The introductory editorials prepared by Dr. Milton I. Levine for Pediatnc Annals capsulize the intent of the individual articles and underscore the overall themes of the issues in a most instructive and entertaining manner. They are enriched by his reminiscences comparing "then and now," his personal acquaintance with historic figures and medical milestones, plus the interesting experiences with patients he has had. Of course, that I first met Dr. Levine as a pediatric resident in 1951 when he was my teacher and have respected, admired him, and cherished our relationship doesn't lessen my appreciation of these introductory essays.
One might, therefore, expect that I would not dare to write a separate introduction, especially in view of the very kind references to my career which Dr. Levine has made in his introduction to two previous issues of Pediatric Annals on gastroenterology. Nevertheless, this current issue is of such a special nature that I would be derelict if it were published without some personal words of explanation.
During my training as a pediatric house officer in the early 1950s I was impressed with the tentati veness with which most pediatricians approached children with digestive tract diseases. The gastroenterologists to whom they turned for advice were usually uncomfortable with children and were especially unfamiliar with the modifying effects imposed on the underlying disease processes by growth and maturation. The need to translate state-of-the-art knowledge to management of children stimulated my interest. A host of malnutritional, maldigestive, malabsorptive, and inflammatory diseases involving the hollow viscera, as well as problems of the liver and pancreas, awaited more rational approaches. Development of pediatric gastroenterology as a subspecialty might lead to more comprehensive and unified approaches to nutritional problems and such frequently occurring conditions as infant diarrhea, which up to that time was parcelled out among infectious disease experts, electrolyte physiologists, or nutrition-oriented pediatricians.
Pediatric gastroenterology has expanded rapidly since those early days. Excellent textbooks on gastroenterology and nutrition have been written in a number of languages by acknowledged pediatric experts. Respected societies of the subspecialty now exist in North America, Europe, the Middle East, Australia, Latin America, and other parts of the world. Annual meetings are conducted with active interchange of ideas and reports of scientific investigations and clinical advances. There is currently justifiable activity on the part of the American community of pediatric gastroenterologists to set up a separate subspecialty board. This is a reflection of the many universities and major hospitals that now have separate department divisions and training programs in this area.
My own training in gastroenterology followed pediatric residency and took place in the Department of Medicine at the New York Hospital-Cornell Medical Center. Dr. Thomas P. Almy, to whom I shall be eternally indebted and grateful, supported my work in his previously adult-oriented specialty program. As I gradually learned to distinguish between patients with organic bases for their complaints (eg, demonstrable peptic ulcers, proved inflammatory bowel disease) and those with functional difficulties, it was eye opening to learn that a majority of the adult patients fell into the functional category. Many of these patients suffered more intensely and intractably than did those with organic problems. As I began to translate my newly acquired gastroenterology knowledge from adults to pediatric patients I was surprised that similar trends also applied to the children. It is, therefore, no wonder that an important part of my clinical and research interest since those days has been occupied with the diagnosis and management of functional gastrointestinal problems of children.
I believe that the setting in which I trained was particularly fortunate. My mentor, Dr. Almy, a doyen of the scientific approach to functional gastrointestinal problems, had himself trained at the New York Hospital-Cornell Medical Center. This was the very institution where Wolf and Wolff conducted their classic studies on Tom, the young man with a large gastrocutaneous fistulous opening through which they observed the relationships of the mind and emotional states to stomach functions. 1 Dr. Almy also conducted classic experimental observations on gastrointestinal physiology and its relation to the emotional state with many prominent associates including Fred Kern of Denver, and Marvin H. Sleisenger of San Francisco. Dr. Almy's studies on the relationship between functional states and the emotions and distal colonic activity have served as models for succeeding generations of clinicians and investigators. Current approaches to observations on mind-gut interactions with the most sophisticated equipment in well endowed research centers are indebted to the humble beginnings of simple smoked kymographs and the Utube manometers which Dr. Almy and his colleagues used in their small laboratory at Cornell. The size of the laboratory and simplicity of their equipment did not detract from the excellence and veracity of the observations.
