By Gary Logan
When J. Alex Haller, Jr., M.D., begins to talk about his 48 years at the Johns Hopkins Children's Center, he first mentions an African violet presented to him by medical students at one of his recent lectures. The plant, he explains, was a progeny of African violets cared for by renowned Hopkins surgeon Alfred Blalock himself, who with the collaboration of pediatric cardiologist Helen Taussig and surgery technician Vivien Thomas performed the famous “Blue Baby” operation in 1944. With Blalock’s increasingly busy schedule, he was neglecting the flowers and asked Thomas to care for them. Since then, over six decades, technicians in Thomas’s lab and others have done just that.
“When Vivien died, as part of the heritage here they decided they would keep that Blalock African violet going and it’s still going,” says Haller. And at 84, so is he.
Haller’s Hopkins story began in 1947, when as a fresh young graduate of Vanderbilt University he stepped off the train at Pennsylvania Station in Baltimore and asked for directions to Johns Hopkins. He didn’t specify the School of Medicine, his destination, so instead found himself at the University’s Homewood campus. What a great campus, he thought, admiring the architecture until he was re-directed to a streetcar that took him through some disadvantaged areas of East Baltimore and dropped him off at the corner of East Monument and Wolfe streets. His first image of Johns Hopkins Medicine was of three scrawny sheep grazing in a vacant lot next to the then-School of Hygiene across the street.
Haller recalls, “I said to myself, ‘What in the world is this? This is my medical school?’”
It was, and in it he continued to be attracted to surgery and especially neurosurgery, at least until he discovered the complex world of neuro-anatomy. It was then, he decided, that he might best be suited for a career in general surgery with a focus on treating children. Why pediatric surgery?
“If I had a child who was sick or badly injured, it was the noblest approach in medicine because you could offer them a normal life,” Haller says. “Also, I had a fascination with several congenital abnormalities, and not just of the heart.”
So after his second year in medical school, Haller spent two months at Boston Children’s working with pediatric cardiac surgeon Robert Gross, who in 1938 performed the world's first successful surgical repair of a congenital heart defect. The experience confirmed Haller's interest in doing pediatric surgery.
“This is where I’ll have to come to do pediatric surgery, I thought,” says Haller, noting that while Hopkins offered surgery for children it did not have a separate pediatric surgical service. Haller explains that the traditional thinking at the time was that children were little adults. Pediatricians loathed that concept, but as the most junior department at the time they didn’t have much of a voice.
Blalock, director of the Department of Surgery, Haller says, was interested in seeing pediatric surgery develop as a subspecialty, but with one caveat: “He felt very strongly you should first get your general surgery training and then pursue pediatric surgery.”
Haller, on the other hand, felt the time was now. Children had special anesthesia, surgical and post-operative care needs, and they were experiencing high mortality except at the few places, like Boston Children’s, that focused solely on children’s care. But as Haller completed his general surgery residency in 1959, Hopkins still hadn’t established a separate division of pediatric surgery. So Haller packed his bags: “Dr. Blalock asked if I wanted to stay, but I felt I should try my skills somewhere else.”
That somewhere else was the Department of Surgery at the University of Louisville, where over the next three years he would launch the hospital’s cardiac surgery program for children and adults. During that time Haller’s interests drifted toward kidney and liver transplant surgery, but that meant some training in immunology. He found it at the Wistar Institute in Philadelphia with renowned immunologist Rupert Everett Billingham. Six months later his old mentor Alfred Blalock called. Hopkins was building a children’s hospital. The time had come to form a division of pediatric surgery at Hopkins.
“Indeed,” says Haller, “Dr. Blalock insisted that the hospital be called the ‘Children’s Medical and Surgical Center (CMSC).’”
David Sabiston, one of Haller’s former chief residents, would lead the new division, but Haller would help develop it, too, and with a vision. With the roof of the CMSC completed and hard-hat faculty tours being conducted, Haller started planting pediatric ideas in departments like orthopedics, neurosurgery and urology. Initially, there was some resistance but some department chairs soon saw the wisdom of establishing pediatric specialty divisions in the new CMSC. After all, now there was a place for them to practice.
“In their wisdom, Blalock and Sabiston set aside space in the CMSC for these other pediatric surgery departments,” Haller explains. “We can thank their insight into how the field was going to develop.”
