As a young man he dreamed of becoming a medical missionary, healing the sick and spreading his practical Christian faith in foreign fields, patient by patient and soul by soul. Instead, Robert Salter became one of the most famous orthopedic surgeon in the world, making a difference on a grand scale by healing the deformed and injured limbs of millions of children, inventing surgical methods and equipment that revolutionized orthopedic surgery, circling the globe to impart his medical know-how in more than 30 countries and training hundreds of visiting doctors at the Hospital for Sick Children in Toronto so that they could take his mentoring, his procedures and his practices home with them.
During a more than 50-year career as a pediatric orthopedic surgeon, Dr. Salter developed a surgical procedure to fix congenital deformities of the hip. It was called the Salter innominate osteotomy for hip dysplasia (although he preferred to call it the "no name, no fame" operation). Dr. Salter over-rode centuries of medical theory that said broken limbs needed to be immobilized in rigid casts for prolonged periods and he invented a postoperative apparatus called the continuous passive motion machine (CPM), which to date has been used by nine million patients. Besides the Salter-Harris classification of growth plate injuries, he wrote the authoritative orthopedic textbook, Disorders and Injuries of the Musculoskeletal System, which is used throughout the world. Dr. Salter was making revisions for the fifth edition when he died, aged 85, from complications of Parkinson's disease in Toronto on May 10.
He was "the late 20th-century icon" of orthopedic surgery, says John Wedge, former surgeon-in-chief at the Hospital for Sick Children and one of some 300 surgical fellows who came to Toronto specifically to train under Dr. Salter. A decisive, determined and driven individual, Dr. Salter was also inspiring, quick witted and humble enough to tell stories on himself. "Everything he did was for a purpose and it was always for a noble purpose," said Dr. Wedge. In the end, he wanted to be remembered "as a surgeon who treated children," a doctor who helped children overcome congenital deformities and grow straighter and taller after devastating injuries.
One of those patients was Colleen Beanish, now a special-education consultant with the Ottawa Catholic School Board. Born in 1961 in Ottawa with a congenital dislocated hip, she was confined in a body cast from 18 months until she turned 3. By the time she was 10, she was limping and in pain. After a failed procedure, she was sent to Dr. Salter the following year. "I trusted him completely from the first," she said of the surgeon who operated on her several times over the ensuing years, including a hip replacement at age 30. "He always spoke to the child before the parents," she said. "He explained everything, he never lied and he always held my hand while the anesthetic was taking effect." Today she "gives him credit for being able to walk unassisted," but what she remembers more than anything was the way he always made time for her and her children and the way he said goodbye at the end of each medical appointment. "Friends for life," he invariably said, a mantra he exchanged with each and every one of his small patients.
As a young resident from Saskatchewan in the early 1970s, Dr. Wedge saw his future mentor in action at a major conference in the United States. Dr. Salter was making a presentation on growth-plate injuries to illustrate the principles of the Salter-Harris classification system. The patient, a four-year-old boy from rural Ontario, had been run over by a lawn mower, suffering devastating injuries to his lower leg and ankle. Fixing the broken bones and damaged joints was one thing, but Dr. Salter also devised an unorthodox treatment that allowed the bones to grow normally so that the little boy, who at best should have become lame, walked normally on legs of equal length.
Even before the slide show was finished, the audience roared with enthusiastic applause, all except a rival researcher from Harvard who was "not familiar with being upstaged," according to the eulogy Dr. Wedge delivered for his supervisor-turned-friend. "Salter, you were very lucky to get away with how you treated that boy - you must have a four-leaf clover up your ass," Dr. Wedge recalls him saying in the panel discussion that followed the presentation. To which Dr, Salter flashed back: "No, we Canadians excel in practical solutions based on principles established from careful research. ... It isn't a four-leaf clover stuck up there, but rather ... a maple leaf."
Robert Bruce Salter came from Loyalist stock on both sides of his family. His father, Lewis Salter, from Chatham, N.B., was the manager of the Bank of Nova Scotia in Liverpool, N.S., the home town of Katherine Cowie. After he wooed and wed her, they moved to Stratford, Ont., where he headed up the local BNS branch. There the Salters had three sons, Douglas Campbell, (who died in 1993) and fraternal twins, Robert Bruce and Andrew Jack, who were born on Dec. 15, 1924.
Almost from birth, Bob Salter seemed destined to care for others, an ambition nurtured by his mother, a woman he once described as shy, loyal, kind and "deeply religious, in the best sense." Another huge influence was David Smith, the family physician. At age 6, Bob told his twin brother that he wanted to be a doctor, but only "if he could be as good, or better than Dr. Smith," recalled Jack Salter. 'He worshipped him."
When the boys were 9, Jack became seriously ill with rheumatic fever; in those pre-antibiotic days, the treatment was complete bed rest for a year. "Bob taught me all during the summer holidays and I wrote the exams so that when I was well and able to go back to school I could stay in the same room with him," Jack said. "That was very important to us."
In the mid-1930s, Lewis Salter embarked on a serious career change when he quit the bank to launch an orange-juice business with a partner. The family moved to North Toronto and the three boys transferred from Romeo Public School in Stratford to Lawrence Park Collegiate. Even then, Bob was interested in research. When he was 16, he brought home a dead monkey from the Connaught Medical Labs. "I went into the basement and there was Dr. Bob dissecting the poor little monkey, which was staring up at the ceiling," said his brother. "I honestly believe that is how he became fascinated with bone surgery, because he ended up with the skeleton of the monkey and he could see how the various joints functioned."
