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Surgery in a children's hospital
:EDITOR'S COLUMN
they may wish to prescribe later in their practice. It is difficult to see how everyone can be satisfied but we might t r y to remove the major inequities. Perhaps our hospitals might offer a choice of the three major types of formula --whole milk, evaporated milk, and
497
prepared formulas. I n each instance the purchasing department should be instructed to rotate orders among the recognized competitors. W e are assured that such a system would automatically end one type of conditioned gift. S. H. C.
S U R G E R Y IN A C H I L D R E N ' S H O S P I T A L N R E A D I N G the new Surgery of Infancy and Childhood by Gross, which is reviewed elsewhere in this issue by a surgeon, the editor was struck by the statement that in the opinion of the author the best results in pediatric surgery are obtained when surgery is an independent unit, and the entire preoperative and postoperative care is the responsibilitY of the surgical staff. This is the plan of organization started at the Boston Children's Hospital in 1927 b y Dr. William Ladd and under which Dr. Gross has worked. The best evidence to s u p p o r t this viewpoint is found in this text. Some of the results in Boston are striking; for example, the results of surgery in the p r e m a t u r e infant, and the steady reduction of the operative mortality rate for pyloric stenosis in a series of 1,787 cases from 1932 to 1951 as shown in Table 8 of the text. There are relatively few children's hospitals in the country with a similar organization, and with a surgical staff devoting their time exclusively to surgery in children. As one reads the introductory chapters on preoperative and postoperative care one is impressed by the breadth of knowledge of what is generally c o n s i d e r e d " pediatr i c s " held by Dr. Gross, in addition
I
to the p u r e l y surgical techniques. On first thought it seems logical that this is the plan of organization our children's hospitals should attempt to obtain. A f t e r mulling the idea over for some time doubt began to enter in, and w e began to question if it is the best plan for the development of surgical techniques applicable to conditions in childhood requiring s u r g e r y in their correction or treatment, particularly the best plan of organization for the care of the surgical patient for most children's hospitals. In the first place Gross' text covers only a limited section or part of pediatric surgery. Of the sixty-six chapters in the book dealing with specific conditions, thirty-eight are concerned with the digestive system and intraabdominal organs, nine with the genit o u r i n a r y system, and six with cardiac surgery, leaving only a few for miscellaneous conditions. The surgical material at this hospital is enormous with 2,447 operations in the field of "general" surgery in 1950. However, we note that there were 407 neurosurgical operations in a special department of which Dr. Ingraham is in charge, 494 orthopedic operations, 1,877 otolaryngologic, 111 dental, and 64 ophthalmologic. The sum of these totals more than the operations in the
498
THE
JOURNAL
field of general surgery. No figures, moreover, are given for plastic surgery which constitutes no small part of the infant surgery in many hospitals for children. One wonders if all of the surgeons in these various fields have the same broad knowledge of anesthesia, antibiotic therapy, and fluid therapy as Dr. Gross and his staff in "gene r a l " surgery. There is a great deal to be said, when pediatric surgery is looked upon as a whole, for the type of organization found in most children's medical centers where the pediatric staff is in constant touch with the surgical patients beyond the point of diagnosis. Relatively few children's services have the amount of material available which will enable a surgeon to confine himself to surgery in children. Nevertheless the surgical services in many of these hospitals have added much to the development of surgery in infancy and childhood. To cite some of the developments in a hospital where the other plan of organization is followed. It is the plan generally followed and this one is cited simply because the writer has personally watched it over a period of forty years. A number of the surgical staff have made significant contributions to the surgery of childhood, although none has confined his work to children. Vilray Blair, for example,
OF P E D I A T R I C S
has done much to advance plastic surgery in the newborn infant. Evarts Graham's pioneer work in thoracic surgery, like the work of Blair, received worldwide recognition. Ernest Sachs in neurosurgery and Caulk and Rose in genitourinary surgery have made definite contributions in their particular fields to the surgery of childhood. The same holds true for many surgeons in other institutions who do not confine their work to children. Blalock's work in cardiac surgery is an example that will flash through everyone's mind. The question raised by Gross, and concerning which there can be honest differences of opinion, is whether pediatric surgery should be a special field, or whether surgery is best carried out by surgeons particularly qualified in a special field of surgery with the active cooperation and participation in the care of the patient by the pediatric staff. With due respect to the opinion of Dr. Gross, and with full appreciation of the splendid work and the important contributions to the development of the surgery of infancy and childhood made by the surgical staff of the Boston Children's Hospital, we believe that for the large majority of children's hospitals and services the plan of organization now in use at most institutions is probably better.
they may wish to prescribe later in their practice. It is difficult to see how everyone can be satisfied but we might t r y to remove the major inequities. Perhaps our hospitals might offer a choice of the three major types of formula --whole milk, evaporated milk, and
497
prepared formulas. I n each instance the purchasing department should be instructed to rotate orders among the recognized competitors. W e are assured that such a system would automatically end one type of conditioned gift. S. H. C.
