Surgical pediatrics

Surgical pediatrics

Critical Review SURGICAL P E D I A T R I C S I~ERB~RT E. CoE, ~ . D . SEATTLE, WASI-I. T IS interesting to note the increased frequency of reference i...

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Critical Review SURGICAL P E D I A T R I C S I~ERB~RT E. CoE, ~ . D . SEATTLE, WASI-I. T IS interesting to note the increased frequency of reference in recent

l i t e r a t u r e to the subject of surgical pediatrics. W h e t h e r this foreIshadows an additional division of s u r g e r y or the beginning of segregations within the specialty of pediatrics is impossible to estimate. Certain it is t h a t a knowledge of the peculiar reactions, the active physiologic processes, and the anatomic limitations of infancy and childhood must be so t h o r o u g h and f u n d a m e n t a l t h a t the p e d i a t r i c surgeon must be possessed of a pediatric as well as a surgical and an aseptic conscience. The differences between adults and ehiidre~ are not alone matters of size b u t are even more m a r k e d i n anatomy, physio]0gy, and psychology?, 2 These differences have given rise to the specialty of pediatrics, and the same facts and conditions are equally i m p o r t a n t when applied to surgery. Since the limits of safety are marrow in the s u r g e r y of children and even n a r r o w e r in t h a t of infants, surgical procedures and technic must be varied accordingly. The statement t h a t children do not stand s u r g e r y well is being much less f r e q u e n t l y h e a r d as the realization is becoming more general that t h e y do not stand adult surgery well. I n an excellent article Schulz 3 says, " I n f a n t s and children present surgical problems so different from adults t h a t the practice of pediatric sl~rgery p r o b a b l y should be as specialized as is the practice of pedia t r i c s . " And later, " T h e field of pediatric s u r g e r y is i m p o r t a n t and large enough to deserve some place in the curriculum of medical educatio,n." W i t h the opinion, however, t h a t all possible s u r g e r y should be d e f e r r e d until after the age of eighteen or t w e n t y - f o u r months and operating upon aa i n f a n t only for emergencies or conditions incompatible with life, we cannot agree, and would r e f e r to an earlier statemerit ~n the same article to the effect t h a t infants and children can easily u n d e r g o m a j o r s u r g e r y if the physiologic mechanism is understood and 'if there is good p r e o p e r a t i v e and postoperative care and good operating. In the congenital defects involving muscle function, normal anatomic relations should be secured as soon as possible so t k a t n o r m a l g r o w t h and development m a y take place during the early months of life when physiologic processes are in the period of greatest activity. The statement r e g a r d i n g medical curriculums deserves more than passing mention. How often does a y o u n g man leave a medical school and a general interneship with f u l l knowledge and ability to do a g a s t r o e n t e r o s t o m y or a h y s t e r e c t o m y only t o find himself c o n f r o n t e d d u r i n g his early years of practice b y problems in the s u r g e r y of infants or small children which he is t o t a l l y u n p r e p a r e d to meet. If he 37O

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has had no instruction in the preoperative and postoperative requirements of these little patients and no warning of tile operative hazards, the unnecessary fatalities which must inevitably occur are chargeable not to the y o u n g man but squarely to the faculty of his school in whom he h a d placed his trust. In a m a s t e r l y article Prof. J o h n F r a s e r of E d i n b u r g h reviews the progress of pediatric surgery during the past twenty-five yearsr A review of such a review is impossible. It must be read to appreciate the great b r e a d t h of experience and vision and the delightful style. He summarizes the advancements of the q u a r t e r c e n t u r y as, (1) striving for simplicity, (2) application of physiologic and anatomic principles to the t r e a t m e n t of disease, and (3) endeavoring to attain the objective with the least possible disturbance of the processes of body chemistry. A thesis could be w r i t t e n on e a c h of these. The utilization of the principles of rest and minimum interference with the physiologic defense mechanism 5 is seen in maaay of the methods of t r e a t m e n t of infection which are perhaps considered of receat origin but which may well be a revival of Hilton's principles of rest enunciated n e a r l y a century ago. As such may be mentioned the Orr t r e a t m e n t of osteomyelitis; the saline pack, the Carrel-Dakia method, the phenomenon of bacteriophage, vaseline packs in chronic sinuses or fistulas Gusing i r r a d i a t e d vaseline which gives off no ultraviolet emanations, etc. The principles m a y well be applied to the care of v e r y sick infants and children who are often ia a n a r r o w and unstable zone between r e c o v e r y and death. Meddlesome therapeutics or too close adherence to a disturbing nursing routine of e x t e r n a l cleanliness m a y pus h such a patient over the wrong b o u n d a r y of the zone r a t h e r than assist him over the right one. ANESTHESIA

While ether is u n d o u b t e d l y the safest anesthetic for general use, the avoidance of psychic shock with consequent e~tdoerine disturbance and postoperative upset in eases requiring multiple anesthetics deserves careful consideration. To meet this condition there is an increasing p o p u l a r i t y of basal anesthetics, chief among which are avertin and the various barbiturates. Evipan, 7 a barbiturate used intravenously, gives a quick anesthesia of c o m p a r a t i v e l y short duration. I t has the same depressant effect on r e s p i r a t i o n and blood pressure that has beert noted in conneetion with the use of other barbiturates. T h i s : m a y at times require an airway or .stimulation by carbog'en, but untoward results are ext r e m e l y rare, especially w h e n a skilled anesthetist and careful posto p e r a t i v e a u r s i n g are available. I f p r e o p e r a t i v e narcotics are used, total anesthesia is possible} but the risk is increased; the greatest field of usefulness is as a basal anesthetic supplemented b y light inhalation anesthesia. Tables of dosage are supplied by the m a n u f a c t u r e r s and should be followed exactly. Coramine 9 is of great value as an antidote for either avertin or spinal anesthetics and m a y be given intrave.nously for quick effect or intramuscularly or orally when mere prolonged action is desired; Spinal anesthesia is of limited value in children, but caudal anesthesia has a distinct field of usefulness for urologic procedures, permitting valuabl.e diagnostic measures in p y u r l a and enuresis and making u r e t h r a l s u r g e r y possible without general anesthesia.

