Pediatric Patients as a Source of Bias in Joseph Lister's Study of Antisepsis

Joseph Lister's (1827-1912) use of carbolic acid to prevent wound infection in open fractures of the extremities (1865) provided a basic science rationale for the practice of surgery. His series of 11 patients included 4 children, aged 7 to 13. Children, today known to better survive a given injury when compared with adults, may have biased his results in favor of survival, and led him to conclude that his method of carbolic-soaked dressing changes prevented fatal wound sepsis. His success with antisepsis may have been less a testament to his application of germ theory to surgery than to the physiological resilience of his young patients.

Japanese Immigration in America: Fleeing Riots, Escaping Imprisonment, and Assimilating

When 13-year-old Teruichi Nakayama, my grandfather, came to San Francisco from Osaka in 1906, he was assured of an education in a public school by an 1894 treaty between the United States and Japan that gave the latter most-favored-nation status. In 1906, racist mobs forced a decision by the school board to assign 41 school aged Japanese children, including him, to a segregated school for Asian children in violation of the pact. In 1907, he escaped street violence to work as a migrant laborer on inland farms. Settling in the state's Central Coast, he started a confectionary, the family business he knew from his childhood in Japan. He eked enough money to raise a family with a wife arranged for him in the traditional manner by a go-between in Japan. The school board action opened a diplomatic rift between the 2 countries that never resolved and ended in war in 1941. Just days ahead of the imprisonment of Japanese living in California in 1942, he and his family fled to Colorado, a sanctuary state where he reestablished the confectionery. He faced every misapprehension of the current immigration crisis: racism, unfair labor competition, the impossibility of assimilation, and suspicion of a fifth column. Now 5 generations later, none of the fearful predictions when he first arrived came true. His legacy proves immigration as an essential rejuvenating force in America.

The Opium Wars of China in the Nineteenth Century and America in the Twenty-First

The Opium Wars of 1839-1843 and 1856-1860 revealed the devastating effects of narcotic addiction on the health of the body politic of China. The defeated Qing dynasty lost effective sovereignty to the British, leaving it helpless against more than 100 years of exploitation by the European powers, the United States, and Japan. Today we see the same risk posed by prescription narcotics and illegal opioids imported from China that can be seen as retribution for the "Century of Humiliation" nearly two centuries ago.

Chinese Railroad Workers, the Transcontinental Railroad, and the Indispensability of Immigration to America

Asian migration to America began with Chinese railroad workers on the transcontinental railroad (1862-1869). Their labor saved the foundering Central Pacific Railroad, challenged by building a rail line through the Sierra Nevada. By mid-1864 only 50 miles of track had been laid, grueling work that dissuaded its white workforce from going any further. To save the railroad 50 Cantonese workers were hired in early 1864 from neighboring mines to lay rail through forests, canyons, and granite mountains. High explosives, rockslides, cave-ins, and winter avalanches were constant dangers. The trial worked so well that thousands of Chinese joined the effort, many from the rural districts surrounding Guangzhou (Canton). The wages, less than half of that paid to white workers, were beyond the imaginations of subsistence farmers escaping abject poverty, plague, and famine. A good proportion of their earnings were remitted to families back home. As many as 20,000 may have worked on the railway. The death toll was staggering, estimated in the thousands. After Promontory Summit in 1869, Chinese were in great demand, building scores of rail lines throughout the country and Canada. Just 13 years later rising anti-Asian sentiment led to the passage of the Chinese Restriction Act of 1882 that for the first time barred a racial group from American shores. But they opened America to Asian immigrants that includes today's Asian surgical community, which owes its present-day success to the hardworking forebears that created a global country with ribbons of steel rail.

