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We've come a long way: it's finally time to get started!

2005; Elsevier BV; Volume: 40; Issue: 1 Linguagem: Inglês

10.1016/j.jpedsurg.2004.10.001

1531-5037

Bryan Rodgers,

Medical History and Innovations

From its very beginning, pediatric surgery struggled with acceptance by the remainder of the medical community and with the definition of its own identity. At the time when many medical and surgical specialties had begun to form their own guilds, in the 1920s and 1930s, there were only a handful of individuals devoting their entire practice to the surgical treatment of children. The first two of these, Dr William Ladd, in Boston, and Dr Herbert Coe, in Seattle, became very important figures for our specialty as they lobbied for appropriate representation for pediatric surgery in the major national surgical and pediatric organizations. At that time, virtually all of the children's surgery in the United States was performed by general surgeons and they could see no need for a separate specialty of pediatric surgery. Ladd and Coe were both visionaries who understood the benefit to children of the development of their specialty and understood the importance of special training to acquire the additional skills required to provide surgical care to children. Both were resolute in their efforts to establish appropriate training programs and to achieve appropriate representation for this new specialty. Ladd quoted from Sir Lancelot Barringer-Ward in saying that the “adult may safely be treated as a child, but the converse can lead to disaster.” He used statistics from The Children's Hospital in Boston to illustrate the marked drop in mortality for most pediatric surgical conditions when handled by pediatric surgical specialists. Ladd was at least 30 years ahead of his time when he said,There has been no attempt in the Medical Profession so far to draw a distinction between those who are qualified to do children's surgery and those who are not. I believe this should be a matter of serious consideration. It is possible that there eventually should be established still another specialty with its Board, but I think the consensus at the moment is that there are already enough Boards and perhaps already too many. It is possible that the Board of General Surgery should modify their certificates for those who are qualified to do Children's Surgery and those who are not! [[1]Ladd W.E. Children's surgery and its relation to the specialties.Thirteenth annual Arthur Dean Bevan lecture. Chicago Surgical Society, 1944Google Scholar] Pediatric surgery indeed has come a long way since those days and everyone is aware that we have now achieved leadership positions in all of the major national organizations representing surgery and pediatrics. Not everyone, however, may be aware of the vision, hard work, and determination required of many pediatric surgeons to get us to this point. Two hundred years ago last Friday, on May 21, 1804, the 48 men and one Newfoundland dog of the so-called “Corps of Discovery” left St Charles, Mo, on the beginning of an incredible journey that would test the ingenuity and skill of each of these men for the next 2 years and 4 months. With all of the publicity surrounding the bicentennial of the Lewis and Clark expedition, most are aware of the adventures of these explorers along the Missouri and Columbia Rivers and the incredible scientific discoveries that resulted from this expedition. Many, however, may not be aware of the vision, hard work, and determination required of the men who conceived and organized this exploration into terra incognita. I would like to draw some parallels between the route to the establishment of a bedrock foundation for the specialty of pediatric surgery and the meticulous groundwork leading up to the start of the Lewis and Clark expedition. Although 200 years apart, both groups have come a long way and are in a position in May of 04 when it is finally time to get started and there still is much to be done. The American Academy of Pediatrics was founded in 1930, primarily as an organization devoted to the education of physicians for children within the United States. The involvement of pediatric surgeons within the Academy initially evolved because of the resolute determination of one man, Herbert E Coe, a pediatric surgeon practicing in Seattle, Wash. Although he functioned in his early years as a general practitioner, Dr Coe gravitated to surgery and served apprenticeships with several of the surgeons in the Seattle area. In 1919, he traveled to Boston to spend time at the Boston Children's Hospital, observing the work of Dr Ladd. On returning to Seattle the following year, he decided to limit his practice to the surgery of infants and children [[2]Randolph J.G. History of the section on surgery, the American Academy of Pediatrics: the first 25 years (1948-1973).J. Pediatr. Surg. 1999; 34: 3-18Abstract Full Text PDF PubMed Google Scholar]. At the