pediatric surgery--4/16/25

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Today's selection--from Surgeons and Something More by Clyde and Elizabeth Barker. The founding and evolution of the specialty of pediatric surgery:

“Steven Fishman (HUP chief resident, 1992) is chairman of surgery at Boston Children's Hospital. This position is usually considered the top one in pediatric surgery, a view based in part on US News & World Report's ranking of Boston Children's as the country's best pediatric hospital. This is arguable because CHOP [Children’s Hospital of Philadelphia] has sometimes been ranked first and Boston Children's second, but in either case, Penn Surgery has played a major role in the development of this field. An interesting story is how the surgeons who led these two hospitals have interacted and determined the history and evolution of pediatric and cardiovascular surgery. Six of these surgeons have a strong Penn connection.

“In 1946, when I. S. Ravdin returned to HUP from commanding World War II's 20th General Hospital, one of his first actions as department chairman was to appoint one of his residents, C. Everett Koop, as chief of surgery at CHOP. Koop was just finishing his HUP residency but had virtually no training or experience in children's surgery. To compensate for this inconvenience, Ravdin sent him to Boston Children's Hospital for a short course in pediatric surgery with the founders of the field, William Ladd and Robert Gross.

“At the time, pediatric surgery as a specialty was quite new–in the United States only twenty years old. Legend has it that in this country, it began as the result of a tragic explosion. On December 6, 1917, a French munitions ship full of wartime explosives collided with a Swedish ship in Canada's Halifax harbor. This set off an explosion that was said to be the world's most powerful one prior to the first atom bomb in 1945. Two thousand people were killed and 9,000 others injured. Thousands more were left homeless.

“A Red Cross relief train came from Boston carrying enough equipment to set up a 500-bed hospital.  It was led by a young Harvard-trained surgeon, William Ladd. The experience of caring for 500 injured and burned children was claimed to be the reason he decided to become a pediatric surgeon. This is an exaggeration as he was already focused on children's surgery. But after his experience in Halifax, he decided to devote himself full-time to the field.  Moving his practice to Boston Children's Hospital as a junior attending, he studied, acquired clinical experience, chronicled, and wrote about surgical maladies of children, such as malrotation, pyloric stenosis, cleft palate, biliary atresia, and so forth. He became such an authority in the field that in 1927, he was appointed as chief of surgery at Boston Children's Hospital, and since then, he has been considered the father of pediatric surgery. He also started the country's first formal training program in pediatric surgery. One of his residents, Robert Gross, was particularly accomplished and seemed to be Ladd's obvious heir apparent. Gross's interests were not limited to the general pediatric surgery he learned from Ladd. In fact, he was more interested in congenital cardiac abnormalities, which he studied in the department of pathology for two years. With animal experiments and dissection of human cadavers, he developed a plan for a new operation, ligation of the patent ductus arteriosus. In 1938, he told Ladd that he believed he was prepared to do this operation, the first in a human patient. However, Ladd was convinced that this was too dangerous and explicitly forbade Gross to attempt it.

“Disregarding his chief, Gross chose the opportunity of Ladd's absence on a European vacation and scheduled the operation. He then performed it successfully on a seven-year-old girl. When Ladd returned, he was furious that Gross had defied his order. According to Alden Harken (later a Gross resident), Ladd fired Gross, banishing him from Boston Children's Hospital for six weeks. Ladd never forgave Gross for this transgression, even though the operation Gross had done opened an entirely new field — heart surgery. Nor did Ladd relent in 1945 when Gross was further acclaimed for performing the first successful operation for coarctation of the aorta.

Koop in U.S. Public Health Service uniform

“As a result of their antagonism, when Ladd retired in 1945, he did his best to block Gross's appointment as his successor. According to Koop, as quoted in Ziegler's oral history of him, Ladd bitterly criticized Gross as an incompetent surgeon, a dishonest researcher, and even on moral and religious grounds.

“The antagonism between Ladd and Gross was at its height in 1946 when Koop showed up at Boston Children's for his fellowship. Ladd's criticism had delayed Gross's appointment as chief of surgery and poisoned the atmosphere. This unpleasantness resulted in Gross's frequent absence from the hospital and caused Koop to shorten his fellowship there from the planned twelve months to only eight. Nevertheless, in 1947, the widely-acclaimed Gross was appointed chief of surgery at Boston Children's. Recognized as the founder of cardiovascular surgery, he became one of the world's most praised and honored surgeons.

“During his brief fellowship in Boston, Koop watched Gross operate, but he attached even more importance to his discussions with the recently retired Ladd on the complex art of caring for children and their families. Koop then returned to Philadelphia where at CHOP, he soon became a major figure in pediatric surgery.

“In 1967, when Robert Gross retired as Boston Children's chief surgeon, Harvard appointed as his successor Judah Folkman, then only thirty-four years old, brilliant but known mainly for his research on angiogenesis. During Folkman's surgical training at MGH, he had little exposure to the surgery of children. To prepare him for his new position, he came to Philadelphia for a six-month fellowship at CHOP with C. Everett Koop, who by then was considered the country's leading pediatric surgeon. Fourteen years later, Folkman retired from a successful career in children's surgery to devote himself to research full-time. He was succeeded by Hardy Hendren (no Penn connection). When Hendren retired in 1998, he was succeeded by Mory Ziegler, who was trained in general surgery at HUP and by Koop at CHOP. Ziegler's spectacular career was capped in 2016 by his winning the prestigious Ladd Medal. He was followed by Robert C. Shamberger (no Penn connection), who was chief from 2004-2019. Completing the circle, Steve Fishman, another HUF-trained surgeon, became chief of surgery at Boston Children's in 2019.

“Steven J. Fishman is professor of surgery at Harvard Medical School and the Stuart and Jane Weitzman Family Chair in Surgery at Boston Children's Hospital where he is also vice-chair of surgery for clinical operations. He obtained BS and MD degrees at Northwestern University. As a HUP general surgery resident, Steve was president of the housestaff and won the Inouye Teaching Award, the Rhoads Research Award, and the Resident Scholar Award. After residency, he completed his pediatric surgery fellowship at Boston Children's Hospital in 1994. He has remained at Boston Children's for his entire career. Although always active in the practice and teaching of the broad spectrum of pediatric surgery, he has a particular clinical and research focus on vascular malformations.  In 1999, he became codirector of the Vascular Anomalies Center at Boston Children's Hospital. Annually this center's multidisciplinary group evaluates about 1,700 patients with hemangiomas, rare vascular tumors, and vascular malformations of all types. Steve originated and continues to maintain an international registry of hepatic hemangiomas. He is past president of the International Society for the Study of Vascular Anomalies.

“Dr. Fishman has authored over 200 scientific publications and chapters, as well as two books, including a comprehensive reference work on vascular anomalies. He has a particular interest in vascular abnormalities of the viscera. These anomalies are extremely rare, but Steve's international referral practice allows him to recognize patterns in their clinical presentation and opportunities for treatment. Dr. Fishman has extensive experience with resecting, debulking, and reconstructing vascular malformations and associated overgrown tissues of the torso, genitalia, neck, and extremities. He has also studied the role of dynamic contrast lymphangiography of the thoracic duct, which has led to the use of novel treatments and reconstruction of thoracic duct anomalies. He was the recipient of the Penn Department of Surgery's Distinguished Graduate Award in 2018.”

author:	Clyde F. Barker, Elizabeth Barker
title:	Surgeons and Something More: The History of Surgery at the University of Pennsylvania
publisher:	The American Philosophical Society Press
pages:	350-354