The Great Migration and Healthcare to Black America

The Great Migration, the movement of 6,000,000 black Americans from the South to the great urban centers of the eastern seaboard, the industrial Midwest, and West Coast port cities from roughly 1915-1970, was one of the defining demographic events in American history. It dwarfed the 100,000 49ers who swarmed westward in search of gold, the incarceration of 110,000 Japanese to concentration camps in the American interior during World War II, and the 300,000 Okies who escaped the Dust Bowl to California. In the words of writer Isabel Wilkerson, "[It] swept a good portion of all the black people alive in the United States at the time into a river that carried them to all points north and west."Blacks crammed into urban districts rife with crime and communicable disease, subjecting them to risks of death far higher than their proportion of the population. Without access to adequate inpatient hospital facilities, they received care in public hospitals run by hospital staffs that excluded black physicians from their membership and medical schools that refused admission to black students. The untenable health station of Black America was one of the leading causes of the civil rights movement of the 1950s and 1960s, activism that succeeded in integrating the hospitals and medical schools by federal acts passed in 1964 and 1965 that transformed American medicine.

Injury Patterns, Imaging Usage, and Disparities Associated With Car Restraint Use in Children

BACKGROUND

Motor vehicle collision (MVC) is a leading cause of accidental death in children. Despite effective forms of child safety restraint (eg, car seat and booster seat), studies demonstrate poor compliance with guidelines. The goal of this study was to delineate injury patterns, imaging usage, and potential demographic disparities associated with child restraint use following MVC.

METHODS

A retrospective review of the North Carolina Trauma Registry was performed to determine demographic factors and outcomes associated with improper restraint of children (0-8 years) involved in MVC from 2013 to 2018. Bivariate analysis was performed by the appropriateness of restraint. Multivariable Poisson regression identified demographic factors for the relative risk of inappropriate restraint.

RESULTS

Inappropriately restrained patients were older (5.1 years v. 3.6 yrs, P < .001) and weighed more (44.1 lbs v. 35.3 lbs, P < .001). A higher proportion of African American (56.9% v. 39.3%, P < .001) and Medicaid (52.2% v. 39.0%, P < .001) patients were inappropriately restrained. Multivariable Poisson regression showed that African American patients (RR 1.43), Asian patients (RR 1.51), and Medicaid payor status (RR 1.25) were associated with a higher risk of inappropriate restraint. Inappropriately restrained patients had a longer length of stay, but injury severity score and mortality were no different.

DISCUSSION

African American children, Asian children, and Medicaid insurance payor status patients had an increased risk of inappropriate restraint use in MVC. This study describes unequal restraint patterns in children, which suggests opportunity for targeted patient education and necessitates research to further delineate the underlying etiology of these differences.

The Christmas Miracle of Emil von Behring

The foundation story of immunology is the Christmas miracle of Emil von Behring, whose diphtheria antitoxin was first used to save the life of a child on Christmas Day 1891. Modern scholarship has dismissed it as historically and scientifically implausible: Behring's lab did not have enough antitoxin serum for use in humans, and Ernst von Bergmann had prohibited its use at the Charité.But antitoxin was tried that December by their assistants, Erich Wernicke, who processed injected rams and horses and harvested the serum for Behring, and Heinrich Geissler, who was one of Bergmann's house physicians. Especially during the Christmas season, it is easy to imagine Wernicke and Geissler bypassing protocol and giving the serum a try as a last-ditch effort to save a dying child. Derek Linton, a Behring biographer, wrote:A harried nurse confronted by a dying infant belatedly remembers that a doctor with a promising remedy for diphtheria urged her to bring hopeless cases to his attention and has him roused from his slumber on the other side of Berlin in the middle of the night on December 20, 1891. The injection of his wonder serum then rapidly resuscitates the comatose infant. Five days later, the parents celebrate the most joyous Christmas of their lives with their fully recovered daughter.