S U R G E R Y IN A C H I L D R E N ' S H O S P I T A L N R E A D I N G the new Surgery of Infancy and Childhood by Gross, which is reviewed elsewhere in this issue by a surgeon, the editor was struck by the statement that in the opinion of the author the best results in pediatric surgery are obtained when surgery is an independent unit, and the entire preoperative and postoperative care is the responsibilitY of the surgical staff. This is the plan of organization started at the Boston Children's Hospital in 1927 b y Dr. William Ladd and under which Dr. Gross has worked. The best evidence to s u p p o r t this viewpoint is found in this text. Some of the results in Boston are striking; for example, the results of surgery in the p r e m a t u r e infant, and the steady reduction of the operative mortality rate for pyloric stenosis in a series of 1,787 cases from 1932 to 1951 as shown in Table 8 of the text. There are relatively few children's hospitals in the country with a similar organization, and with a surgical staff devoting their time exclusively to surgery in children. As one reads the introductory chapters on preoperative and postoperative care one is impressed by the breadth of knowledge of what is generally c o n s i d e r e d " pediatr i c s " held by Dr. Gross, in addition
I
to the p u r e l y surgical techniques. On first thought it seems logical that this is the plan of organization our children's hospitals should attempt to obtain. A f t e r mulling the idea over for some time doubt began to enter in, and w e began to question if it is the best plan for the development of surgical techniques applicable to conditions in childhood requiring s u r g e r y in their correction or treatment, particularly the best plan of organization for the care of the surgical patient for most children's hospitals. In the first place Gross' text covers only a limited section or part of pediatric surgery. Of the sixty-six chapters in the book dealing with specific conditions, thirty-eight are concerned with the digestive system and intraabdominal organs, nine with the genit o u r i n a r y system, and six with cardiac surgery, leaving only a few for miscellaneous conditions. The surgical material at this hospital is enormous with 2,447 operations in the field of "general" surgery in 1950. However, we note that there were 407 neurosurgical operations in a special department of which Dr. Ingraham is in charge, 494 orthopedic operations, 1,877 otolaryngologic, 111 dental, and 64 ophthalmologic. The sum of these totals more than the operations in the
498
THE
JOURNAL
field of general surgery. No figures, moreover, are given for plastic surgery which constitutes no small part of the infant surgery in many hospitals for children. One wonders if all of the surgeons in these various fields have the same broad knowledge of anesthesia, antibiotic therapy, and fluid therapy as Dr. Gross and his staff in "gene r a l " surgery. There is a great deal to be said, when pediatric surgery is looked upon as a whole, for the type of organization found in most children's medical centers where the pediatric staff is in constant touch with the surgical patients beyond the point of diagnosis. Relatively few children's services have the amount of material available which will enable a surgeon to confine himself to surgery in children. Nevertheless the surgical services in many of these hospitals have added much to the development of surgery in infancy and childhood. To cite some of the developments in a hospital where the other plan of organization is followed. It is the plan generally followed and this one is cited simply because the writer has personally watched it over a period of forty years. A number of the surgical staff have made significant contributions to the surgery of childhood, although none has confined his work to children. Vilray Blair, for example,
OF P E D I A T R I C S
has done much to advance plastic surgery in the newborn infant. Evarts Graham's pioneer work in thoracic surgery, like the work of Blair, received worldwide recognition. Ernest Sachs in neurosurgery and Caulk and Rose in genitourinary surgery have made definite contributions in their particular fields to the surgery of childhood. The same holds true for many surgeons in other institutions who do not confine their work to children. Blalock's work in cardiac surgery is an example that will flash through everyone's mind. The question raised by Gross, and concerning which there can be honest differences of opinion, is whether pediatric surgery should be a special field, or whether surgery is best carried out by surgeons particularly qualified in a special field of surgery with the active cooperation and participation in the care of the patient by the pediatric staff. With due respect to the opinion of Dr. Gross, and with full appreciation of the splendid work and the important contributions to the development of the surgery of infancy and childhood made by the surgical staff of the Boston Children's Hospital, we believe that for the large majority of children's hospitals and services the plan of organization now in use at most institutions is probably better.