OPENING REMARKS

INTERNATIONAL CONGRESS
ON
PEDIATRIC NEUROSURGERY

C, Everett Koop, M.9,, Sc.D,
SURGEON GENERAL, !.S, PuBLic HEALTH SERVICE
&
DEPUTY ASSISTANT SECRETARY FOR HEALTH
DEPARTMENT OF HEALTH & HUMAN SERVICES

CHILDRENS HOSPITAL OF PHILADELPHIA
SEPTEMBER 13, 198:
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 181] 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 tn A PRacticAL TREATISE ON THE DISEASES OF CHILDREN

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 LADD AND Gross IN 1941.

THE FIRST CHILDREN’S HOSPITAL IN THE ENGLISH SPEAKING
WORLD WAS THAT WHICH WE KNOW TODAY AS THE HOSPITAL 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. JUST 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 4TH, 1946, I.S. RAVDIN, THE THEN JOHN PAE
BARTON PROFESSOR OF SURGERY AT THE !INIVERSITY OF PENNSYLVANIA,
SENT ME TO THE CHILDRENS HOSPITAL OF PHILADELPHIA FOR A THREE-
MONTH PROBATIONARY PERIOD, AFTER WHICH I WENT TO THE ROSTON
CHILDRENS HOSPITAL 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 £. LADD’S IN BOSTON,

THE CHILDRENS HOSPITAL 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 | BELIEVED WAS NECESSARY, THE SINGLE OPERATING ROOM
WAS BUILT AFTER THE FASHION OF THOSE IN THE ALLEMAGNE 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 [ WOULD HAVE TO HAVE SOMEONE INTERESTED
IN CHILDREN AND WITH THE PHYSIOLOGIC AND PHARMACOLOGIC BACKGROUND
TO MAKE A CONTRIBUTION TO THE FIELD OF CHILDREN’S ANESTHESIA,

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WITH THE CONCURRENCE OF |.S. RAVDIN AND ROBERT DRipps, UR. MARGO
DEMMING CAME TO US AS OUR FIRST PEDIATRIC ANESTHESIOLOGIST AND
TO HER | OWE MORE THAN COULD BE RECOUNTED IN GETTING STARTED

IN THIS NEW SPECIALTY IN PHILADELPHIA,

MANY TIMES MARGO AND I SAT UP 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 BACHMAN CAME TO FOUND

THE FIRST REAL DIVISION OF PEDIATRIC ANESTHESIOLOGY AT THE
CHILDRENS HosPITAL OF PHILADELPHIA. HIS ENTRANCE INTO THE
POLITICAL ARENA PuT DR, JAcK DOWNES IN COMMAND OF WHAT I THINK
IS THE BEST GROUP OF PEDIATRIC ANESTHESIOLOGISTS AND INTENSIVE
CARE SPECIALISTS THAT CAN BE FOUND,

BACK IN 1947 ann 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,

AMONG THE LESIONS IN QUESTION WERE SEVERAL NEUROSURGICAL
LESIONS, PARTICULARLY THE VARIOUS TYPES OF SPINA BIFIDA,
MENINGOCELE, MENINGOMYELOCELE AND HYDROCEPHALUS,

IT WAS MY DREAM IN 1947 anp ‘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 DEPARTMENT OF
SURGERY OF THIS HOSPITAL GAVE FOR THE BOARD OF MANAGERS IN
JANUARY OF 1980, I ANNOUNCED THAT MY GOAL OF 1943 HAD BEEN
REALIZED WITH THE FIRM ESTABLISHMENT OF EIGHT DIVISIONS OF
SURGERY IN THE DEPARTMENT OF SURGERY IN THE CHILDRENS HOSPITAL
OF PHILADELPHIA. IT HAD TAKEN MORE THAN 39) YEARS,

Back To 1947, HOWEVER, THE GREATEST NEED THAT I saw
FOR OUR FIRST SURGICAL SUBSPECIALIST WAS IN NEUROSURGERY, |
WAS AT THAT TIME A SURGEON OF THE SKIN AND ITS CONTENTS, BUT
IN THE FIELD OF NEUROSURGERY | CONCENTRATED ON SPINA BIFIDA
AND ITS COMPLICATIONS.

UROLOGICAL COMPLICATIONS WERE THE MOST LIFE THREATENING
AND, THEREFORE, THE SECOND SUBSPECIALIST THAT I SOUGHT WAS A
PEDIATRIC UROLOGIST.