The Immigrant Backstories of Asian American Surgeons

The stories of Asian immigrants have both shared themes and ones that are unique to the histories of their homelands. Their labor was essential to the settlement and economic development of America, yet their presence incited riots and official restrictions to their rights to immigration and citizenship. Chinese laborers mined the Gold Country, built the transcontinental railroad, and reclaimed tillable land in the Central Valley. Yet they were denied the immense bounty they created, and their immigration was blocked by the Chinese Exclusion Act of 1882.Japanese, Asian Indians, and Filipinos replaced them on farms as migrant laborers. As foreign nationals they were not allowed to own land, but they thrived as independent farmers on leased plots. Their success attracted discrimination and racist violence. They, too, were barred from immigration and citizenship (Johnson-Reed Act, 1924).World War II was a watershed event for Asians in America. Japanese Americans, ethnically identical to the enemy, were imprisoned in concentration camps in the American interior. China, the Philippines, and India, all allies of the US, were rewarded with naturalization rights for their nationals. In 1965 Congress liberalized immigration quotas and reversed the 1924 restrictions, with priority given to those with advanced technical ability in science, including medicine. Asians from Taiwan and India took advantage of the new regulations and predominated among the newcomers. After the fall of Saigon in 1975, America accommodated yet another Asian population in the country, the tens of thousands of refugees from Southeast Asia.

St. Zenobius, the Patron Saint of Injured Children and Non-accidental Trauma

St. Zenobius (337-417), second only to John the Baptist as a Patron Saint of Florence, revived a 5-year-old boy who appeared to be dead after he was struck by an ox cart, one of his several acts of resurrection for which he was revered. His miracles inspired some of the greatest artists of the Florentine Republic, including Ghiberti and Botticelli. Celebrated from Late Antiquity as protector of the city, St. Zenobius might also be considered the guardian of injured children. But it wasn't the only instance where he had to revivify an injured child: a boy died while he was entrusted to the saint's care, a circumstance that today would qualify as non-accidental trauma (NAT) from neglect and prompt an investigation from the police and child protective services.

Guild Rivalries Between Barbers and Surgeons in Medieval London and England

The origins of today's surgical societies are the guilds of medieval London. The Company of Barbers and the Guild of Surgeons vied for dominance no different from the scores of conflicts between rival artisans and merchants whose trades overlapped. The Company dates from 1308, when the council of London passed ordinances that installed its first master, Richard le Barber. When the surgeons received ordinances of their own in 1368, the barbers had the Council reassert theirs in 1376, 1390, 1415, and 1424. Faced with a vigorous organization with greater numbers the surgeons aligned with the physicians in 1423 to form a short-lived ruling "commonalty" with an elite membership based on educational achievement and proven ability that excluded the barbers. The surgeons were thereby granted authority over all of surgery, including that practiced by barbers, an arrangement that failed after only a year. The surgeons formed a guild in 1435 but could not compete with the barbers. The barbers' primacy became complete in 1462 when Edward IV chartered them to govern all aspects of surgery, along with the power to fine and imprison. From then barbers and surgeons amiably coexisted, likely because the rapidly growing population and the democratization of the practice of physic provided plenty of work. Henry VIII formally united the barbers and surgeons in 1540 under the Worshipful Company of Barbers and Surgeons, an amalgamation that lasted for two centuries until the surgeons broke away in 1745.

Asian American Surgery: A Short History of Immigration, Naturalization, and Refugee Laws and Policies that Brought Asians to America

Chinese immigration in America in the mid-nineteenth century incited violence and governmental sanctions to restrict Asian immigration and reject citizenship rights. In 1870, Chinese strikebreakers in Massachusetts ignited nationwide demonstrations against Chinese immigration, which ended altogether with the Chinese Exclusion Act (1882). Japanese schoolchildren in San Francisco public schools sparked rioting in 1907, leading Japan to unilaterally limit emigration to the United States (Gentlemen's Agreement, 1908). Congress responded to anti-Punjabi riots (Bellingham, WA, 1907) by refusing naturalization rights to Asians (Barred Zone Act, 1917), policies supported by the Supreme Court (Ozawa, 1922; Thind, 1923). All immigration from Asia was soon prohibited (Johnson-Reed Act, 1924). Anti-Asian measures peaked in 1942 with imprisonment of Japanese in concentration camps, including those with birthright citizenship. Anti-Asian policies unwound in the last half of the 20th century, culminating in sweeping changes in US immunization policy. Naturalization rights were granted to wartime allies against Japan (China, 1943; the Philippines and India, 1946) and the Japanese themselves (1952). Asian women marrying American servicemen were allowed entry into the country (1945, 1950). Prohibitions against Asian immigration were lifted in 1965 (Hart-Celler Act), with preference for those trained in science, technology, and medicine. The refugee crisis that followed the fall of Saigon (1975) drove humanitarian policies that brought evacuees from Southeast Asia and others from throughout the world seeking freedom from persecution (Refugee Act, 1980). Hundreds of thousands from China, South Asia, the Philippines, and Southeast Asia thus settled in the United States, changing American society and medicine.

