John M. Howard: A pioneer in vascular, trauma, and pancreatic surgery

Editor’s note: The American College of Surgeons (ACS) Surgical History Group (SHG) hosts an annual Poster Competition at the ACS Clinical Congress. The following article is based on the second-place winner of the SHG Poster Competition at Clinical Congress 2018 in Boston, MA. An article based on the third-place winning poster was published in the April issue of the Bulletin.

John M. Howard, MD, FACS, is one of the leading figures in trauma, vascular, and pancreatic surgery. This article recounts his contributions to our profession during his service in the Korean War, his leadership of the National Research Council’s Committee on Emergency Medical Services, and his innovative approaches to surgery that he introduced as chair of the department of surgery, Medical College of Ohio, Toledo.

Upbringing and education

Dr. Howard was born August 24, 1919, on a cotton plantation in Prattville, AL, to a well-to-do family. His father, Fontaine Howard, was an educated man who owned and worked the plantation with his wife Mary and their four children, who were each tasked with tending to a patch of cotton after school.¹ Dr. Howard often cited this experience, along with his Methodist upbringing, as instilling the work ethic that would continue throughout his life.

In 1947, Dr. Howard married Nina Abernathy, his high school sweetheart. After 53 years of marriage, Nina passed away in 2000, survived by their five children. (He married an old friend, Sara Sheppard Rice, two years later.) After graduation from medical school and completion of residency training in general surgery at the University of Pennsylvania, PA, in 1950, Dr. Howard joined the faculty of Baylor University, Dallas, TX.

Korean War and vascular surgery

The Korean War began June 25, 1950, when North Korea invaded South Korea. In December 1951, Dr. Howard, as part of the Berry Plan (also known as The Armed Forces Physicians’ Appointment and Residency Consideration Program),² was assigned to the 46th Mobile Army Surgical Hospital (MASH) unit, and he was appointed to lead the U.S. Army’s Surgical Research Team. Captain Howard believed he was one of only two surgeons certified by the American Board of Surgery working in the Korean theater.³

His primary responsibility was to improve the care of battlefield casualties. It was here that his journey as a scholar, surgeon, and a scientist truly began. His “lab,” as he described it, was indiscernible from the trauma unit. Under Dr. Howard’s supervision, casualties were first brought to battalion aid stations from the front lines, stabilized, then transported by ambulance to a MASH unit eight miles away.³

Because of their limited personnel and resources, MASH units only dealt with the most urgent and emergent injuries. Under protocol at the time, vascular injuries to an extremity were suture ligated. In World War II, Michael E. DeBakey, MD, FACS, Dr. Howard’s mentor, found ligation of major vascular injuries had an amputation rate of 63 percent.^4,5 Hemostat clamps crushed injured vessels, making them unsuitable for subsequent attempts at anastomosis. Seeing the alarming rate of amputation once more in Korea, Dr. Howard accepted the challenge of vascular repair and the prevention of major amputation.

The solution was found in the advances occurring in vascular techniques in the civilian domain. The following surgical milestones in particular ushered in a new era in cardiovascular surgery: operations on the great vessels of infants and children; ligation of a patent ductus arteriosus by Robert E. Gross, MD, FACS, in 1938; and subclavian-to-pulmonary anastomosis by Alfred Blalock, MD, FACS, surgical technician Vivien Thomas, and pediatric cardiologist Helen Taussig, MD, in 1944.

Improvements in surgical devices also played a part in advancing vascular techniques. Noncrushing bulldog clamps lay in the field and got in the way of delicate surgery. Modified clamps—like the clamps used by Dr. Gross, where the serrations were smoothed and the handles were held closed with rubber bands—tended to slip with disastrous results. Pediatric surgeon Willis J. Potts, MD, FACS, in 1948, invented the noncrushing vascular clamp that had fine serrations to hold the vessel wall in place and jaws designed to close the lumen without excessive force. The instrument was long enough so that handles were outside the immediate operative field, some angled so that they lay flat while the jaws bent inward into the wound.

Dr. Howard saw the Potts clamp as a possible solution. In defiance of military dogma on the management of major vascular injury, Dr. Howard assigned Edward J. Jahnke, Jr., MD, FACS, a surgery resident at the time, to bring a supply of Potts clamps to Korea. Using the new instrument, the two began to repair major arterial injuries, saving the limbs of numerous soldiers.^3,5 But two problems seemed insurmountable: a lack of clamps and too few surgeons in the Korean War theatre who were familiar with vascular repair.

