INTERNATIONAL CONGRESS

        ON
PEDIATRIC NEUROSURGERY

   C, EVERETT KOOP, MJ,, ScJ,
SURGEON GENERAL, rJ,S, PUBLIC I~EALTH SERVICE

              &

DEPUTY ASSISTANT SECRETARY FOR HEALTH
DEPARTMENT OF HEALTI-I & NJNIN SERVICES

CHILDRENS HOSPITAL 0F PHILADELPHIA
    SEPTEMBER 3.3, 1982


THE CONCEPT OF THE SEPARATION OF PEDIATRIC SURGERY FROM

ITS ADULT COUNTERPART IS NOT RECENT IN WORLD HISTORY OF SURGERY
BUT THERE IS NO DOUBT ABOUT THE FACT THAT THE UNITED STATES
LAGGED BEHIND EUROPEAN COUNTRIES,  IN THE INDEX CATALOG OF THE
SURGEON GENERAL'S OFFICE IN 1311 THERE IS A REFERENCE TO A
TRANSLATION PUBLISHED IN LONDON IN 1656 OF A FOUR-VOLUME

HISTORY OF MEDICINE TO WHICH TRANSLATION WAS ADDED A SECTION
ON SURGERY, INCLUDING AN APPENDIX ON CHILDREN'S SURGERY,

  IN 1846 IN A PRACTICAI TRFATISE ON THE DISEASFS OF CHILDRFN
BY J,M, COLEY OF LONDON THERE WAS INCLUDED A SPECIAL SECTION

ON SURGICAL DISEASES,

  FROM 1856 TO 1877 THERE ARE LISTED FIFTEEN ARTICLES AND
BOOKS ON SURGICAL CONDITIONS OF CHILDREN BY ENGLISH, FRENCH,
AND ITALIAN AUTHORS, ONE BEING A COMPLICATION OF TWELVE
LETTSOMIAN LECTURES BY MR, T, BRYAN OF LONDON IN 1863,

BOOKS ON PEDIATRIC SURGERY IN MANY LANGUAGES HAVE BEEN

APPEARING DURING THE PAST SIXTY YEARS, CLEARLY INDICATING AN

INCREASED DEMAND FOR IMPROVEMENT IN THE SURGICAL CARE OF

CHILDREN,  THE FIRST SPECIFIC BOOK ON PEDIATRIC SURGERY IN
THIS COUNTRY WAS ONE BY DEFOREST WILLARD IN 1910, THE FIRST

MODERN BOOK WAS THAT VERY PERSONAL COMPENDIUM OF RELATIVELY
LITTLE EXPERIENCE BY IADD AND GROSS IN 1941,

  THE FIRST CHILDREN'S HOSPITAL IN THE ENGLISH SPEAKING
WORLD WAS THAT WHICH WE KNOW TODAY AS THE ~~OSPITAL FOR SICK


CHILDREN, GREAT ORMOND STREET, LONDON, IT IS INTERESTING TO

NOTE THAT IN THE INITIAL SUBSCRIPTION FOR THE BUILDING THAT

MR. CHARLES DICKENS PLAYED A PROMINENT ROLE IN PERSUADING HIS

FELLOW COUNTRYMEN THAT THE NEEDS FOR CHILDREN REQUIRED SPECIAL
`
ATTENTION,  J~JST A FEW YEARS LATER IN 1855 -- THE SECOND
CHILDREN'S HOSPITAL IN THE ENGLISH SPEAKING WORLD AND THE

