Pediatric Annals

EDITORIAL 

A Pediatrician's View

Milton I Levine, MD

Abstract

Sixty years ago, to gain a full background in pediatrics, I chose a pediatric surgery internship at a hospital, no longer in existence, affiliated with Cornell University Medical College on the southern border of Hell's Kitchen in New York City. Our patients were area children as well as many referred from hospitals lacking facilities for adequate pediatric therapy. We saw the usual array of surgical conditions: appendicitis, inguinal hernias, harelips and cleft palates, intussusceptions, fractures, and an occasional omphalocele, spina bifida, or a splenectomy for thalassemia. One frequent condition was empyema, rarely seen today.

While there I published my first paper, in collaboration with Dr. Charles E. Farr, Professor of Surgery at Cornell. It was titled "Empyema in Children" and reviewed 371 cases treated at the hospital during a 20-year period. 1 wrote that all cases were definitely diagnosed by x-ray, aspiration, and culture; it almost always followed pneumonia and was treated by rib resection and open drainage. We had no antibiotics; the mortality was approximately 25%. Modern pediatric textbooks give little mention to empyema. One even states bluntly that it should not occur in adequately treated cases.

Although we had no pediatric surgeons, some of our general surgeons had special skills: Dr. Charles E. Farr was an able abdominal and chest surgeon; Dr. Frank S. Matthews was skilled at repairing harelips and cleft palates; and Dr. Edward D. Truesdell specialized in the treatment of fractures. Pediatric surgery began to develop in the early 1940s. One of my friends, Dr. Robert Gross, became Professor of Children's Surgery at Harvard in 1947. Under his tutelage pediatric surgery received an important impetus. It has since become a specialized field, and today there are hundreds of pediatric surgeons in the US.

As the primary physician, the pediatrician often makes a tentative diagnosis before referring patients for specialized care. Therefore, pediatricians must be aware of the latest methods of diagnosis and treatment. And, as I have often remarked, they should be the ones to discuss all aspects of the condition with the parents.

This issue of Pediatric Annals discusses the most frequent pediatric surgical problems, presenting the latest methods of diagnosis and treatment. The Guest Editor is Dr. Dick G. Ellis, who for many years was Chief of Surgery at the Cook-Fort Worth Children's Medical Center, Fort Worth, Tex. He was recently Chairman of the Surgical Section of the American Academy of Pediatrics.

Dr. Ellis opens with "Chest Wall Deformities in Children." He emphasizes that children with pectus deformities suffer great psychological damage as well as physiological detriment as they grow and describes the most effective surgical treatment.

The second article deals with "The Acute Abdomen in Childhood." It is authored by Dr. Franklin J. Harberg at the Texas Children's Hospital, and Professor of Clinical Surgery and Clinical Pediatrics at the Baylor College of Medicine, Houston, Tex. He stresses the urgency of a correct diagnosis, especially in cases of acute appendicitis where operation should be performed before necrosis and perforation occur. The steps in diagnosis are clearly reviewed; most can be performed before surgical consultation.

The third contribution studies the "Common Lumps and Bumps of the Head and Neck in Infants and Children." It was written by Dr. Howard C. Filston, Professor of Pediatric Surgery and Pediatrics at the Duke University Medical Center, Durham, NC. When "lumps" occur on the head or neck of a child, are they of bacterial origin or are they tumors or congenital lesions? The differential diagnoses are explained, reminding us of less common causal agents such as atypical mycobacteria and cat scratch disease.

The fourth article discusses "Inguinal and…

Sixty years ago, to gain a full background in pediatrics, I chose a pediatric surgery internship at a hospital, no longer in existence, affiliated with Cornell University Medical College on the southern border of Hell's Kitchen in New York City. Our patients were area children as well as many referred from hospitals lacking facilities for adequate pediatric therapy. We saw the usual array of surgical conditions: appendicitis, inguinal hernias, harelips and cleft palates, intussusceptions, fractures, and an occasional omphalocele, spina bifida, or a splenectomy for thalassemia. One frequent condition was empyema, rarely seen today.

While there I published my first paper, in collaboration with Dr. Charles E. Farr, Professor of Surgery at Cornell. It was titled "Empyema in Children" and reviewed 371 cases treated at the hospital during a 20-year period. 1 wrote that all cases were definitely diagnosed by x-ray, aspiration, and culture; it almost always followed pneumonia and was treated by rib resection and open drainage. We had no antibiotics; the mortality was approximately 25%. Modern pediatric textbooks give little mention to empyema. One even states bluntly that it should not occur in adequately treated cases.

