Journal of Indian Association of Pediatric Surgeons Medknow Publications on behalf of the Indian Association of Pediatric Surgeons ISSN: 0971-9261 EISSN: 1998-3891 Vol. 12, Num. 4, 2007, pp. 190-191

Journal of Indian Association of Pediatric Surgeons, Vol. 12, No. 4, October-December, 2007, pp. 190-191

Editorial

Pediatric surgery: Forty years ago

Chatterjee SubirK

Emeritus Editor-in-Chief, Journal of Indian Association of Pediatric Surgeons, Kolkata
Correspondence Address:4, Gorky Terrace, Kolkata 700017, parkclinic@vsnl.net

Code Number: ip07063

As 2007 drew to a close, my thoughts turn to the fateful year when, forty years ago, after a spell in the US I started a career in Pediatric Surgery in Calcutta. Some of my close friends also embarked on careers in Pediatric Surgery in other parts of India, a year or two earlier or later. I thought it would interest the younger generation to know what Pediatric Surgery was like in those days; hence this brief presentation.

The most important single item that is necessary for successful pediatric surgery is venous access. Forty years ago, none of the wonderful gadgets existed, which allow a doctor to enter a vein of a newborn at the drop of a hat. All that we had were rigid butterfly needles and tubes that could be introduced after an open venotomy. It was routine in Chicago that prior to every major operation, the resident would perform a cutdown and ensure that the channel would stay in patent for the next few days. This is the same routine I followed for several years, until modern cannulas dropped into our laps like manna from heaven!

Similarly, the most important single diagnostic tool in pediatrics today is ultrasonography. This was unavailable forty years ago. In fact I remember a day in 1967 when Orvar Swenson showed me how an enlarged liver could be demonstrated by a new device known as ultrasonogram; the boys would never learn how to palpate livers if this caught on, he would mourn. The second most important diagnostic tool is the CT scan; until its arrival in the 1980s, the management of pediatric neurosurgical problems was almost hit and run. Later on came MRI, and life became easier than ever for both patients and doctors.

It was the heyday of conventional X-ray; its latest advance, the image intensifier, had appeared forty years ago. New contrast X-ray studies, both with radiolucent and radio opaque substances, were being popularized year after year. X-ray after introducing some substances into the subarachnoid space and the ventricles allowed a reasonable amount of safe neurosurgery. The sheet anchor in diagnosing disorders of the alimentary tract was, of course, the introduction of radio opaque contrast fluid into its various parts. Its progress could be followed up with the image intensifier. Radio opaque contrast could also be introduced in a myriad different ways into the respiratory, urinary and genital tracts and into veins and arteries. Thus, almost all the hollow organs of the body could be visualized. Some procedures were easily done, others were more difficult and a few were risky; the possible benefit and the risk factor had to be weighed before taking a decision. Forty years ago, it was possible to cut down on a blood vessel and pass a catheter to enter the heart and great vessels to collect blood samples and perform an angiogram. However, unlike today, angiograms could not be done at the drop of a hat!

The only other form of imaging that had just entered the field was Radioisotope imaging; disorders of the thyroid gland, the kidneys and liver could be demonstrated with the relatively crude counters of the 1960s.

Forty years ago, there was no fibreoptic endoscopy, and the incandescent devices available allowed visualization of only the upper respiratory and alimentary tracts and the lower alimentary and urinary tracts through rigid instruments. Only a few relatively simple procedures could be carried out through these instruments with safety. It was difficult to pass a catheter into a child′s ureter with the help of an incandescent cystoscope, and it was even more difficult to fulgurate urethral valves with this instrument, but we did.

Turning now to monitoring devices, life today without a pulse oximeter is unthinkable, but the only monitoring device readily available forty years ago was the electrocardiogram. Patient assessment had to be done by clinical measurement of pulse rate, blood pressure, respiration and urine volume. Techniques of anesthesia were sufficiently advanced to allow safe neonatal surgery. The mechanical ventilator had yet to put in an appearance, but our colleagues were experts in controlling breathing by manipulating bags. In fact, even before I had gone to the US, I had successfully treated esophageal atresia, jejunoileal atresia and diaphragmatic hernia with the help of excellent anesthesiologists.

Similarly in the laboratory, sophisticated microanalyzers did not exist, but blood gases, electrolytes and various biochemical parameters could all be estimated accurately with what was available. However, the processes required relatively large volumes of blood, and the estimations were laborious and time-consuming.

By the time I arrived in the US, many therapeutic advances were already in place. Conjoined twins had been successfully separated. The Pudenz shunt had entered the field of neurosurgery; the heart lung machine allowed the correction of cardiac malformations, the dialysis machine allowed the management of end-stage renal disease, and some successful renal transplants had already been done. In fact, on my very first day in the operating room, I was stunned to find that an operation for bilateral nephroureterectomy had been advertised in the day′s list.

However, there was little to offer for patients with solid tumors apart from radical surgery and rather primitive radiation therapy. Actinomycin D had just been introduced, but its value had yet to be assessed.

The first journal devoted exclusively to pediatric surgery was launched exactly a year earlier; it was aptly named Journal of Pediatric Surgery . Until it appeared, pediatric surgeons had to use either journals controlled by pediatricians or journals controlled by general surgeons; they received step-motherly treatment from both. It was a matter of great consolation for us to find that the appearance of the early issues of this new journal was not significantly different from the early issues of the Journal of the Indian Association of Pediatric Surgeons that we started in 1995.

With all the advances that have taken place since 1967, one may well sit back and think that nothing new will take place after 2007. I have no doubt that the complacent will be proved wrong and that many new things will appear before 2047. Perhaps some of those who are reading this will then write about how difficult life was in 2007!

Copyright 2007 - Journal of Indian Association of Pediatric Surgeons