FIRST IN THIS HEMISPHERE WAS ESTABLISHED; NAMELY, THIS ONE,

THE CHILDREN'S HOSPITAL OF PHILADELPHIA,  IT HAS MOVED ON THREE

OCCASIONS, THE MOST RECENT BEING TO THIS SITE AND THIS PRESENT
BUILDING IN 1974,

  IN NORTH AMERICA AT THE TURN OF THE CENTURY THERE WERE

FEW CHILDREN'S HOSPITALS BUT THEY WERE BEING RECOGNIZED AS

CENTERS OF PROGRESS AND INFORMATION AS WELL AS TRAINING IN

PEDIATRICS,  THE DEVELOPMENT OF PEDIATRICS WAS RAPID BUT

THERE IS NO DOUBT THAT PEDIATRIC SURGERY DID NOT KEEP PACE

WITH IT,  PEDIATRIC SURGERY IN THOSE DAYS IF CALLED MEDIOCRE

WAS BEING DESCRIBED IN MOST CHARITABLE TERMS,  CHILDREN DIED

BECAUSE OF FAILURE TO MAKE CORRECT DIAGNOSES, BECAUSE OF

TRAUMATIC TECHNIQUES, FAILURE TO RECOGNIZE THE PATHOLOGICAL

CONDITIONS FOUND IN OPERATION, AND DUE TO ABYSMAL POST-

OPERATIVE CARE,

THE PERSISTENCE OF MEDIOCRITY CONTINUED BECAUSE SURGEONS

DISCUSSED ONLY ADULT CONDITIONS AT THEIR MEETINGS AND DID NOT

ATTEND PEDIATRIC MEETINGS, READ PEDIATRIC LITERATURE, OR STUDY

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PEDIATRIC PHYSIOLOGY SO THAT THEY WERE NOT EVEN AWARE OF HOW

SHORT OF THE MARK THEIR EFFORTS FELL,  ENCOUNTERS WITH PEDIATRIC

SURGICAL LESIONS BY GENERAL SURGICAL RESIDENTS IN TRAINING WAS

SPARSE INDEED,

  ON JANUARY ~TH, 1946, I,S, RAVDIN, THE THEN JOHN RAE
BARTON PROFESSOR OF SURGERY AT THE UNIVERSITY OF PENNSYLVANIA,
SENT MOE TO THE CHILDRENS HOSPITAL OF PHILADELPHIA FOR A THREE-
MONTH PROBATIONARY PERIOD, AFTER WHICH 1 WENT TO THE ROSTON
CHILDRENS !-!OSPITAL FOR THE REMAINDER OF THAT YEAR WITH INSTRUC-
TIONS TO RETURN TO PHILADELPHIA AND ESTABLISH A PEDIATRIC SURGICAL
SERVICE EQUIVALENT OF THAT OF DR, !~/ILLIAM E, I-ADD'S IN BOSTON,

THE CHILDRENS ~~OSPITAL OF PHILADELPHIA WAS IN THOSE DAYS

ESSENTIALLY A MEDICAL SANITARIUM FOR CHILDREN AND THEY WERE

NOT GEARED TO MY AGGRESSION IN TRYING TO BUILD THE KIND OF
SERVICE 1 BELIEVED WAS NECESSARY,  ?-HE SINGLE OPERATING ROOM
WAS BUILT AFTER THE FASHION OF THOSE IN THE P.LLEMAGNE KRANKENHAUS
IN VIENNA WITH THE OPERATING FLOOR ITSELF BEING IN THE DEPTHS OF
A GREEN TILE PIT SURROUNDED BY 125 UNOCCUPIED SEATS,

  THE FIRST TIME I SCHEDULED 10 OPERATIONS ON THE SAME DAY,
THE OR STAFF QUIT,

  IT WAS EVIDENT ALMOST IMMEDIATELY THAT IF PEDIATRIC
SURGERY WAS TO PROSPER 1 WOULD HAVE TO HAVE SOMEONE INTERESTED

IN CHILDREN AND WITH THE PHYSIOLOGIC AND PHARMACOLOGIC BACKGRO'JND

TO MAKE A CONTRIBUTION TO THE FIELD OF CHILDREN'S ANESTHESIA,

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!/ITH THE CONCURRENCE OF IA RAVDIN AND YOBERT ~RIPPS, /JR, MARGO

DEMMING CAME TO us AS OUR FIRST PEDIATRIC ANESTHESIOLOGIST AND

TO HER 1 OWE MORE THAN COULD BE RECOJJNTED IN GETTING STARTED
IN THIS NEW SPECIALTY IN PHILADELPHIA,

   MANY TIMES MARGO AND I SAT !JP AT NIGHT AT THE BEDSIDE OF A

CHILD WHOM WE THOUGHT MIGHT NEED A TRACHEOSTOMY AND WE FREQUENTLY

TRIED ALL MANNER OF PHARMACOLOGIC EXPERIMENTS IN CHILDREN WITH

DIFFICULT RESPIRATORY PROBLEMS THAT WE UNDERSTOOD VERY POORLY,
AFTER MANY YEARS OF FAITHFUL SERVICE AND MAJOR CONTRIBUTIONS,