Although we had no pediatric surgeons, some of our general surgeons had special skills: Dr. Charles E. Farr was an able abdominal and chest surgeon; Dr. Frank S. Matthews was skilled at repairing harelips and cleft palates; and Dr. Edward D. Truesdell specialized in the treatment of fractures. Pediatric surgery began to develop in the early 1940s. One of my friends, Dr. Robert Gross, became Professor of Children's Surgery at Harvard in 1947. Under his tutelage pediatric surgery received an important impetus. It has since become a specialized field, and today there are hundreds of pediatric surgeons in the US.

As the primary physician, the pediatrician often makes a tentative diagnosis before referring patients for specialized care. Therefore, pediatricians must be aware of the latest methods of diagnosis and treatment. And, as I have often remarked, they should be the ones to discuss all aspects of the condition with the parents.

This issue of Pediatric Annals discusses the most frequent pediatric surgical problems, presenting the latest methods of diagnosis and treatment. The Guest Editor is Dr. Dick G. Ellis, who for many years was Chief of Surgery at the Cook-Fort Worth Children's Medical Center, Fort Worth, Tex. He was recently Chairman of the Surgical Section of the American Academy of Pediatrics.

Dr. Ellis opens with "Chest Wall Deformities in Children." He emphasizes that children with pectus deformities suffer great psychological damage as well as physiological detriment as they grow and describes the most effective surgical treatment.

The second article deals with "The Acute Abdomen in Childhood." It is authored by Dr. Franklin J. Harberg at the Texas Children's Hospital, and Professor of Clinical Surgery and Clinical Pediatrics at the Baylor College of Medicine, Houston, Tex. He stresses the urgency of a correct diagnosis, especially in cases of acute appendicitis where operation should be performed before necrosis and perforation occur. The steps in diagnosis are clearly reviewed; most can be performed before surgical consultation.

The third contribution studies the "Common Lumps and Bumps of the Head and Neck in Infants and Children." It was written by Dr. Howard C. Filston, Professor of Pediatric Surgery and Pediatrics at the Duke University Medical Center, Durham, NC. When "lumps" occur on the head or neck of a child, are they of bacterial origin or are they tumors or congenital lesions? The differential diagnoses are explained, reminding us of less common causal agents such as atypical mycobacteria and cat scratch disease.

The fourth article discusses "Inguinal and Scrotal Problems in Infants and Children. " It is presented by Dr. John R. Campbell, Chief of Pediatric Surgery, School of Medicine of the Oregon Health Sciences University, Portland, Ore. A number of potentially dangerous or debilitating problems are considered including inguinal hernias and undescended testes. I once saw a 4-month-old infant die of a strangulated hernia. The parents of a crying baby called the pediatrician on a Saturday morning. Away in the country, he assumed that the child had a gastric upset and said he would return the next evening. The parents called him several times when the crying continued and the baby vomited. They were advised to give a mild sedative. When the pediatrician arrived the next evening it was too late: the baby died late that night. The hernia was completely strangulated.

The next article deals with the "Gastroesophageal Reflux in Childhood: Implication for Surgical Treatment." It is authored by Dr. William P. Tunell, Professor and Chief of Pediatric Surgery at the University of Oklahoma College of Medicine, Oklahoma City, OkIa. This subject is important to all pediatricians as there are definite dangers to untreated children: failure to gain and, more importantly, recurrent attacks of pneumonia from aspiration of inhaled vomitus. Clinical and diagnostic features are presented as well as the medical and surgical treatment.

The sixth article discusses "The Pediatric Acute Scrotum" and was written by Dr. Darrell Hermann, Clinical Assistant Professor of the Division of Pediatric Surgery at the University of Texas Southwestern Medical Center at Dallas. It discusses the various causes of the acute scrotum and advises on diagnostic methods. In a large pediatric practice spanning more than 50 years I diagnosed two cases of testicular torsion and a fair number of cases of mumps orchitis.

The final article discusses "Circumcision," a topic of considerable interest in the past year. It is contributed by Dr. Glen F. Anderson, Attending Pediatric Surgeon at the Minneapolis Children's Medical Center, and the Children's Hospital of St. Paul, Minn. It has long been general medical opinion that circumcision was an unnecessary surgical procedure and that there is a minimal chance of penile cancer in uncircumcised males. But recent studies have demonstrated a marked increase in urinary tract infections in the uncircumcised male. These results await further confirmation.

10.3928/0090-4481-19890301-04

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