And did it develop—not only at Hopkins but nationally as Haller spearheaded collaborative efforts to establish new pediatric surgical specialty divisions with the blessings of academic medicine. As Haller puts it, “Everything we did was new. We were a section of the American Academy of Pediatrics, which meant we were not independent. Until we got pediatric surgery certification and our own boards, we were not in a strong position to lobby the American College of Surgeons for recognition.”
Some of that recognition came when Robert Jeffs—thanks to the foresight of then Department of Urology Director Patrick Walsh, Haller notes—was named director of the Division of Pediatric Urology.
“Bob Jeffs was the first pediatric urologist to be designated as such in a university hospital in the United States,” Haller says. “So this academic medical center was the first to implement the concept of pediatric surgery specialists.”
Even pediatrician-in-chief and CMSC director Robert Cooke, who led the design and construction of the new children’s hospital, Haller adds, was surprised by the development: “Dr. Cooke used to tell me he didn’t know there was such a thing as a pediatric urologist,” Haller says. “And I used to joke with him that I had to train the director of pediatrics as to what a pediatric surgeon was.”
As other departments followed suit, Haller incorporated a research component into the pediatric surgery residency program, an unprecedented concept in the United States. Hopkins pediatric surgeons would not only have superior operating room techniques, Haller explains, but a deep understanding of the pathophysiology of the congenital abnormalities they were treating. Incrementally, with colleagues like surgery chief George Zuidema—who wanted his residents to rotate through pediatric surgery—Haller was strengthening the academic structure for pediatric surgery. When Sabiston stepped down in 1964 to become chairman of surgery at Duke, the selection of Haller as director of pediatric surgery was a no-brainer.
“What it meant to me was what I always wanted to be a part of,” Haller says. “Not only would we have a self-standing children’s hospital, but one within a university environment. So we could have the same academic requirements for being a pediatric surgeon that you had for being a cardiac surgeon.”
Haller, however, was hardly done. Observing that he was seeing more and more children with trauma, but no trauma program, he established one in 1973—the first designated pediatric shock trauma unit in the United States. He credits collaborator R. Adams Cowley, who with Haller developed the adult shock trauma program at the University of Maryland Medical Center.
“We learned from battlefield injuries with adults that you had to get the patient resuscitated quickly, within the ‘golden hour,’ or they were going to die,” Haller says. “So we needed to develop systems to get injured children in here as rapidly as possible, within a ‘platinum half hour,’ which nobody had yet done.”
But doing the unprecedented has defined the forward-thinking Haller’s half-century at Johns Hopkins. During his time pediatric anesthesiology and critical care medicine were formalized, and with it pediatric intensive care. With clinicians like Mary Ellen Avery, Haller notes, neonatology came of age. Over the past five decades, life-threatening newborn emergencies have yielded to new surgical techniques—some of which Haller pioneered—supported by pediatric critical care specialists.
Indeed, he describes his time in pediatric surgery as one of super specialization and rapid development of medical technology. But he cautions that these developments should not interfere with the collegiality of bright young minds. The wheels of Hopkins turn through interaction, Haller explains, a daily sharing of what’s going on in clinics and research labs that leads to collaborative ideas about patient care.
“In other places people are often sequestered so no one can steal an idea and get ahead,” Haller says. “That’s not true here.”
Haller’s achievements are many, including the surgeon-in-charge at CMSC from 1964 to 1992 who launched a training program with a research component for pediatric surgeons and who established the first regional trauma center for children in the country. So, is he an icon? As magnetic and resilient as an African violet?
Nonsense, Haller might say. In his mind he found a home with like-minded souls who had a passion for patient care, research and teaching. So any success has a lot to do with effort but also with the serendipity and synchronicity that happens often in the sphere of Johns Hopkins.
Then again, Haller is a descendant of the Blalock-Taussig era, and he has experienced incredible growth and development as a physician, an innovative surgeon and a nurturing leader and mentor who has helped spawn many productive careers in pediatric surgery. He himself has blossomed many times over, yet the substance of the man has not lost its illumination. House staff and nurses can’t help but gaze at him as he walks down a hallway in the PICU, like they know him and that his history is so much an intrinsic part of the care they provide today. Bounced back to them is that broad Haller smile. Perhaps the African violet imagery isn’t so remote after all.