LARGELY UNSUNG, TO THE FIELD OF PEDIATRIC ANESTHESIOLOGY,
DR, DEMMING RESIGNED AND DR, LEONARD 3AcHriiAN CAME TO FOUND

THE FIRST REAL DIVISION OF PEDIATRIC ANESTHESIOLOGY AT THE
CHILDRENS f!OSPITAL OF PHILADELPHIA, !!IS ENTRANCE INTO THE
POLITICAL ARENA PUT DR, JACK ~OWNES IN COMMAND OF I~!HAT 1 THINK

IS THE BEST GROUP OF PEDIATRIC ANESTHESIOLOGISTS AND INTENSIVE

CARE SPECIALISTS THAT CAN BE FOUND,

  SACK IN 1947 AND 1948 MEDICAL PATIENTS DIED ON THE WARDS
OF THE CHILDRENS HOSPITAL WITHOUT EVEN HAVING A SURGICAL CON-

SULTATION WHEN A SIMPLE SURGICAL PROCEDURE COULD HAVE SAVED

THEIR LIVES,

  ArioNG THE LESIONS IN QUESTION I~!ERE SEVERAL NEUROSURGICAL

LESIONS, PARTICULARLY THE VARIOUS TYPES OF SPINA BIFIDA,

MENINGOCELE, MENINGOMYELOCELE AND HYDROCEPHALUS,

IT WAS My DREAM IN 1947 AND '43 TO ESTABLISH EVENTUALLY

THE MOST COMPREHENSIVE GROUP OF PEDIATRIC SURGICAL SPECIALISTS

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ANYWHERE IN THE WORLD,  AT A DINNER, WHICH THE UE~ARTMENT OF

SURGERY OF THIS !~OSPITAL GAVE FOR THE BOARD OF YANAGERS IN
JANUARY OF 1980, I ANNOUNCED THAT MY GOAL OF 1948 HAD BEEN

REALIZED WITH THE FIRM ESTABLISHMENT OF EIGHT DIVISIONS OF
SURGERY IN THE DEPARTMENT OF SURGERY IN THE CHILDRENS UOSPITAL
OF PHILADELPHIA,  IT HAD TAKEN MORE TH.4N 30 YEARS,

  EAcK TO 1947, HOWEVER, THE GREATEST NEED THAT I SAG
FOR OUR FIRST SURGICAL SUBSPECIALIST WAS IN NEUROSURGERY, 1

WAS AT THAT TIME A SURGEON OF THE SKIN AND ITS CONTENTS, BUT
IN THE FIELD OF NEUROSURGERY 1 CONCENTRATED 0.N SPINA BIFIDA

AND ITS COMPLICATIONS,

  UROLOGICAL coMpLIcATIoNs P!ERE THE MOST LIFE THREATENING
AND, THEREFORE, THE SECOND SUBSPECIALIST THAT 1 SOUGHT wAS A

PEDIATRIC UROLOGIST,

  THE FIRST EFFORT THAT I MADE TO TREAT HyDRocEpH.4Lus WAS
CONFINED TO FOUR PATIENTS IN WHOM 1 DID A URETERO-DU!?AL

ANASTOMOSIS AFTER PERFORMING A NEPH!?ECTOMY,  AND SUCCESSFULLY,
1 MIGHT ADD,

  BEFORE 1 WENT TO BOSTON, 1 WAS, TO THE BEST OF MY KNOWLEDGE,
THE FIRST SURGEON IN THE UNITED STATES TO USE PLASTIC TUBING IN