time of the formation of the Academy, Dr Coe was one of only 3 surgeons in the United States devoting their practice solely to the care of children. The two others in this group were William Ladd in Boston and Oswald Wyatt, in Minneapolis. In 1940, Dr Coe first approached the leadership of the American Academy of Pediatrics, asking for official Academy recognition for children's surgeons. After repeated requests, Dr Coe was asked to prepare a program dealing with pediatric surgical issues for presentation to the general assembly at the Academy's 1947 annual meeting [[2]Randolph J.G. History of the section on surgery, the American Academy of Pediatrics: the first 25 years (1948-1973).J. Pediatr. Surg. 1999; 34: 3-18Abstract Full Text PDF PubMed Google Scholar]. The following year, Dr Coe was appointed to a committee within the Academy to work out the details for a special membership category within the Academy for physicians who were not board-certified pediatricians but who devoted most of their professional practice to the care of children. In September 1948, the Academy established a new class of membership known as “affiliate members” and established the sections of allergy, mental growth and development, and surgery (Fig. 1). The initial executive committee of the Surgical Section consisted of Drs Herbert E Coe (chairman), Robert E Gross, William E Ladd, Jay Lozoya-Solis, Henry Swann, and Oswald Wyatt. Initially envisioned to provide a forum for the discussion of pediatric surgical problems and to disseminate the principles of children's surgery to other members of the American Academy of Pediatrics, the role of the surgical section within the Academy has expanded considerably since that time. Other sections of children's surgical specialists have developed, including the sections of neurosurgery, ophthalmology, orthopedics, otolaryngology, plastic surgery, and urology. Presently, the various surgical sections within the Academy have joined to form the Surgical Advisory Panel, which has access to the leadership of the Academy through the Council on Sections Management Committee. In the past several years, this group has had considerable impact on the Academy's activities, culminating in 2002, in the publication of the Academy's recommendations for referral of children with surgical needs to specialty trained individuals [[3]American Academy of PediatricsPolicy statement, guidelines for referral to pediatric surgical specialists.Pediatrics. 2002; 110: 187-191Crossref PubMed Scopus (56) Google Scholar]. Dr Thomas R Weber currently chairs the Surgical Section executive committee. It is perhaps not surprising that the American College of Surgeons (ACS), founded originally in 1913 primarily as a forum for the education of general surgeons in the United States, tried very early in its history to embrace the surgical specialties. Indeed, Dr Franklin Martin, considered by most to be the “father” of the College, was a practicing gynecologist. The College decided upon a format of advisory councils for the surgical specialties, which would report to the Board of Regents and coordinate the educational activities of those specialties within the College [[4]Adams W.E. Advisory councils for the surgical specialties.Bull. Am. Coll. Surg. 1971; 59: 26-27Google Scholar]. In 1937, the first advisory councils in ophthalmology and otolaryngology were formed. In 1949, the Advisory Councils of Gynecology/Obstetrics, Neurologic Surgery, Orthopedic Surgery, Thoracic Surgery, and Urology were added, to be followed by the Advisory Council for Plastic and Maxillofacial Surgery in 1952 and the Advisory Council for Proctology in 1960. The Advisory Council for Pediatric Surgery, the first specialty afforded this status without an underlying board, was formed in 1969 (Fig. 1) [[5]Herendeen J.F. The college at work: the advisory councils.Bull. Am. Coll. Surg. 2000; 85: 26-30PubMed Google Scholar]. The organizational meeting for this group was held at the time of the 1969 ACS Clinical Congress in San Francisco on October 6, 1969. The Executive Committee of the Advisory Council was composed of Drs Orvar Swenson (Chair), Harvey Beardmore, C Everett Koop, Hugh Lynn, and Lawrence Pickett. The Advisory Council quickly established alliances with many of the standing committees of the College. From this beginning, the Advisory Council for Pediatric Surgery has expanded not only its membership, but also its sphere of influence within the College. In the past decade, the ACS has become increasingly involved with many of the sociopolitical issues impacting surgery in the United States. The Health Policy Steering Committee of the ACS has become very active in the past few years, focusing on issues of access to care, malpractice, and reimbursement. Issues all very important to our membership. Pediatric surgery has had a member on this committee since its inception. Through the vision and persistence of several members of the Advisory Council for Pediatric Surgery of the