As a privileged heir to this physical and intellectual environment I was fortunate to be able to build on the adult studies and introduce what must now be regarded as primitive electronic pressure recording techniques to the studies of children. These studies constituted most of my early reports on normal colonic and esophageal physiology and the changes induced by organic diseases and abnormal functional states.
The pediatric environment at New York HospitalCornell Medical Center in those years was equally stimulating to a focus on interactions of emotions and somatic complaints. The Department of pediatrics included attending physicians such as Dr. Milton I. Levine, who always displayed a sensitivity toward children and their problems. At about the time I joined the department he wrote on a subject covered in this issue and suggested the use of pacifiers in infantile colic.2 The department was then headed by Dr. Samuel Z. Levine, who despite his preeminence as a methodical scientist and logical clinician, never lost the humanistic touch and sensitivity in defining functional problems and meeting the psychological needs of patients. Dr. Milton Senn, who bridged the gap between training and practice in psychiatry and pediatrics, had just become a member of the Pediatric Department at Cornell prior to my arrival.
Colleagues outside New York Hospital-Cornell Medical Center also served to stimulate my early interest in functional problems. Dr. Guilio Barbero, who was also a pediatrician turned gastroenterologist, was in Philadelphia at that time conducting motility studies similar to ours with emphasis on the relationship of gastrointestinal function to the emotions and to the autonomic nervous system. Attempts to understand the diarrheal symptoms of childhood irritable bowel syndrome, which we later defined and which is discussed in this issue, were being made in Boston by Dane Prugh and Harry Shwachman. 3
This issue of Pediatric Annab is entirely devoted to the very common subject of functional disease of the bowel, so often troublesome to the practicing pediatrician. In the initial article of the series I have summarized the physiologic, genetic, and psychologic backgrounds common to all of the functional disturbances of the lower colon. Although I appreciate that Pediatric Annah stresses practical articles on clinical problems with deemphasis on the theoretical-experimental, it is impossible to approach the individual entities grouped under the umbrella of functional bowel difficulties without touching on the experimental and clinical evidence that indicates a common denominator in these problems. This common denominator is not theoretical but rather a unifying physiologic concept that may simplify the practical approach to diagnosis and management of the specific entities covered in these articles.
Another example of the rapid growth of pediatric gastroenterology is the number of programs in the subspecialty. While expansion of this type may in some instances be a questionable evidence of progress, it does offer promise for improved patient care and ability to deal with heavy clinical loads without causing undue strain and delay in investigative programs. It also provides opportunity for individual group members to concentrate on specialized areas of expertise. I am especially proud that our own group at Schneider Children's Hospital contains sufficient breadth of staff that it has been possible to prepare this issue with my associates only.
Following my overview presentation, Dr. Michael Pettei discusses constipation, the most frequently occurring functional bowel problem of children and analyzes the various complications which may emanate from this basic disorder. Dr. Larry Adams, recently graduated Senior Fellow in Pediatric Gastroenterology joins me in a discussion of infantile colic, the earliest manifestation of functional difficulty seen in children. This article is followed by a discussion by Dr. Jeremiah Levine of the pattern of recurrent diarrhea which is observed in the toddler period and was originally labelled by us as the irritable bowel syndrome of children. The clinical entities are concluded with an analysis of one of the most troublesome common problems of childhood and adolescence, chronic recurrent abdominal pain, by Dr. Allan Olson. Finally, just as I have attempted to develop a unifying theme in the opening article, I close the issue with a brief discussion of those approaches to management which are common to all of the conditions.
1. Wolf S, Wolff HO: Human Gastric Function. New York, Oxford University Press, 1943.
2. Levine MI. Bell Al: The treatment of "colic" in infancy by use of the pacifier. J Pedum 1950; 37:750-755.
3. Prugh Du, Shwachman H: Observations on "unexplained" chronic diarrhea in early childhood. Am J Dis Child 1955; 90:496-500.