until 1945, when he chose to retire. During 1940 and 1941, the William E. Ladd Chair in Surgery at the Harvard Medical School was funded and completed, and Dr Ladd himself served as the first holder of the Ladd Chair until his retirement.
When Ladd stepped down as Chair of Surgery at the Children's Hospital at Boston in 1945, 2 candidates to fill this position were considered by the search committee at Harvard. The candidates were Dr Gross, with his brilliant work in cardiac surgical matters of the chest, and Dr Swenson, with his ongoing work with respect to congenital megacolon. It is no secret that Dr Ladd strongly preferred that Dr Swenson take his place. Consequently, the Harvard search committee struggled for 2 years before finally deciding that Dr Gross was to be named Chief of Surgery at Boston Children's Hospital and the second holder of the William E. Ladd Professorship in Children's Surgery [12].
In addition to the technical advances in surgery put forth by the active surgical laboratory and clinical services at Children's, this surgical service became a resource to other medical centers for well-trained pediatric surgeons. In 1946, Dr Tague Chisholm, at the suggestion of Dr Ladd, joined Oswald Wyatt in Minneapolis in the pure practice of pediatric surgery. Dr Alexander Bill, who had completed his residency in surgery at the Brigham Hospital and had joined Swenson in the exciting surgical advances relative to Hirschsprung's Disease, was recommended to Dr Herbert Coe in Seattle, and he went there in 1948 to practice surgery with Coe at the Children's Orthopedic Hospital in Seattle. In 1946, Dr C Everett Koop came to Boston for a period of 9 months (Fig. 5), having been sent there by Dr Isidor Ravdin of the University of Pennsylvania, who had nominated Dr Koop to head up a new Department of Pediatric Surgery at the Children's Hospital of Philadelphia. Simultaneously, Dr Willis Potts of Chicago came to Children's Hospital, remaining there for 3 months observing the activities within the Department of Surgery. Dr Potts attended a clinical pathologic conference which showed that a child with Tetralogy of Fallot had succumbed after the patent ductus, which had been functioning as a reverse shunt of blood into the lungs, became plugged by a clot (Fig. 6). Dr Potts recognized the importance of pulmonary blood flow in the Tetralogy deformity which had been so carefully described by Taussig and operated upon by Dr Blalock with an operation that was to become known as the Blalock-Taussig shunt (subclavian artery to pulmonary artery). On returning to Chicago, Dr Potts worked with Dr Sydney Smith in the laboratory and devised a direct shunt between the aorta and the pulmonary artery. For this procedure, a side-biting clamp to partially exclude the aorta was necessary so that the clamped aorta could be opened and adjoined to the pulmonary artery. It was Dr Smith's work ably supported by Potts which produced the necessary clamp. An enormous contribution in itself, The Potts shunt derived a good deal of publicity and use throughout the 1950s, but with the advent of the pump oxygenator and direct correction of the Tetralogy deformity, the Potts shunt fell into disuse. This occurred because taking down the Potts shunt was much more difficult than simply dividing the Blalock shunt. However, the Potts-Smith clamp was designed with many tiny sharp teeth which would prevent the clamp from slipping but not injure the aortic wall. The teeth design has served as the prototype for vascular clamps ever since, a seminal contribution to vascular surgery.
Fig. 5.
Dr C. Everett Koop, Surgeon-in-Chief, Children's Hospital of Philadelphia, 1947-1981.
Fig. 6.
Dr Willis Potts, Surgeon-in-Chief, Children's Memorial Hospital, Chicago, 1946-1960.
The Boston Children's Hospital Department of Surgery produced another product that would have a great impact on the education of pediatric surgeons, Dr H. William Clatworthy (Fig. 7). After completing an internship in the Brigham and Children's program, Dr Clatworthy served in the Armed Forces and returned in 1944 to continue his training. He served as Dr Ladd's last resident and subsequently as Dr Gross's first resident. Thereafter, as the requirements for the American Board of Surgery (founded in 1938) were becoming more pronounced, it was adjudged that Dr Clatworthy needed 2 more years of general surgical training. Being a westerner, Dr Clatworthy wrote to Wangensteen at Minnesota requesting 2 senior years of training in general surgery. He then asked Dr Ladd to write a letter a letter of recommendation, which Dr Ladd said that he would be glad to do. He also solicited support from Dr Gross, who agreed to send a letter to Wangensteen as well.
Fig. 7.
Dr H. William Clatworthy, Surgeon-in-Chief, Columbus Children's Hospital, 1950-1972.