Ernest Amory Codman and the End Result Idea in Surgical Quality

The quality movement in 21st century healthcare-quality, patient safety, and the value equation (value equals quality divided by cost)-had their start with Ernest Amory Codman (1869-1940), the quixotic surgeon who started it all a century before. He was on track for prosperity and success, given a Boston Brahmin pedigree and his impeccable credentials from Harvard College, its medical school, and the Massachusetts General Hospital.In 1910, nearing 40, Codman instead detoured toward a revolutionary idea that he called the End Result system, the seemingly unachievable goal of reaching "perfection" in surgery: complete recovery without death, complications, or lasting disability. He scrutinized any case that fell short, seeking honest explanations and improvements so that his next case would more likely reach a perfect outcome.The system that was so clear to him was audacious to his colleagues, who summarily rejected it. When Codman suspected greed and self-interest, he was ostracized from the Boston medical community. To apply his concepts, he opened a proprietary hospital called the End Result Hospital that drove him to insolvency.His career never recovered from the debacle even when he later reached prominence as an authority on bone malignancies and shoulder pathology. When he died, his resting place went unmarked. As quality became central to healthcare at the end of the 20th century, Codman's prescient End Result system was recognized as a fundamental contribution to medicine.

Thurgood Marshall, Hero of American Medicine

One of the heroes in American history, Associate Supreme Court Justice Thurgood Marshall (1908-1993) sought legal remedies against racial discrimination in education and health care. As director of the Legal Defense Fund (LDF) of NAACP from 1940 to 1961, his success in integrating law schools in Texas led to the first black medical student admitted to a state medical school in the South. Representing doctors and dentists needing a facility to perform surgery, the LDF brought cases before the courts in North Carolina that moved the country toward justice in health care. His ultimate legal victory came in 1954, Brown v. Board of Education of Topeka, the decision that declared racial segregation in public schools unconstitutional. In 1964, the LDF under Jack Greenberg, Marshall's successor as director, won Simkins v. Moses H. Cone Memorial Hospital, a decision that held that hospitals accepting federal funds had to admit black patients. The two decisions laid the judicial foundation for the laws and administrative acts that changed America's racial history, the Civil Rights Act of 1964 and the Social Security Act Amendments of 1965 that established Medicare and Medicaid. His achievements came during the hottest period of the American civil rights movement of the 1950s and 1960s. Well past the middle of the twentieth century, black Americans were denied access to the full resources of American medicine, locked in a "separate-but-equal" system woefully inadequate in every respect. In abolishing segregation, Marshall initiated the long overdue remedy of the unjust legacies of slavery and Jim Crow.

Surgical Professionalism, the White Owl, and Tar Heel Basketball

The University of North Carolina (UNC) has storied traditions beyond its champion Tar Heel basketball teams. One of its best-and least known off campus-is the white owl, today a lapel pin given to chief residents in surgery at Memorial Hospital in Chapel Hill. Former residents in anesthesia and surgery at the San Francisco General Hospital (SFGH) remember it as a stuffed owl that anesthesia residents brought into the operating room whenever there was an appendectomy for appendicitis and the appendix was normal, an operation familiarly called a negative appendectomy. Standing at the table closing the incision their surgical counterpart endured the imagined smirks of the anesthesiologists behind their masks and the scrub techs and circulating nurses who also knew of the bird's significance. Alumni of the SFGH training programs also remember it as evidence of the good-natured repartee between anesthesia and surgery, teams that worked hard at all hours to serve the injured and disadvantaged populations of the city. In retrospect, the white owl signifies owning one's decisions and mistakes, an essential aspect of surgical professionalism.