College and with considerable help from this year's Journal of Pediatric Surgery lecturer, Dr Scott Jones, we were able to convince the College of the merit of a policy that each Advisory Council should be represented by at least one member on the Board of Regents, the governing body of the College. In 2003, pediatric surgery's first regent of the College, Dr Thomas Whalen, was elected. Tom and his successors will work closely with the Advisory Council for Pediatric Surgery to represent the needs of pediatric surgery to the college. The Advisory Council for Pediatric Surgery is currently chaired by Dr Marshal Schwartz. Through the vision and persistence of this small group of pioneering pediatric surgeons, our specialty had begun to define itself and had established a foundation upon which it could begin to further expand its influence. The vision for the exploration of the western half of our continent and for the Lewis and Clark expedition was almost exclusively that of Thomas Jefferson. The genius of Jefferson was that he was always curious about things and always expanding his base of knowledge. He was always ahead of his time in his thinking. The genesis of the ideas that formed the basis for this exploration and most of the preparation for the trip took place in and around Charlottesville, Va. In a sense, it could be said that the preparation for this journey had begun more than 300 years earlier. Much of the earliest exploration of the North American continent, including Christopher Columbus' initial voyage in 1492, was aimed at discovering a sea route to the Pacific Ocean to facilitate trade with the Orient [[6]DeVoto B. The journals of Lewis and Clark.in: Houghton Mifflin Co., New York1997: XIViGoogle Scholar]. By the mid-17th century, French and British explorers had occupied much of the eastern portion of Canada, establishing profitable trade arrangements with the Native Americans in the west. The French explorers LaSalle, Marquette, and Jolliet had traveled through the Great Lakes and had charted most of the Mississippi River, down to New Orleans. LaSalle laid claim to the Louisiana territory for France in 1682, naming it in honor of Louis XIV. The precise boundaries of the Louisiana Territory were never defined, but they were generally agreed to encompass the western half of the drainage basin of the Mississippi River. At the time of Thomas Jefferson's birth, just outside Charlottesville in Shadwell, Va, in 1743, very little was known about the vast stretches of North America west of the Mississippi River. Indeed, when Jefferson became president 58 years later, two thirds of the population of the United States still lived within 50 miles of the Atlantic Ocean [[7]Duncan D. Burns K. Lewis and Clark.in: Alfred A. Knopf, New York2002: 5Google Scholar]. Jefferson's father, Peter, a successful planter and surveyor, was a member of The Loyal Land Company, a group of planters in the Charlottesville area who petitioned the Crown for a large land grant west of the Allegheny Mountains [[8]Malone D. Jefferson and his time, Volume One: Jefferson the Virginian.in: Little Brown and Co., Boston1948: 31Google Scholar]. One of the Loyal Land Company members, Dr Thomas Walker, a physician who had founded Charlottesville, was selected to create a map of this region, which he completed in 1750. The Loyal Land Company, which included Thomas Meriwether, the grandfather of Meriwether Lewis, had made plans to explore the Missouri River basin, which was felt to be a likely water route to the Pacific Ocean. The French and Indian War of 1760 intervened and those plans never materialized. Undoubtedly from this early exposure, Jefferson himself had a long interest in the West, even though he personally never traveled further west than Hot Springs, Va. Even before assuming the Presidency, in 1801, Jefferson had made at least 3 attempts to find a practical water route to the Pacific across the Northwest to establish trade with the Indians and a route to the Far East. In 1783, fearful that the British were preparing to explore the territory west of the Mississippi and to colonize this area, Jefferson asked George Rogers Clark, a revolutionary war hero, who had been born in Charlottesville, to lead an expedition of exploration [[9]Duncan D. Burns K. Lewis and Clark.in: Alfred A. Knopf, New York2002: 7Google Scholar]. Clark declined Jefferson, on the grounds of financial hardship. In 1785, while serving as ambassador to France, Jefferson heard of a French plan to explore the northwestern portion of North America by sailing around Cape Horn. At this time he met a young man by the name of John Ledyard, a former Dartmouth student, who had sailed with Captain Cook along the western coast of America in 1778. Ledyard was attempting to walk across Russia, cross the Bering Straits, and explore the Pacific Northwest to find a route to the Mississippi River. Ledyard's plan was of interest to Jefferson principally because of its potential for mapping the Pacific