THE FIRST EFFORT THAT I MADE TO TREAT HYDROCEPHALUS WAS
CONFINED TO FOUR PATIENTS IN WHOM | DID A URETERO-DURAL
ANASTOMOSIS AFTER PERFORMING A NEPHRECTOMY. AND SUCCESSFULLY,
I MIGHT ADD,

Berore | went To Boston, I wAS, TO THE BEST OF MY KNOWLEDGE,
THE FIRST SURGEON IN THE UNITED STATES TO USE PLASTIC TUBING IN
CLINICAL PRACTICE. I 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 END OF THE SHUNT.
QNE OF THE FEW GADGETS I EVER CONTRIBUTED TO 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. I DON’T KNOW HOW MANY SCORES
OF THESE I DID, BUT THE SUCCESS RATE OF THE SHUNTING PROCEDURE
IMPROVED RAPIDLY.

THE ONLY OTHER EXPERIENCE I HAD THAT MIGHT BE OF INTEREST
TO YOU WAS REALLY NOT NEUROSURGICAL ALTHOUGH ITS GOAL WAS
NEUROLOGICAL, WE TEND TO THINK THAT ALL OF THE CURRENT PUBLICITY
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 WAS REPORTING AN IMPROVEMENT
IN INTELLIGENCE IN RETARDED CHILDREN FOLLOWING THE CONSTRUCTION
OF ARTERIC-~VENOUS FISTULAE IN THE NECK,

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] 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. [| CARRIED 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 OXYGENATED BLOOD SUPPLY TO THE BRAIN
IMPROVED INTELLIGENCE OR PERFORMANCE. IN SHORT, WE COULD NOT
CONFIRM THE REPORTS OF OTHER INVESTIGATORS CLAIMING SUCCESS
IN INTELLIGENCE IMPROVEMENT FROM THIS PROCEDURE,

SHORTLY THEREAFTER A CONFESSION OF FALSIFICATION OF
STATISTICS BY THE OTHER INVESTIGATIVE GROUP SETTLED THE MATTER
AND I TOOK DOWN ALL OF THE ANASTOMOSES AND RECONSTRUCTED 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 HOLTER
HAD ARRIVED ON THE SCENE AND | RETREATED TO THE FIELD OF
GENERAL SURGERY WHERE | MORE PROPERLY BELONGED,

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I WOULD BE REMISS IF I DID NOT ON THIS OCCASION EXPRESS
MY APPRECIATION TO Dr. Luis ScHUT WHOM I HAD KNOWN AS A
RESIDENT IN NEUROSURGERY AND WAS HAPPY TO COME HERE AS CHIEF
OF NEUROSURGERY IN 1966. THAT WAS JUST 20 YEARS AFTER MY
INITIAL CONVERSATIONS WITH THE LATE GREAT FRANCIS C, GRANT
ON THE FEASIBILITY OF THE SPECIALTY OF PEDIATRIC NEUROSURGERY,
ALTHOUGH I THINK HE VIEWED ME AS SOMEWHAT OF AN UNREALISTIC
DREAMER HE WAS SUPPORTIVE WHEN | NEEDED NEUROSURGICAL HELP
SO DESPERATELY IN 1947,

DR. SCHUT PROVIDED NOT ONLY THE LEADERSHIP SO ABLY
DEMONSTRATED IN PEDIATRIC NEUROSURGERY, BUT WAS A REAL FACTOR
IN HELPING ME REALIZE THE GOAL | SET FOR PEDIATRIC SURGERY IN
GENERAL IN THIS INSTITUTION. My THANKS TOO TO Dr, Derick Bruce
WHO HELPED MAKE MY LAST YEARS HERE AS SURGEON-IN-CHIEF PLEASANT
ONES. DR. SUTTON CAME WHEN I LEFT BUT I AM SURE WILL UPHOLD
THE TRADITION OF EXCELLENCE IN THIS INSTITUTION, I EXPECT TO
BE STANDING HERE 3 MONTHS FROM TODAY FOR A SURGEON SENERAL’S
CONFERENCE ON SuPPORT FOR MECHANISMS FOR THE FAMILY OF A
HANDICAPPED CHILD USING HoME CARE FOR THE RESPIRATOR-DEPENDENT
CHILD AS A MODEL,

THE RESPIRATOR-DEPENDENT CHILD PRESENTS ENORMOUS ECONOMIC
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, I AM FLATTERED TO HAVE BEEN ASKED TO ADDRESS

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YOU THIS MORNING AND AM VERY PLEASED TO COME BACK TO MY OLD
STAMPING GROUNDS, I TRUST THAT YOU WILL FORGIVE MY DABBLING
IN NEUROSURGERY AS I DID. I REALLY LEFT AS SOON AS | COULD.

May YOU HAVE A VERY SUCCESSFUL MEETING.