A Japanese Family Experience in America

Even though my uncle was not in the health professions, much less surgery, I share his memorial as the story of one family that had one of its offspring become integrated into the professional mainstream through the opportunity of medical education.

Medicine and History: a Surgical Model for National Integration

Historians and physicians have struggled to incorporate history into American medical education for over a century. Most efforts focus on local initiatives targeting a narrow audience. We describe a novel method involving the American College of Surgeons, a national organization with tens of thousands of members. Capitalizing on its infrastructure and influence over the field, we have implemented a variety of ventures that include panel sessions at meetings, poster competitions, travel grants, themed breakfasts, online communities, and other such projects. This programming has reached thousands of participants, ranging from pre-medical students to retired physicians, and it has increased both the exposure to and production of surgical history. Our article describes the process of establishing this nationally coordinated enterprise in the hopes that other medical specialties can emulate it and further the study of and appreciation for medical history.

John Hunter and the Descent of the Testis

The descent of the testis and the development of an inguinal hernia were the earliest published scientific work by John Hunter, the Scottish surgeon and anatomist who is acknowledged as the father of scientific surgery. Hunter's anatomic descriptions are the ones we use today to describe the prenatal descent of the testis and to explain the pathogenesis of an undescended testis and inguinal hernia in infancy. His work appeared in print in 1762, not as a formal publication but as an addendum to a screed written by his older brother William publicly accusing Percival Pott of pirating John's observations on the pathogenesis of an inguinal hernia and publishing them as his own, an early example of scientific rivalry.

Accountability in Healthcare: Sovereign Authority to Democratization

While accountability in healthcare is associated with Ernest Amory Codman (1869-1940), its origins can be traced to the beginning of recorded history. A physician guilty of a medical misdeed under the Code of Hammurabi (ca. 1755 BCE) had his fingers severed. The authority to regulate medical practice passed from sovereign to physicians in 1241 when emperor Frederick II gave the medical faculty of the University of Salerno the responsibility of examination and licensure to practice medicine. Thomas Linacre (1460-1524) convinced Henry VIII to assign licensure to a newly constituted College of Physicians (1518) that set standards for education and practice. In his code of medical ethics (1803) Thomas Percival (1740-1804) introduced the notion that medical misdeeds be judged by a panel of peers. In enacting an analogous code (1847) the American Medical Association incited strong opposition from a prevailing attitude of professional autonomy distrustful of outside interference (1883). Codman's innovation, the End Result system (1914), reflected his belief that surgery was an industrial process where the goal was perfection: survival without complications and full recovery to complete health. This required the systematic collection of clinical data on all surgical patients and an objective assessment of outcome. The approach evolved decades later to modern concepts of quality improvement (QI), using scientifically derived data to standardize processes and minimize variability and sources of error. With the objective tools of QI physicians and their patients judge for themselves the care they offer and select under the democratization of healthcare.

Cost of Pediatric Trauma: A Comparison of Non-Accidental and Accidental Trauma in Pediatric Patients

BACKGROUND

Nonaccidental trauma (NAT) affects >100,000 children in the United States every year and is associated with significant mortality and morbidity. Little is known about the financial burden of NAT, particularly in comparison to accidental trauma (AT). We sought to compare hospital charges and outcomes between children presenting with NAT and AT.

METHODS

Pediatric (<16 y) trauma hospitalizations from 2006 to 2018 were identified using the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) and Kid's Inpatient Sample (KID) databases. Hospitalizations were identified as NAT or AT based on ICD codes. Discharge weights were used to obtain national estimates and standardize them across the different sampling structures. Outcomes (hospital charges, length of stay (LOS), and mortality) were compared, and multivariate regression analyses were used to assess independent predictors of hospital charges and mortality.