Northwest [[9]Duncan D. Burns K. Lewis and Clark.in: Alfred A. Knopf, New York2002: 7Google Scholar]. Jefferson attempted to get approval for Ledyard's passage through Russia from Catherine the Great, but was unsuccessful in doing so. Ledyard proceeded nonetheless, perhaps with clandestine support from Jefferson, but was arrested in Siberia and forbidden from ever returning to Russian soil! Like Herbert Coe, Jefferson was determined and, in 1793, while serving as George Washington's secretary of state, he convinced the American Philosophical Society of Philadelphia, of which he was a member, to fund an exploration of the western part of the country. The Philosophical Society contracted with a French botanist, André Michaux, to proceed to the headwaters of the Missouri and attempt to find a “nearby river” that would lead to the Pacific coast [[10]Duncan D. Burns K. Lewis and Clark.in: Alfred A. Knopf, New York2002: 8Google Scholar]. This exploration was brought to an end when Jefferson learned that Michaux was a secret agent for the French government! Michaux got no further than Eastern Kentucky in his expedition. In 1802, after having been elected to the presidency, Jefferson obtained a copy of Alexander MacKenzie's publication, Voyages from Montreal, on the River St. Lawrence, Through the Continent of North America, to the Frozen and Pacific Ocean. MacKenzie, a fur trader and explorer, had reached the Pacific Ocean in 1793 by boat with only a short portage between rivers of the East and rivers of the West, Jefferson was aware enough of the known geography at the time to realize that MacKenzie had not reached the Columbia River and he felt that the headwaters of the Missouri and Columbia Rivers would be close enough together to provide a more suitable all-weather water passage, with only a short portage. Nonetheless, this publication rekindled Jefferson's fears that the British were planning to colonize the Western part of America and monopolize its trade [[11]DeVoto B. The journals of Lewis and Clark.in: Houghton Mifflin Co., New York1997: 12Google Scholar]. The following year Jefferson casually approached the Spanish minister asking if the United States could send a “scientific expedition of exploration” up the Missouri River, which encompassed lands at that time owned by Spain in the Louisiana Territory. This request was denied because Spain feared the Americans planned to colonize the Louisiana Territory. On January 18, 1803, Jefferson sent an extraordinary secret message to Congress proposing allocation of $2500 for the “purpose of extending the external commerce of the United States.” Jefferson's desire to discover the fabled Northwest Passage to the west coast and to establish trading partnerships with the Indians was thinly disguised as a scientific expedition to explore the flora and fauna of the Western part of the continent. Over the objection of the Federalists, Congress approved the princely sum of $2500 to outfit this expedition, which ultimately cost a total of $39722.35 [[12]Duncan D. Burns K. Lewis and Clark.in: Alfred A. Knopf, New York2002: 12Google Scholar], perhaps the first of a long tradition of congressional cost overruns! Thomas Jefferson offered the leadership of this expedition to his friend of many years and his personal secretary of 2 years. Meriwether Lewis accepted immediately and began his preparations. As the exhaustive preparations progressed, Lewis and Jefferson both recognized that Lewis would need skilled help in a journey of this magnitude. Lewis contacted William Clark of Clarksville, Indiana Territory, with whom Lewis had spent time in the military during the Indian Wars, and offered him the co-captaincy of the expedition. Lewis and Clark had much in common and turned out to be an incredibly compatible pair. Both had been born in central Virginia, although there is no evidence that they were acquainted with each other in early life. Both had served in the military and were experienced outdoorsman. Lewis, born in 1774 just outside of Charlottesville, was 4 years the younger. He was better educated than Clark and had a speculative, scientific mind. He was somewhat introverted and unpredictable in his personality. Clark, born in 1770 in Caroline County, Virginia, was the more skilled geographer and was a master of frontier survival. He had greater skills with boats and a greater gift for dealing with Indians than did Lewis. Clark was extroverted and even-tempered in his personality. The men of the party trusted both leaders completely and both led the expedition at various times. Jefferson recognized that Lewis was going to require special training to successfully complete the many aspects of this expedition. He arranged for Lewis to travel to Philadelphia to study with several professors at the College of Philadelphia. On the way to Philadelphia, in the spring of 1803, Lewis stopped at the military arsenal at Harper's Ferry, Va, and ordered 15 of the newest rifles being developed by the military—a