CLINICAL PRACTICE,  1 HAD USED IT FOR THE ADMINISTRATION OF

FLUIDS INTRAVENOUSLY IN INFANTS AND IT WAS ONLY NATURAL THAT

WE SHOULD TRY SHUNTING EXCESS CEREBRO-SPINAL FLUID FROM THE

VENTRICLES ELSEWHERE WITH THIS NEW CONDUCT,  ELSEWHERE PROVED

TO BE THE THORACIC CAVITY AND THE PERITONEAL CAVITY,

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  THOSE EARLY EXPERIMENTAL PROCEDURES WERE FAUGHT WITH ALL

SORTS OF DIFFICULTY,  ALL TUBING DID NOT REMAIN FLEXIBLE AFTER

EXPOSED TO TISSUE FLUIDS, AND TIGON, PARTICULARLY, BECAME AS

BRITTLE AS UNCOOKED SPAGHETTI,  THEREFORE, EVEN SUCCESSFULLY

FUNCTIONING SHUNTS WERE SUDDENLY DISRUPTED IF A TODDLER FELL

AND CRACKED HIS TUBING,  COLLECTIONS OF SPINAL FLUID APPEARED HERE

AND THERE ALONG THE COURSE OF THE SHUNT,

ANOTHER PROBLEM WHICH CONFRONTED us WAS THE TENDENCY OF THE

OMENTUM TO WRAP ITSELF AROUND THE PERITONEAL EN3 OF THE SHUNT,
ONE OF THE FEW GADGETS I EVER CONTRIBUTED ~0 THE ART OF NEURO-

SURGERY WAS SOMETHING THAT LOOKED LIKE A HIGHLY POLISHED PLASTIC

SALT SHAKER TOP INTO WHICH WE FITTED A FLANGED PLASTIC TUBE,
THIS IMPROVED THE SITUATION SOMEWHAT BUT NOT SUFFICIENTLY TO

SATISFY US,  THE NEXT STEP WAS TO PERFORM A PROPHYLACTIC

OMENTUMECTOMY IN AS BLOODLESS A FASHION AS POSSIBLE BEFORE

INSERTING THE PERITONEAL SHUNT,  1 DON'T KNOW HOW MANY SCORES

OF THESE 1 DID, BUT THE SUCCESS RATE OF THE SHUNTING PROCEDURE

IMPROVED RAPIDLY,

  THE ONLY OTHER EXPERIENCE 1 HAD THAT MIGHT BE OF INTEREST

TO YOU WAS REALLY NOT NEUROSURGICAL ALTHOUGH ITS GOAL \'!AS

NEUROLOGICAL,  CjE TEND TO THINK THAT .4LL OF THE CUPRENT PlJBLICITY

ABOUT ETHICS IN RESEARCH OR THE LACK OF IT, MIGHT SOMEHOW OR

OTHER INDICATE THAT RESEARCHERS WERE ALWAYS HONEST IN THE OLD
DAYS, SUCH WAS NOT THE CASE,

  A GROUP OF AMERICAN INVESTIGATORS w,4s REPORTING AN IMPROVEMENT

IN INTELLIGENCE IN RETARDED CHILDREN FOLLOWING THE CONSTRUCTION

OF ARTERIC-VENOUS FISTULAE IN THE NECK,


  1 WAS APPROACHED BY REPRESENTATIVES OF THE AMERICAN ACADEMY
OF PEDIATRICS TO CARRY OUT A STUDY FOR THEM ON FIFTY CHILDREN

WITH VARIOUS DIAGNOSES ASSOCIATED WITH MENTAL RETARDATION, WITH

THE COMPLETE UNDERSTANDING OF THE PARENTS THAT THIS WAS A

PURELY EXPERIMENTAL PROCEDURE,  I C4RRIED OUT SIDE-TO-SIDE

ANASTOMOSES BETWEEN THE COMMON CAROTID ARTERY AND THE INTERNAL
JUGULAR VEIN IN 50 CHILDREN,  BEFORE AND AFTER THIS PROCEDURE,
THE MOST SOPHISTICATED INTELLIGENCE TESTING AVAILABLE TO US