RESULTS

Fifty-eight Thousand Two Hundred Seventy-five pediatric hospitalizations were included with 17,954 (0.3%) categorized as NAT. Children with NAT were younger, more female, less likely to identify as White, and more under public insurance than those with AT. Hospital charges were significantly higher in patients with NAT ($27,100 versus $19,900, P < 0.0001). Mortality (4.9% versus 0.0%, P < 0.0001) and LOS (3.2 d versus 1.5 d, P < 0.0001) were significantly higher among patients with NAT. Multivariable regression analyses identified NAT as a predictor of higher hospital charges, mortality, and LOS.

CONCLUSIONS

Nonaccidental trauma in pediatric patients is associated with significantly higher hospital charges, mortality, and LOS than accidental trauma. Ongoing research focused on the relative impact of known risk factors and resource utilization is needed.

Racial Disparity, Social Determinates of Health, and Slavery During the Boston Smallpox Epidemics of the Eighteenth Century

When Benjamin Franklin published the mortality rates from smallpox during the Boston smallpox epidemic of 1752, he revealed that Blacks not only had a higher mortality rate from smallpox (12.8%, 62/485; 8.9% for whites, 452/5,059), but once inoculated, had less protection from fatal disease (mortality rate 5.0%, 7/139; 1.2% for whites, 23/1,954). His report was thus the first publication to document racial disparities in a disease and its treatment. The differential outcomes came about in the context of slavery, poverty, and war, the predecessors of the social determinates of health that we observe today.During the 1752 outbreak only 28 percent of the Boston's occupants were inoculated, a level that failed to protect the community. When the contagion returned in 1764, the town selectmen decided to provide inoculations at no cost to all that needed them. That year inoculated smallpox reached 87 percent of the total caseload. "This lowered the death rate for smallpox so markedly,' wrote John Blake, historian at the National Library of Medicine, "that for the first time a smallpox year failed to stand out as one of unusual mortality." One final observation came from Franklin's data: the unexpectedly high prevalence of inoculations among Blacks (6.8% of those inoculated, 146/2,143; 8.5% of all those contracting the disease, 693/8,201). Boston's whites had made certain enslaved Blacks were inoculated, evidence the extent to which slavery was essential to the economy of colonial Boston.

Gertrude Herzfeld: The woman who dared to be a surgeon

Gertrude Marianne Amalia Herzfeld (1890-1981), the first practicing female surgeon in Scotland, overcame bias against women in medicine and pediatric specialists in surgery. After her graduation from the University of Edinburgh Medical School (1914), she became the first female house surgeon at the Royal Hospital for Sick Children, Edinburgh. In 1920, she became the first practicing woman surgeon to become a Fellow of the Royal College of Surgeons of Edinburgh. She left a handful of publications in pediatric surgery: a "radical cure" for inguinal hernia, i.e., early surgery (1925); a review of abdominal surgery in infancy and childhood (1937); surgery for the acute abdomen (1939); and intestinal obstruction (1945). They offer a twenty-year window into how children's surgery was once practiced, when operations were done in patients' homes, and decisions for operation depended solely on the history and physical exam without laboratory testing and radiological imaging. As a series of snapshots over two decades, they reveal how her practice evolved in such areas as fluid resuscitation and radiological reduction of intussusception. She remained steadfast to a careful physical examination and early operation. While she did not document her practice in the care of children with ambiguous genitalia and intersex conditions, she approached the formidable anatomic, psychological, and social challenges of her patients and their families with patience and understanding. Herzfeld was devoted to the care of yet another marginalized population that today is subsumed by the acronym LGBTQIA, yet another area where she was far ahead of her time. Level of evidence: Level VII.

Queen Caroline's Umbilical Hernia

Never a monarch nor head of state, Queen Caroline of Ansbach (1683-1737) is among the legendary women rulers of England and Great Britain alongside Queens Elizabeth I and II, Queen Victoria, and Lady Margaret Thatcher. As queen consort, she was the acknowledged power behind the throne of her husband, King George II (1683-1760), working with Robert Walpole, the first Prime Minister of England. George accepted her intellectual superiority and backstage dominance even before he acceded to the throne in 1727. "[He had] no pretensions toward intellect and [was] basically interested in little more than military glory, political power, and a wife who would do her duty by providing him with male heirs," wrote popular historian John Van de Kiste. After they were wed in 1705, Caroline carried out her task with a remarkable fecundity: a male heir, Frederick Louis, in 1707, followed by Anne (1709), Amelia (1711), Caroline (1713), George William (1717), William (1721), Mary (1723), and Louise (1724). With good reason she believed that her influence over George came from his sexual attraction to her. It was a conceit that proved to be her undoing as she strove to hide from common knowledge an unsightly umbilical hernia. The rupture caused her death in 1737 at age 54. It strangulated, perforated, and spilled feculent succus entericus and fetid fluid onto the royal bed, a vivid example of the consequences of an untreated surgical condition.