Under patent, one supplier produced the Potts clamp, and the demand for the instrument was so high that it was back-ordered, and, according to the manufacturer, none were available for months. The U.S. Army, at Dr. Howard’s urging, wrote to the manufacturer and emphasized the urgent need of the clamps to support the war effort. The U.S. Army was unsuccessful in procuring the needed instruments. With soldiers continuing to suffer limb-threatening vascular injuries, Dr. Howard and his colleagues tried a bolder gambit. They sent a letter of their own that stated that because of the demands of war, the government would be obliged to break the patent and manufacture the clamps if the instrument maker did not supply them. It was a bluff worthy of Hawkeye Pierce and Trapper John McIntyre (characters from M*A*S*H, the American war comedy-drama television series that aired on CBS from 1972 to 1983)—but it worked. Within two weeks, six clamps (one for each MASH unit) were delivered to the MASH headquarters unit in South Korea.^3,5

The next step was training the other surgeons in South Korea. A call was sent out to each MASH unit for a pair of young surgeons to be sent to the 43rd Surgical Hospital, where Dr. Howard’s colleague, Carl Hughes, MD, was based. Drs. Howard and Hughes conducted a one-day training session on vascular repair, after which the surgeons returned to their stations. With training and the new clamps, the amputation rate fell to 7 percent according to Dr. Howard’s study, and, tongue in cheek, Dr. Howard called his session the first abbreviated but authentic vascular fellowship.^3,5

The initiatives developed by the Army Surgical Research Team reflect Dr. Howard’s ingenuity. Acute renal failure following extensive trauma carried a mortality rate of 90 to 95 percent, whereas soldiers with similar injuries uncomplicated by acute renal failure had less than a 10 percent mortality.⁶ Dr. Howard recognized that adequate treatment of acute renal failure could improve survival. At the time of the Korean conflict, the U.S. had only two functioning dialysis machines in the region. Under Dr. Howard’s direction, physicians and technicians devised a machine of their own using sausage skins, electrolyte fluid, and a washing machine, similar to a device designed by dialysis pioneer Willem Kolff, MD, in WWII.⁷ Using 200 feet of cellophane membranes from sausages, intravenous tubing as cannulas, and appropriate electrolyte solutions, a dialysis center was established 75 miles from the front lines. Patients requiring dialysis were flown in by helicopter to the center. The result was a significant reduction in mortality from renal failure. Other projects pursued by the research team were resuscitation techniques, replenishment of fluid and electrolytes, the use of prompt surgical intervention, and procurement of plastic bags for storage of blood.⁶ On his return to the U.S., Dr. Howard wrote a four-volume book titled Battle Casualties in Korea: Studies of the Surgical Research Team,⁶ published in 1955. The work chronicled his observations and the research conducted by the Surgical Research Team.

Trauma and emergency medicine

After his service, Dr. Howard returned to Baylor University, where he worked with Dr. DeBakey for two years. He continued to work in surgical innovation and education with appointments as the chair of surgery at Emory University School of Medicine, Atlanta, GA; Hahnemann Medical College (now Drexel University College of Medicine), Philadelphia, PA; and, eventually, at the Medical College of Ohio (today the University of Toledo College of Medicine).

Dr. Howard wanted to translate his progress in Korea into civilian health care in the U.S. Compared with his success in Korea, the treatment of trauma injuries in the U.S. was in its infancy. For example, most ambulance services were owned by funeral homes. Hospital emergency rooms were staffed by health care professionals on a rotational basis. Emergency medicine and trauma training had yet to emerge as disciplines, and no formal training programs had been established for paramedics and first responders.⁸

Dr. Howard prodded the National Research Council (NRC) to create a Committee on Emergency Medical Services (EMS), which he chaired from 1960 to 1973. In 1966, the committee published a white paper titled Accidental Death and Disability: The Neglected Disease of Modern Society, which chronicled the shortcomings of the approach to trauma in the U.S.⁹ The committee recommended sweeping changes, including standardized training for EMS personnel, medical requirements for ambulance design, and the need for a nationwide emergency medical communication system. He also founded the American Trauma Society (ATS) in 1968, serving as president for two years.

In 1973, Dr. Howard joined the faculty at the Medical College of Ohio, where he received a $2.5 million grant to test the EMS system he proposed at the NRC. Previous attempts to create nationwide emergency medical communication systems had failed because of sporadic interest. Under his supervision, an EMS system was developed in 15 counties, which would serve as the model for the national system in place today.

Pancreatic surgery

In addition to his contributions to vascular and trauma surgery, Dr. Howard was known for his expertise in pancreatic surgery, earning him the informal moniker “The Pancreas Man.” His dedication to the diseases of the pancreas led to advances in the surgical treatment of pancreatitis and pancreatic cancer. At the time, pancreaticoduodenectomy, also known as the Whipple procedure, was considered the only curative operation for pancreatic cancer. With a mortality rate of 25 percent, many members of the surgical community considered the procedure prohibitively dangerous. George Crile, Jr., MD, FACS, of the Cleveland Clinic, OH, called for a moratorium on the operation.

