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Thoughts from A Surgeon For Adults Towards A Paediatric Surgeon. Part II

Editorial

Professor DHC Vasile Sârbu Ovidius University of Constanta

Professor Sebastian Ionescu “Carol Davila” University of Bucharest


Part II

CHAPTER II. Different Elements between the Surgeon for Adults and the Pediatric Surgeon

II.1 An evolutionary historical analysis of the general surgery and a comparison with the branches that have emerged from it shows us the fact that in the late nineteenth century and early twentieth century progress in this area was so great that it could not “fit its own clothes”. The appearance of general, spinal and locoregional anesthesia, the discovery of microbial germs, asepsis and antisepsis led to an explosion of surgical interventions in general, as it cannot be called implosion with the loss of its own identity. Surgery was finally recognized as a part of Medicine and after a secular fight, the diplomas of „Medicine and Surgery” were issued which can be admired today as museum curiosities. A historical marvel is the fact that in the Ancient Egypt when the first separations of the medical fields occurred, a “specialty” dealing with the diseases of the children emerged.

- the Edwin Smith papyrus (1600 BC) discovered in 1930 (5 meters long) contains writings about surgical conditions: 48 cases with injuries to the head, neck, shoulders and chest, as well as fractures;

- the Ebers papyrus dating from the times of pharaoh Den (3000 years BC) discovered in 1875 (30 cm wide and 20 meters long) contains data about diseases of the eye, skin and internal medicine;

- physicians working in the „House of Life” had many specialties: dentistry, obstetrics, etc. It is known the name of dentist Hesy-Ra, who’s name appears mentioned in 2670 BC during Pharaoh Djoser, probably the first known physician in history (the first known woman physician appears mentioned in 2700 BC Merit – called Ptah);

- the Smith papyrus (1600 BC) describes surgical treatments in abscesses, tumors and burns;

We find data about the treatment of children’s illnesses in the Ancient Egypt, in the Ramesserum Papyrus, chapters III, IV, and V where there are mentioned other specialties as well: ophthalmology, gynecology, diseases of the muscles and tendons. This papyrus was found in the Ramesseum temple and was displayed in the Ashmoulian museum in Oxford. Regarding more minor pathology and vascular conditions there is information dating back approximately 2000 years BC in the Hearst papyrus which can be found in the library of the University of California.

We can also find data related to pediatrics, ophthalmology, obstetrics, gynecology, internal medicine in the Carlsberg papyrus (2000 years BC).

The ancient Egyptians Sutured the Injuries, Opened the Abscesses and Made Circumcisions, although they also made gestures encountered today in pediatric surgery of the newborns.

Circumcision was not considered a pediatric operation as it was made as a ritual and not with the purpose to cure a disease. In the Jewish culture, biblical documents of about 3,500 years old talk about the circumcision which was done in the eighth day after birth - “When the eighth day came, when the Child had to be circumcised, they named him Jesus” (Luca 2/21). Because this surgery is performed only after 8 days and not earlier, one might think that during the first 7 days there is not salvation for children with severe malformations. In the eighth day things were already clarified.

General surgery, the product of a much longer evolution epoch was based on the anatomy of the adult and has behind it a past and a patrimony towards which the surgeon for adults feels closer to compared to the pediatric surgeon. During history, the greatest surgeons actually carried on their shoulders all the branches of surgery but our perception does not overlaps this truth. If you read the history of the cardiovascular surgery you shall return back to Napoleon’s doctor, Domenique Larrey (1766 – 1842), who unsuccessfully sutured a heart wound in 1810. In other specialties derived from the mother field, references can be made up to brain trepanation (for neurosurgeons) or to the physicians of the antiquity for trauma surgery. This greatness of the historical patrimony assumed by a generalist surgeon nonetheless remains. He considers that among his parents are: Henri de Mondeville (1260 – 1316); Guy de Chauliac (1300-1368); Ambroise Pare (1510 – 1590); William Halsted, John Hunter (1728 – 1793); Antonio Scarpa (1752 – 1832); Baron Guillaume Dupuytren (1777 – 1835); Astley Cooper (1768 – 1843); Joseph Lister (1827 – 1912) etc.

This pride that gives a sense of paternity to the Generalist Surgeon for adults is in fact unjust, as surgery itself is one and indivisible. We must admit that these surgeons never operated the heart of a newborn, nor performed laparoscopic surgery, nor microsurgery, nor surgeries of the last decade related to urology, orthopedics, robotics, transplants and many others. But this linage of the historical surgery seems set on an uninterrupted film.

II.2 Let us remember that the first children’s hospital in the world opened in Paris in 1802 „L’Hospital des Enfants malades”. But the responsibility for any child’s care and their health is huge. Let us remember what Juvenal was saying in Satire XIV: „Maxima debetur puero reverentia”. In Romania, only in 1883 a paper called „The art of caring for young children” was published having as author an English doctor, named John Barkere Mawer (who came in Romania in 1858). In 1857 Dimitrie Ghica has established the first children’s hospital in Bucharest (under the care of Iuliu Barasch) who’s headquarter moved from Diaconeselor St reet to Grigorie Alexandrescu Street, where it functioned till today. In this hospital the first surgical interventions were performed on children by surgeons for adults – Dr. E. Patzelt and N. Turnescu (first dean of the Faculty of Medicine in Bucharest). At this new address (Gr. Alexandrescu Street) the Surgery Clinic was opened and led by Dr. Gr. Romniceanu until 1915. Between 1914 and 1938 the Paediatric and Orthopedic Surgicak Clinic was led by Prof. Ion Bălăcescu (student of Th. Ionescu); followed by Dr. Ion Marian, then Iacob Iacobovici (1938 – 1942 helped by Prof. Ion Marian), followed by the famous Professor Alex Cosăcescu (1942 – 1951) and then Filip Gottlieb (1952 – 1961) and Dimitrie Vereanu. These great professors and surgeons were born from the school of Thoma Ionescu, directly or indirectly. Their professional value was equal to that of the surgeons for adults. Developing the infant surgery they built the base of the newborn surgery and pediatric urology. Their glory was and shall remain in history not only equal to that of the Romanian school of surgery, but even higher as they set the base for new areas, as we mentioned, for example the surgery of the infant.