short-barreled, .54-caliber weapon. In addition, he ordered knives, hatchets, and ammunition for use during the expedition. In Philadelphia, during the spring and summer of 1803, Lewis studied botany and taxometry with Benjamin Smith Barton. He learned to accurately determine latitude and longitude from Robert Patterson and studied zoology with Casper Wistar. Jefferson had made a special introduction for Lewis to Dr Benjamin Rush, the professor of chemistry at the College of Philadelphia and probably the foremost physician in the United States at that time [[13]Patton B.C. Lewis and Clark: doctors in the wilderness.in: Fulcrum Publishing, Golden (Colo)2001: 19Google Scholar]. Rush was a good friend of Thomas Jefferson's, although the two did not agree on many aspects of medical therapy. In the spring of 1803, Rush taught Meriwether Lewis that all disease was related to tension in the blood vessels and recommended the use of bloodletting for most medical ailments. He also recommended Rush's pills—later to be termed “thunder clappers” by members of the Corps of Discovery—a combination of mercury, chlorine, and jalap, used as a laxative. Lewis spent $800 in Philadelphia procuring the medical supplies for the expedition, including 15 lb of cinchona bark (quinine), 4 oz of laudanum (tincture of opium), 600 Rush's pills, lancets, and penis syringes for the treatment of syphilis [[14]Ambrose S.E. Undaunted courage.in: Simon and Schuster, New York1996: 90Google Scholar]. Later that summer, Lewis went to Pittsburgh and supervised the construction of a keelboat, 55 ft in length and 8 ft wide, capable of carrying 12 tons of supplies. This would prove to be the principal craft that would be sailed, towed, and pushed up the Missouri River as far as Fort Mandan, just north of the present-day city of Bismarck, ND, where the corps would spend the winter of 1804. Two smaller pirogues, flat-bottomed rowboats 20 and 22 ft in length, were built in Wheeling, WVa, and were picked up as Lewis floated down the Ohio River. By the fall of 1803, Jefferson and Lewis had established a sound foundation with which to begin the expedition, not unlike the status of pediatric surgery in 1969, although it had taken Lewis considerably less time to get to this important juncture. The road to recognition of the specialty of pediatric surgery by the American Board of Surgery was considerably more difficult than that required for recognition by the Academy and required determination on the part of an increasing number of pediatric surgeons. By 1955, the number of individuals who devoted their surgical practice to the care of children was increasing, and the members of the executive committee of the surgical section of the American Academy of Pediatrics decided that it was time to approach the American Board of Surgery and request special recognition for proficiency in pediatric surgery, something that Ladd had alluded to 14 years earlier. This request was taken to the Board by the chair of the Surgical Section, C Everett Koop, and was approved by the directors of the American Board of Surgery and sent on for approval by the Advisory Board for Medical Specialties. Pediatric surgery had the support of the ACS for this endeavor, but there was considerable opposition from the boards of urology and orthopedics as well as from the Society of University Surgeons. The request was tabled [[15]Johnson D.G. Presidential address: excellence in search of recognition.J. Pediatr. Surg. 1986; 21: 1019-1031Abstract Full Text PDF PubMed Scopus (18) Google Scholar]. A second request came from the Surgical Section in 1960. At this time, pediatric surgery requested a subsidiary board within the American Board of Surgery and this request was denied by the directors of the American Board of Surgery, with the suggestion that pediatric surgery gain recognition through the American Academy of Pediatrics. It was clear after this exchange that there was still considerable concern among general surgeons that establishment of a specialty of pediatric surgery would infringe on the practice of many of their members. It was evident that pediatric surgery needed better identity and better definition before a new attempt was made. Largely in response to this need, Dr Steven Gans, who was at that time the Program Chairman for the Surgical Section of the American Academy of Pediatrics, in 1964, proposed the creation of a journal of pediatric surgery [[15]Johnson D.G. Presidential address: excellence in search of recognition.J. Pediatr. Surg. 1986; 21: 1019-1031Abstract Full Text PDF PubMed Scopus (18) Google Scholar]. Later that year, he secured an agreement with Grune and Stratton to publish the journal with Dr C. Everett Koop as its editor [[16]Grosfeld J.L. 30th anniversary issue: journal of pediatric surgery, 1966-1996.J. Pediatr. Surg. 1996; 31: 1-2Abstract Full Text PDF Scopus (3) Google Scholar]. The first issue of the Journal of Pediatric Surgery was published in February 1966 (Fig. 1) [[17]Koop C.E. A