Dr. Howard disagreed. Based on his own experience, he was convinced that the mortality rate could be lowered with good surgical technique, intraoperative support, and attentive postoperative care. In 1968, Dr. Howard published “Forty-one consecutive Whipple resections without an operative mortality” in the Annals of Surgery to prove it could be a therapeutic option with an acceptable risk to the patient.¹⁰ His chapter in the 1998 edition of the textbook Surgical Diseases of the Pancreas cemented his legacy as one of the foremost experts on the subject.¹¹

Scholarly contributions and awards

Dr. Howard authored 400 scientific papers, wrote 31 book chapters, and was the author or co-author of 12 books. His last major contribution was a two-volume definitive biography of Allen O. Whipple, MD, that was published in 2004 when Dr. Howard was 85 years old.¹² He was recognized and honored around the world. The Royal College of Surgeons of Edinburgh and the College of Surgeons of Brazil awarded him honorary fellowships. He received awards of distinction from the NRC, ATS, and the Japan Surgical Society. In 2001, the Medical College of Ohio conferred Dr. Howard with the honorary degree (Honoris Causa) in medical sciences and 10 years later established an endowed professorship in pancreatic diseases in his name. Perhaps his proudest accomplishment, however, was receiving the presidential Legion of Merit from President Dwight D. Eisenhower in 1953 for meritorious conduct in the performance of outstanding service.

Conclusion

Dr. Howard contributed to significant advancements in the field of vascular and trauma surgery. He implemented new techniques and medical treatment both during his service in the Korean War and subsequent return to the U.S. As an innovator in pancreatic surgery, he demonstrated that the Whipple procedure was a viable treatment for pancreatic cancer.

Dr. Howard celebrated his 90th birthday surrounded by family, colleagues, and friends in celebration. In his brief remarks, he said the day was one of the happiest in his life, then whimsically invited the guests to return in 10 years to help him celebrate his 100th. In March 2011, Dr. Howard died after a brief illness at the age of 91. Those close to the innovative surgeon say he was a modest man: affable, courteous, and unflappable, who found opportunities to provide care when confronted with adversity. Dr. Howard’s traits are ones all surgeons should strive to possess and demonstrate.

Authors’ note

Dr. Howard was a personal friend of the senior author, Dr. Hussain, for more than 30 years. Though much of the information described in this article is accessible in the literature, some anecdotes are the result of personal conversations Dr. Hussain had with Dr. Howard and his family. His contributions to vascular surgery, trauma, EMS, and pancreatic surgery are outstanding legacies that deserve the surgical community’s wide appreciation. To those who knew him, Dr. Howard was an exceptional man outside of the surgical suite, with rare qualities of persistence amid seemingly insurmountable difficulties, patience over anger, and confidence matched by performance. He left a rich gift of service to humanity. The culture Dr. Howard fostered for surgical innovation and training continues at the University of Toledo and in the department of surgery that he led.

References

1. Ryan C. Dr. John M. Howard, 1919–2011: Surgeon was world famous in medical circles. Toledo Blade. March 18, 2011. Available at: www.toledoblade.com/news/deaths/2011/03/19/surgeon-was-world-famous-in-medical-circles/stories/201103190063. Accessed March 18, 2019.
2. Berry FB. The story of “the Berry Plan.” Bull NY Acad Med. 1976;52(3):278-282.
3. Howard JM. Historical vignettes of arterial repair: Recollections of Korea 1951–1953. Ann Surg. 1998;228(5):716-718.
4. DeBakey ME, Simeone FA. Battle injuries of the arteries in World War II: An analysis of 2,471 cases. Ann Surg. 1946;123(4):534-579.
5. Jahnke EJ, Howard JM. Primary repair of major arterial injuries: Report of fifty-eight battle casualties. Arch Surgery. 1953;66(5):646-649.
6. Howard JM. Battle casualties in Korea: Studies of the Surgical Research Team. Army Medical Service Graduate School, Walter Reed Army Medical Center, 1955.
7. Morrissey M. Willem J Kolff (1911–2009): Physician, inventor and pioneer: Father of artificial organs. J Med Biogr. 2012; 20(3):136-138.
8. Howard JM. Historical background to accidental death and disability: The neglected disease of modern society. Prehosp Emerg Care. 2000;4(4):285-289.
9. National Academy of Sciences. Accidental Death and Disability: The Neglected Disease of Modern Society. 1966. Available at: www.ems.gov/pdf/1997-Reproduction-AccidentalDeathDissability.pdf. Accessed March 18, 2019.
10. Howard JM. Pancreatico-duodenectomy: Forty-one consecutive Whipple resections without an operative mortality. Ann Surg. 1968;168(4):629-640.
11. Nealon WH. Surgical diseases of the pancreas (3rd edition). Ann Surg. 2001;233(4):595-596.
12. Howard JM. The life and times of Allen Oldfather Whipple: The missionary and the surgeon. Ann R Coll Surg Engl. 2010;92(2):180.