WAS CARRIED OUT,

  ON THE BASIS OF OUR STUDIES, ALTHOUGH SOME VERY PHENONOMAL

THINGS SEEMED TO OCCUR, IT WAS IMPOSSIBLE TO PROVE THAT THIS
METHOD OF INCREASING 0XYGE;ATED BLOOD SUPPLY TO THE BRAIN

IMPROVED INTELLIGENCE OR PERFORMANCE,  IN SHORT, WE COULD NOT

CONFIRM THE REPORTS OF OTHER INVESTIGATORS CLAIMING SIJCCESS

IN INTELLIGENCE IMPROVEMENT FROM THIS PROCEDURE,

SHORTLY THEREAFTER A CONFESSION OF FALSIFICATION OF

STATISTICS BY THE OTHER INVESTIGATIVE GROUP SETTLED THE MATTER
AND 1 TOOK DOWN ALL OF THE ANASTOMOSES AND RECONSTR!JCTED THE

INTEGRITY OF THE VESSLES IN THOSE YOUNGSTERS WHO HAD NOT

SUCCUMBED TO THEIR UNDERLYING DISEASE,

  BY THAT TIME PUBLICITY IN THE LAY PRESS WAS BRINGING

UNBELIEVABLE NUMBERS OF CHILDREN WITH ADVANCED HYDROCEPHALUS

TO OUR DOORS,  I WAS BUSY WITH OTHER THINGS AND \JOHN UOLTER
HAD ARRIVED ON THE SCENE AND 1 RETREATED TO THE FIELD OF
GENERAL SURGERY WHERE 1 MORE PROPERLY BELONGED,

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   1 WOULD BE REMISS IF 1 DID NOT ON THIS OCCASION EXPRESS
MY APPRECIATION TO DR, LUI s SCHUT WHOM 1 H.~D KNO~JN AS A

RESIDENT IN NEUROSURGERY AND WAS HAPPY TO COME HERE AS CHIEF
OF NEUROSURGERY IN 1966, THAT WAS \JUST 29 YEARS AFTER MY

INITIAL CONVERSATIONS WITH THE LATE GREAT FRANCIS C, GRANT

ON THE FEASIBILITY OF THE SPECIALTY OF PEDIATRIC NEUROSURGERY,
ALTHOUGH 1 THINK HE VIE!,`!ED ME AS SOMEWH4T OF AN UNREALISTIC

DREAMER HE WAS SUPPORTIVE WHEN I NEEDED NEUROSUREICAL HELP

SO DESPERATELY IN 1947,

   DR, SCHUT PROVIDED NOT ONLY THE LEADERSHIP so ABLY

DEMONSTRATED IN PEDIATRIC NEUROSURGERY, BlJT WAS A REAL FACTOR

IN HELPING ME REALIZE THE GOAL 1 SET FOR PEDIATRIC SIJRGERY IN

GENERAL IN THIS INSTITUTION,  rvl.y THANKS ~00 ~0 !IR, !~ERIcK BRUCE

WHO HELPED MAKE MY LAST YEARS HERE AS SURGEON-IN-CHIEF PLEASANT
ONES, DR, SUTTON CAME WHEN I LEST BUT I AM SURE WILL UPHOLD

THE TRADITION OF EXCELLENCE IN THIS INSTITUTION,  1 EXPECT TO
BE STANDING HERE 3 MONTHS FROM TODAY FOR A SURGEON ~ENERAL'S
CONFERENCE ON SUPPORT FOR MEcHANIsMs FOR THE FAMILY OF A
HANDICAPPED CtmD USING HOME CARE FOR THE RESPIRATOR-DEPENDENT
CHILD AS A ~IODEL,

  THE RESPIRATOR-DEPENDENT CHILD PRESENTS ENoRMous EcoNorSIc

PROBLEMS AND THESE ARE READILY SHIFTED TO THE ETHICAL-MORAL

ARENA,  THE DIRECTION WE CAN PROVIDE WILL CERTAINLY SPILL OVER

INTO THE MANAGEMENT OF DISABLING CONDITIONS OF INTEREST TO THE

NEUROSURGEON,  1 .4M FLATTERED TO HAVE BEEN ASKED TO ADDRESS

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YOU THIS MORNING AND AM VERY PLEASED TO COME BACK TO MY OLD

STAMP I NG  GROUNDS fi  I TRUST THAT You WILL FORGIVE My DABBLING
IN NEUROSURGERY AS 1 DID,  1 REALLY LEFT AS SOON AS I COULD,

MAY YOU HAVE A VERY SUCCESSFUL MEETING,

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