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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The first board examination in pediatric surgery.

The inaugural certifying examination for special competence in pediatric surgery in North America was given by the American Board of Surgery (ABS) in April 1975, the day before the sixth meeting of the American Pediatric Surgical Association at a resort near San Juan, PR. The event came after failed applications before the ABS and the Advisory Board for Medical Specialties in 1957, 1961, and 1967. The specialty had matured with a scholarly publication devoted to the field (Journal of Pediatric Surgery, 1965), the establishment of standards for training and training programs (1966), and a society independent of pediatrics and devoted solely to pediatric surgery (American Pediatric Surgical Association, first meeting 1970). Harvey Beardmore had guided the successful campaign for a certificate for pediatric surgery under the aegis of the ABS that was approved in June 1972. Pediatric surgery had thus gained full recognition as a specialty of surgery. A group photograph of its participants became one of the iconic images in our specialty. Thanks to Jim and Nancy Hopkins of Windsor Heights, IA, and to their many friends and colleagues, nearly half (71 of 151) of the pediatric surgeons in the photo were identified, marking their places in the history of pediatric surgery.

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.