The Surgical Operation that Led to the Declaration of Independence and the Bill of Rights

The debate between individual rights and the limits of government has its roots in an operation in 17th century England. John Locke, the English philosopher whose concepts on the legitimacy of government are bedrocks of Western politics, was also a practicing physician who in 1668 was among a group of physicians that drained an infected hydatid cyst and thus saved the life of his political patron Anthony Ashley Cooper, the 1st Earl of Shaftesbury.Locke, who had been a classics scholar at Oxford with royalist sympathies, had by chance just joined the Cooper home as house physician and tutor the previous year. Forever grateful to his young doctor Lord Ashley nurtured Locke's early involvement in politics. From his association with a powerful peer of the Realm Locke found himself at the very heart of English politics where he began to formulate the foundational principles of Anglo-American government.

Franklin Mall, the first basic scientist of pediatric surgery

Franklin Mall (1862-1917) made fundamental discoveries in the embryology of malrotation and the development of the diaphragm, pathological conditions basic to pediatric surgery. As the inaugural professor of anatomy at the new Johns Hopkins University School of Medicine when it opened in 1893, Mall was among the first fulltime researchers in basic medical science in American medical schools, a new role that came to characterize the modern academic medical center.

Saints Cosmas and Damian and the Traditions of Faith and Charity in Medicine

Sts. Cosmas and Damian, the twin patron saints of medicine, were once among the most recognized saints in Christendom. In today's secularized society their prominence is much less known. The saints were beheaded during the violent persecutions of Christians in the Roman Empire in the end of the 3rd century and the first years of the fourth. Their story, however, is more than miracles and martyrdom. The history of Sts. Cosmas and Damian show the connection between medicine of Classical Greece and the worship of doctor-saints in early Christendom, and the tradition of charity to the poor in medical care.

America's Original Immunization Controversy: The Tercentenary of the Boston Smallpox Epidemic of 1721

The CoVID-19 pandemic marks the 300th anniversary of the Boston smallpox epidemic of 1721, America's first immunization controversy. Puritan minister Cotton Mather learned of inoculation for smallpox from Onesimus, a man enslaved to him. When the disease broke out in May 1721, Mather urged Boston's physicians to inoculate all those vulnerable to the disease. Zabdiel Boylston, alone among his colleagues, decided to proceed with the procedure, igniting a heated debate that occasionally grew violent. The division between the advocates and detractors of inoculation were as deep as religion and politics. Puritan ministers supported inoculation, asserting their right to control the lives of their flock. Challenging them were a secular class of medical professionals that proclaimed primacy in medical matters. The controversy was inflamed by a nascent newspaper industry eager to profit from the fear of contagion and the passionate debate. Despite the furor and physical risk to himself and his family Boylston inoculated 282 persons, of whom only 6 died (2.1%). Of the 5759 townspeople who contracted smallpox during the epidemic, there were 844 deaths (14.7%). In America's first effort at preventive medicine Boylston established the efficacy of inoculation, which helped support its acceptance in England, and later in the century, the adoption of Edward Jenner's technique of vaccination in 1796.