II.3 A difference between the two types of surgeons is that the child patient, starting from the intrauterine life and until 16 years old is more precious. Therefore, pediatric surgery is a bigger challenge and the errors of the pediatric surgeon have larger effects. So it is harder for a pediatric surgeon to stand at the height of its mission, for its mission has a larger load.

II.4 The pride of the surgeon for adults is often overstated compared to a pediatric surgeon, as he considers that he may be proficient in most of the surgical interventions in children without needing any additional training. In turn, the operations performed by him, especially those related to oncology surgery, often involving multiple organs and being complex, would heavily be performed by a pediatric surgeon. This could be explained by the specialization curricula which is very much different between the two specialties. This is where the surgeon for adults commits a slight error, related to the fact that the surgery for adults has also been divided too much. The program of a specialist was crumbled and does not have a joint fund anymore. Thus a prostatectomy or an intervention for kidney stones or a femoral-bilateral bypass, a pulmonary lobectomy, an evacuation of a subdural hematoma cannot be performed at the same level with the colleague from the specialty dedicated to such pathology.

II.5 The complexity and richness of medical knowledge that a surgeon for adults must possess is very high because of the wide variety of techniques. But this is where I have to admit that certain pathology encountered in the pediatric surgery are extremely different from the diseases of the adult. I must remind here the surgical treatment for congenital malformations, as for example in pediatric urology or some severe orthopedic disorders etc., which goes beyond the experience of the adult surgeon or are even foreign to him.

II.6 General Surgeons are the inventors of almost all surgical instruments. Almost all of them bear their names as well. It is well known that the great surgeon Pean Jules (1830 – 1898) gave his name to a clamp, and Theodor Billroth to a surgical technique for gastric resection. This is the chronological order in the appearance first of the surgery of adults, with all the main techniques and instruments which were later adopted by the surgical branches which emerged from the main tree. The main diagnostic tests remained the same in children and adults although there are many particularities.

II.7 Regarding the surgical skills (“the artistic grace”) I think that it should be greater in the pediatric surgeon. I do not have statistics related to the number of surgeons for adults that play the piano, the violin or write literature, paint, compared to pediatric surgeons, but I am convinced that handling the needle holder, looking for the dissection plans, tissue section, thus the required talent must be greater in the pediatric surgeon. We can say he is required to be more talented.

II.8 I have to re-emphasis here just a few reasons why we must revoke, once for all, the idea that a child is a small adult and by extension that a pediatric surgeon is a surgeon for adults with a smaller and less important cases.

The child has an unequal growth from birth to adolescence (the brain increased 4 times, the liver 9 times, spleen 13 times, kidney 14 times, heart 20 times, and the gut 30 times). When operating on a child, the surgeon has these unequal developments in his mind. During the first year of life the eye and the ear reach approximately the sizes of the adult. At puberty, the thymus and lymphoid organs start to involute at any teenager.

Thus, there is a “law of the different rhythm of growth and development” and a law of proportions”. Changes in the growth proportions between parties’ starts during the intrauterine life and ends after puberty. There is also a „law of alternation”. According to this, increased waist circumference and weight alternate with the growth of organs. Bones alternate their growth in length with thickening. The activity of endocrine glands, pituitary gland, the cardiovascular system, the locomotor apparatus, have very important particularities.

Blood pressure and cardiac output have serious variations before puberty. The pulmonary volume is smaller in preschoolers. Adultology will emerge soon and it is much different from the child care and geriatrics. Surgery cannot cover each one of them with the same principles and techniques.

CHAPTER III. Instead of Conclusions

III.1 Surgeons for adults and pediatric surgeons are part of a big, noble and unique family: that of the scalpel bearers, with virtuous hands and enlightened minds. Their essence is unique, just as the Trinity (Father, Son and Holy Spirit) are one and the same.

III.2 At their origins, pediatric surgeons have been surgeons for adults. They did not separate from their parents by divorce, but by birth and burgeoning. It is natural never to forget the first love that covers the greatest wisdom: „La somma sapientia Il primo amore” (the greatest wisdom/the first love) written on the gate between Heaven and Hell in the Divine Comedy by Dante Alighieri.

III.3 Total separation of the surgery of adult from the pediatric surgery is absurd, as their essence is joint.

III.4 In this current era, pediatric surgeons no longer learn their own profession from adult surgeons, as they created their own teachers, their own schools and have very well structured and up-to-date medical literature. Pediatric surgery is the result of creative development from general surgery with focus on children’s pathology, keeping in mind that children are no little adults.

III.5 Selfish feelings are ridiculous and shall not lead to adversities, as they had joint purposes, joint parents and identical work places, identical tools. We have the same reflexes, the same gestures, the same clothes; we are haunted by the same unpredicted complications of our patients. In the war with sufferance and death we occupy the same battlefield: that of the eternal surgery. It shall always crumble and give life to new and new branches, just as the Pediatric Surgery and Orthopedics shall give life to: cardiovascular surgery of the child, pediatric urology, plastic surgery of the child, infant orthopedics, prenatal surgery, newborn surgery, pediatric ophthalmology, neurosurgery of the child, etc.

One day the uniqueness of the sick man shall be rethought and many of the branches of medicine shall be reunited.