Dr Clatworthy promptly received a letter from Dr Wangensteen accepting him for the 2 years of additional training in surgery. When he went to thank Dr Ladd, Ladd admitted that he had not sent the letter but had intended to do so. The same thing happened with Dr Gross, who also had not yet sent a letter. When Dr Clatworthy got to Minnesota in July 1948, he visited a few minutes with Dr Wangensteen, thanked him for receiving him, and found out what his assignments would be. As he turned to leave the office, he asked Dr Wangensteen why he had accepted him so readily, even before his letters of recommendation had reached his desk. Dr Wangensteen is reported to have said, “Oh that. Well, some years ago I got a request for a surgical internship from a fellow named Gross from the Children's Hospital in Boston, and I turned him down. I swore that I'd never make that mistake again.” Dr Clatworthy finished his general surgical training, and on the strength of a mentor/trainee relationship he had formed with Dr Zollinger at the Brigham, went to Columbus, OH and established the very strong, productive surgical educational program in pediatric surgery at the Columbus Children's Hospital.
During the 1950s, with the advent of the pump oxygenator and direct approach to repair of cardiac anomalies, the Children's Hospital in Boston joined another handful of programs around the country which were making clinical advances in this area. The surgical residents trained by Gross through these years then went out to staff and lead programs in various medical centers throughout the country. These included Bishop, Lynn, Pickett, Ferguson, Holcomb, Wrenn, Martin, Holder, Hendren, Randolph, and Filler. In addition, the graduates of the Clatworthy program have proven to provide great leadership in the specialty. These included Rowe, de Lorimier, Fonkalsrud, Othersen, O'Neill, and Grosfeld, among others. Two of these, O'Neill and Grosfeld, became departmental chairmen. As trained pediatric surgeons spread across the land in the decade of the 1950s, their presence impacted the medical school curricula and residency surgical programs in major cities and medical centers.
Although not qualifying as early history, 3 events in the mid to late 1960s strengthened and enriched our specialty. Dr Steve Gans conceived and developed the Journal of Pediatric Surgery and installed C Everett Koop as Editor-in-Chief. Dr William Clatworthy organized an education committee under the auspices of the Surgical Section. This committee was tasked with drafting a set of basic standards for 2-year training in pediatric surgery and, importantly, visiting all extant training programs and pronouncing them as “approved” or “disapproved.” Drs Lucian Leape and Tom Boles felt strongly that our thriving specialty deserved its own separate free-standing association of pediatric surgeons and with much vigor and skill, brought forth the American Pediatric Surgical Association in 1970. Armed with these striking accomplishments, our Diplomat-in-Residence, Harvey Beardmore, approached the American Board of Surgery and worked out the details of the Certificate of Special Competence in Pediatric Surgery, so that Harvey could announce with dramatic flourish in 1974, “Ladies and gentlemen, you have your Boards” (Fig. 8).
Fig. 8.
A Gathering of Pediatric Surgical Leaders: Front Row (L-R): Mark Ravitch, Bob Allen, Harvey Beardmore, Robert E. Gross Back Row L-R): Orvar Swenson, Larry Pickett, Bill Clatworthy, Hugh Lyon. Sandy Bill, Chick Koop, Willis Potts, Dan Cloud, George Dorman, Clifford Benson (circa 1960).
Now, in full flower, our beloved guild has acceded to prominent leadership roles in American surgery. To wit: Dr Kathryn Anderson became the first pediatric surgeon and the first woman President of the American College of Surgeons. Dr Jay Grosfeld is a recent past President of the American Surgical Association, and Dr James ‘Neill was recently elected President of the Southern Surgical Association. American Pediatric Surgical Association's current President, Dr Marshall Schwartz, has been named a Regent of the American College of Surgeons.
The Prince of Surgical Specialties is now full grown and remains the last stronghold of general surgery!
References
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- . Ladd's vision. J Pediatr Surg. 1999;34:32–37
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- . Excellence in search of recognition. J Pediatr Surg. 1986;22:1019–1031
- . Abdominal Surgery of Infancy and Childhood. Philadelphia (Pa): W. B. Saunders; 1941;
- . A brief account of the founding of the American Pediatric Surgical Association. J Pediatr Surg. 1996;31:12–18
- . A direct aortic pulmonary shunt in the treatment of Tetralogy of Fallot. JAMA. 1946;132:627–638
- . The first of the best. J Pediatr Surg. 1985;20:580–591
- . History of the Section of Surgery, The American Academy of Pediatrics: The First 25 Years. J Pediatr Surg. 1999;34:3–18
- . Resection of rectum and rectosigmoid with preservation of the sphincter for benign spastic lesions producing megacolon. Surgery. 1948;24:12–20
- Zwiren G. Personal communication containing letter from William E. Ladd.
PII: S0022-3468(11)00882-7
doi:10.1016/j.jpedsurg.2011.10.012
© 2012 Elsevier Inc. All rights reserved.