Rozycki-Feliciano Lecture Rudolph Matas, the Father of Vascular Surgery

Rudolph Matas (1860-1957) was one of the foremost figures in the history of vascular surgery. He is considered the father of vascular surgery for his operations for arteriovenous fistula and peripheral artery aneurysm, all devised before the isolation of heparin and the wide adoption of techniques for vascular anastomosis. A medical and surgical prodigy, Matas received his medical degree from Tulane University at age 19 (1880) and was named its chair of surgery at 35 (1895), a position he would hold until 1927. A contemporary and friend of Halsted, Matas throughout his career he was known as a leader in the field, holding the presidencies of the American College of Surgeons (1925-1926) and the American Surgical Association (1909). He maintained loyal relationships to those who trained in surgery with him at Touro Hospital in New Orleans, including the author’s grandfather, the first Richard J. Field. Matas was an honored guest at the dedication of the Centreville Clinic in 1928, the facility where three generations of Field surgeons have provided continuous service to its rural Mississippi community for nearly a century.

Jan Hendrik Louw and intestinal atresia - a personal quest in pediatric surgery

Jan Hendrik Louw (1915-1992), considered the father of pediatric surgery in South Africa, gained prominence for his work on congenital intestinal atresia, a condition that had a mortality as high as 75 percent. His hypothesis, that jejunoileal atresia arose from mesenteric circulatory accidents in utero, was the dominant view until recent research uncovered the involvement of genetic and embryological mechanisms. In the mid-1950s he was one of a number of surgeons to resect the enlarged bulbous segment proximal to the site of the atresia, a crucial step in the surgical approach to intestinal atresia that brought mortality below 10 percent. A world leader in surgery as chair of surgery at the Groote Schur Hospital in Cape Town for more than a quarter century, his work in surgical research took root from his private tragedy early in his career of the death of his own infant son of intestinal atresia, a condition to which he would contribute so much.

Missions, Humanitarianism, and the Evolution of Modern Global Surgery

Modern global surgery, which aims to provide improved and equitable surgical care worldwide, is a product of centuries of international care initiatives, some borne out of religious traditions, dating back to the first millennium. The first hospitals (xenodochia) were established in the 4th and 5th centuries CE by the early Christian church. Early "missions," a term introduced by Jesuit Christians in the 16th century to refer to the institutionalized expansion of faith, included medical care. Formalized Muslim humanitarian medical care was marked by organizations like the Aga Khan Foundation and the Islamic Association of North America in the 20th century. Secular medical humanitarian programs developed in the 19th century, notably with the creation of the International Committee of the Red Cross (1863) and the League of Nations Health Organization (1920) (which later became the World Health Organization [1946]). World War II catalyzed another proliferation of nongovernmental organizations, epitomized by the quintessential humanitarian health provider, Médecins Sans Frontières (1971). "Global health" as an academic endeavor encompassing education, service, and research began as an outgrowth of departments of tropical medicine and international health. The American College of Surgeons brought a surgical focus to global health beginning in the 1980s. Providing medical care in distant countries has a long tradition that parallels broad themes in history: faith, imperialism, humanitarianism, education, and service. Surgery as a focus of academic global health is a recent development that continues to gain traction.

The history of surgery for esophageal atresia

Until the successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) in 1941 by Cameron Haight of Ann Arbor, MI, every infant operated upon for this anomaly died within days and often hours of surgery. A key step was the posterior extrapleural approach to the mediastinum pioneered by Charles Mixter of Boston in 1929 that gave direct exposure of the anomaly without entering the pleural cavity and collapsing the lung. From 1936 to 1939 Thomas Lanman, also of Boston, made five unsuccessful attempts at primary repair of EA. His experience established the basic principles of early radiological diagnosis and prompt surgical intervention to minimize the risks of aspiration pneumonia, dehydration, and inanition. In 1939 N. Logan Leven of Minneapolis and William Ladd of Boston independently had the first long-term survivors of EA with a series of operations to construct skin-lined tubes on the anterior chest wall that connected an esophagostomy to a gastrostomy. Haight first tried primary repair in 1939, finally succeeding in his fourth case in March 1941. In their publications Lanman (1940), Haight (1943 and 1944), and Ladd (1944 and 1947) presented case-by-case chronologies. The evolution of surgical management thus can be traced from a fatal condition to one where survival became the expected outcome. History recognizes Haight for his work with EA, not only for its first successful primary repair, but also his lifelong dedication to its surgical management.