perspective on the early days of pediatric surgery.J. Pediatr. Surg. 1999; : 38-45Abstract Full Text PDF PubMed Google Scholar]. The following year, a third approach was made to the American Board of Surgery. Dr Mark Ravitch, the chair of the Surgical Section at that time, proposed to the Board the establishment of a separate Board of Pediatric Surgery within the American Board of Surgery. Again, the Board refused this request, but did establish an ad hoc committee, headed by Dr John Kirkland, to study the entire issue of specialty boards within the American Board of Surgery. It was evident that pediatric surgery was going to have to further establish its own credibility before expecting any success with the American Board of Surgery. The executive committee of the Surgical Section of the Academy decided on a strategy to enhance the quality of education of surgeons for children as a way of defining us as a distinct specialty of surgery. The Surgical Section, in 1966, established the Committee on Postgraduate Education and Resident Training, under the leadership of Dr H William Clatworthy Jr [[2]Randolph J.G. History of the section on surgery, the American Academy of Pediatrics: the first 25 years (1948-1973).J. Pediatr. Surg. 1999; 34: 3-18Abstract Full Text PDF PubMed Google Scholar]. The following year this committee published The Specialty Requirements for Residency Training in General Pediatric Surgery and began to site visit and review the approximately 20 programs in North America training pediatric surgeons at that time. Ultimately, this committee would approve 13 of these as sanctioned Pediatric Surgical Training Programs. The Surgical Section once again approached the American Board of Surgery for affiliate board status, and once again, the Board refused the request, principally because of opposition from many of the general surgery nominating societies for the American Board of Surgery. In the fall of 1968 several of the younger members of the Surgical Section of the academy met with C Everett Koop at the ACS Clinical Congress in Atlantic City [[15]Johnson D.G. Presidential address: excellence in search of recognition.J. Pediatr. Surg. 1986; 21: 1019-1031Abstract Full Text PDF PubMed Scopus (18) Google Scholar]. The younger surgeons felt that it was time that pediatric surgery defined itself as a legitimate surgical specialty by establishing its own organization. Dr Koop reminded them of the considerable support that pediatric surgeons had received from the American Academy of Pediatrics over the previous two decades and indicated to them that he felt that it would have to be the younger surgeons who pushed for this independent organization [[17]Koop C.E. A perspective on the early days of pediatric surgery.J. Pediatr. Surg. 1999; : 38-45Abstract Full Text PDF PubMed Google Scholar]. In April of the following year, a letter was mailed from Drs Thomas E Boles and Lucian Leape to 18 young pediatric surgeons in the surgical section, proposing the formation of an independent pediatric surgical organization. There was an enthusiastic response to this letter, and in May 1969 the organizing meeting of the American Pediatric Surgical Association (APSA) was held at O'Hare airport in Chicago [[18]Leape L.L. A brief account of the founding of the American Pediatric Surgical Association.J. Pediatr. Surg. 1996; 31: 12-18Abstract Full Text PDF PubMed Scopus (6) Google Scholar]. A second meeting was held in July of that year, after notifying 100 members of the surgical section of the academy with regard to this proposal. Dr Harvey Beardmore, the chairman of the Surgical Section, attended this meeting, as did several of his executive committee members and former chairs. In January 1970, an invitation was mailed to 200 of the then 300 members of the Surgical Section, inviting them to become charter members of the APSA. Those invited had to be certified by the American Board of Surgery and had to confine their practice to the care of children. Two of our members who we have lost this past year played important roles in the formation of APSA. Dr Robert Izant of Cleveland drafted the bylaws and arranged for our organization to be incorporated in the state of Ohio. Dr E. Ide Smith organized a group within the organization to screen the potential charter members to be certain that they fulfilled the criteria for membership. The first meeting of the APSA was called to order by Dr Harvey Beardmore, the chair of the Surgical Section, on April 17, 1970, in Pheasant Run, Ill (Fig. 1). Dr Robert E Gross was elected president and Dr C. Everett Koop was elected president-elect. Pediatric surgery had now obtained considerable stature as an independent surgical specialty, with its own advisory council within the ACS, its own journal for publication of scientific articles relating to the specialty, and its own society with the mission of advancing the art and science of the specialty. In March 1971, the chair of the Surgical Section, Dr Harvey Beardmore, ma