After high school, Jack went into the navy and Bob entered a six-year medical program at the University of Toronto, the first time in their lives that the twins had taken divergent paths. Bob was about 5 feet 10 and of average build, but he was very strong, athletic, competitive and driven. "When he played football and hockey, if he tackled or body-checked you, you would beg to live for another day," said his brother. "He played to win."
During school breaks, Bob worked as a labourer and truck driver to earn his tuition, but in his last two years of medical school he combined his religious and medical vocations by spending his summers at the Grenfell Mission, an organization that had been established by medical missionary Wilfred Grenfell in the 1890s to bring medical and social services to remote communities in northern Newfoundland and Labrador. The Grenfell Mission was both a training and a testing ground for his dream to become a missionary doctor in India, China or Africa.
Back in Toronto in 1947 for his final year at U of T, he met Robina McGee, a community-health student. She had done field work on a scholarship in Copper Cliff, a community near Sudbury in Northern Ontario, and was hoping to work for the Grenfell Mission, so "we united our paths," she said, after he completed his internship year. "I didn't know whether it was a proposal or a job description he was offering me," she joked about what turned out to be more than 60 years of marriage, community service and the rearing of five children.
The day after their wedding on July 3, 1948, the Salters left for the Grenfell Medical Mission at St. Anthony on the northern peninsula of Newfoundland, doing "whatever needed to be done," in what "Bob always called 'our two-year honeymoon,'" she said. Then, with a baby on the way, turmoil in post-Communist revolution China and in India in the aftermath of Partition, the Salters agreed to put aside his dream of working in a missionary field.
Instead, he enrolled in postgraduate training under W.E. Gallie, the legendary surgeon and educator who radically overhauled surgical education at U of T. Dr. Gallie believed students should be exposed to a variety of disciplines before specializing and that the coveted position of chief resident should rotate among senior residents so each would have the experience of being "in charge" in a supervised setting before heading off into the "real" world.
Dr. Salter then spent a year as a McLaughlin Fellow in orthopedic surgery at the Royal London Hospital. That's where the trainee from Canada took on Sir Reginald Watson-Jones, the world's reigning orthopedic guru. Listening to Dr. Watson-Jones deliver his dictum that the only treatment for fractured limbs was complete, rigid, enforced and prolonged immobilization, Dr. Salter realized intuitively that this was precisely the wrong thing to do. What's more, he said so, to the rising ire of Sir Reginald, a confrontation that Dr. Salter later delighted in relating to generations of his own graduate students. "Over the next 30 years, Salter proved [Sir Reginald]completely wrong," said Dr. Wedge.
Dr. Salter began working at the Hospital for Sick Children in 1955, when Alfred Farmer was head of surgery. At that time, pediatric surgeons were generalists. But Dr. Farmer believed that doctors needed to specialize, if they were going to grow in expertise, and so he insisted that all of the doctors reporting to him had to pick a specialty. William Mustard, who excelled in both cardiac and orthopedic surgery, decided to concentrate on the former, which allowed room for Dr. Salter to become chief of orthopedic surgery at Sick Kids and a professor of surgery at U of T in 1957.
Children are physiologically different from adults and they have a greater proportion of congenital and developmental issues. As well, having grown up in an era when polio was a prevalent childhood illness and dealing with its ravages was a major preoccupation of pediatric surgeons, Dr. Salter realized early on that the correct intervention at the appropriate moment could make a lasting and life-long difference in a child's life. Disgraced theatre impresario Garth Drabinsky, who contracted polio in 1953 when he was only three years old, went under Dr. Salter's knife six times.
Forcing doctors to specialize "was what put Sick Kids ahead of everybody else in the world in pediatric surgery," said Dr. Wedge. "With the advent of sub-specialization at Sick Kids, it rapidly became the principal training place for pediatric orthopedic surgeons around the world." And it was Dr. Salter who led the way, becoming surgeon-in-chief in 1966 and a "university" professor at U of T in 1984, a position held by only 15 scholars at a time. He was innately innovative and a committed researcher who spent years in the lab building models and testing procedures on animals before unveiling new techniques.
In a life filled with accolades and honours, Dr. Salter's curriculum vitae included: surgeon-in-chief; professor and head of orthopedic surgery at U of T; president of the Canadian Orthopedic Association and the Royal College of Physicians and Surgeons of Canada; fellow of the Royal Society of Canada; member of the Canadian Medical Hall of Fame; companion of the Order of Canada; winner of the Gairdner Award for Medical Science, the FNG Starr Medal of the Canadian Medical Association and the Bristol-Myers/Squibb-Zimmer Award for Distinguished Achievement in Orthopedic Research.
But Dr. Salter wasn't all theory and medical practice. He loved to paint with oils and had such an obsessive interest in heraldry that he designed a coat of arms for most of the institutions and clubs to which he belonged, including the Hospital for Sick Children. He liked to wear a Sherlock-Holmes-style deerstalker cap with a holster under his suit jacket for his pipe while he drove around town in a 1949 Allard sports car with his foot to the floor and the top down, no matter the weather. The car was so sleek and so low slung that he could drive under parking barriers, and he kept it up until he reluctantly pulled the key out of the ignition in the mid 1980s because spare parts had become scarce.
Although he stopped doing surgery at 70, he continued to research, write, attend conferences and see patients even after he was diagnosed with Parkinson's disease about three years ago. By early this year, the disease was accelerating and he was having increasing difficulty with his balance. He fell at home early in May and was taken to hospital where he died a few days later. "I always referred to him as my pal and twin," said his brother sadly. "There is no living person who has known and loved him as long as I have."
Dr. Salter leaves his wife, his five children, his twin bother Jack, eight grandchildren, two great-grandchildren and his extended family.