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E t h y l e n e is a valuable anesthetic agent, the use of which has been unnecessarily limited b y undue emphasis upon the hazard of explosion. 11 It is most satisfactory when used with th'e same skill and care which should be exercised in the administration of any anesthetic. Moist climates t e n d to eliminate the d a n g e r of static, and a few simple precautions reduce it to a minimum. More explosions have occurred fro.m gas-oxygen-ether anesthesia than from ethylene, and in one series 27,000 ethylene anesthetics have been given without accident. The outstanding objection which has been raised to intravenous and rectal basal anesthetics is the impossibility of stopping absorption at a n y given time or stage, as is possible with inhalation anesthetics. This objection of course deserves careful consideration, but it can be met in practically all instances b y foresight and p r e p a r a t i o n for possible emergencies, as should be the practice w h e n using any anesthetic. The type of a n e s t h e t i c to be used should be suited to the individual ease and wilt depend upon the t e m p e r a m e n t of the child, the pathologic condition, the necessary surgical procedure, and the experience of the anesthetist. The skill of the anesthetist lies not only in his ability to administer an anesthetic but also in his ability to choose the best one for the patient. S u d d e n death during the induction of anesthesia of any t y p e m a y occur and has usually been considered as due to idiosyncrasy or, in children, to some vague thymic abnormality. Idiosyncrasy suggests sensitization which in t u r n suggests allergy, and a most interesting s t u d y 12 correlates these conditions with so-called " t h y m i c d e a t h . " The p a t h o l o g i c changes in such instances are almost identical with those f o u n d in cases of known anaphy]actic shock, and the assumption is t h a t such shock is not necessarily d e p e n d e n t upon a protein antigen b u t m a y be p r o d u c e d b y a n o n p r o t e i n substance absorbed t h r o u g h the r e s p i r a t o r y tract. Such allergic shock, violent enough in some instances to cause death, will. occur if there is a condition of extreme sensitivity with r a p i d absorption of an a m o u n t of antigen definitely above the individuM tolerance. In m a n y of the cases studied there was a f a m i l y history of allergy of some kind, and in a series of t h i r t y children showing enlarged t h y m u s b y x-ray t w e n t y - f o u r had an allergic history or positive dermal tests, la The usual tests have p r o v e d unreliable for n o n p r o t e i n anesthetic agents, and the v e r y p e r t i n e n t suggestion is made that with allergic patients or those hawing allergic relatives small amounts of inhalation or local anesthetic be cautiously administered with a protective dose of ephedrine or epinephrine r e a d y for immediate use. The relation of an enlarged thymus to the allergic state has not been determined, b u t it seems probable t h a t it is more intimate t h a n the relation to the so-called obstructive t h y m i c syndrome of stridor, cyanosis, cough, etc. In a series of 322 n e w b o r n infants with x-ray evidence of thymic enlargement, only fifteen showed clinical symptoms r e f e r a b l e to this condition. ~4 OI~TttOPEDIC S

The merits of the operative and nonoperative treatment of jo.int tuberculosis has been argued pro and con for m a n y years, the weight of opinion for some time having been in f a v o r of nonoperative t r e a t m e n t in the average ease in a child, largely on account of the time and emp l o y m e n t factors. In recent literature, however, there is a constantly

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increasing t r e n d t o w a r d the a d v o c a c y of joint fusion b y operation in children as well as adults. There should be no conflict between the t w o t y p e s of t r e a t m e n t , as s u r g e r y is simply a step in the entire course of t r e a t m e n t , 1G and should be used at the a p p r o p r i a t e time. Since joint i n v o l v e m e n t is usually cosasidered as a local m a n i f e s t a t i o n of a general condition, t h e disease process m u s t be t r e a t e d as a whole, with the closest c o o p e r a t i o n between the surgeon and the internist} 6 Only b y such t r e a t m e n t can the p a t i e n t be r e t u r n e d to the best possible condition in the s h o r t e s t possible time. The decision to use s u r g e r y and w h e n to use it m u s t depend upon the climate, the efficiency of medical t r e a t m e n t , a n d the quality of surgical skill available. W h e n an a d e q u a t e o p e r a t i o n is p e r f o r m e d in a case which has h a d p r o p e r p r e o p e r a t i v e care a n d the p o s t o p e r a t i v e p e r i o d of rest and p r o t e c t i o n well supervised, the prognosis for tubercnlosis of the spine is s u r p r i s i n g l y good. 1~ The results in children, even w h e n the t i m e of choice f o r the operation is before five y e a r s of age, are excellent a n d a f t e r r e c o v e r y these p a t i e n t s h a v e p a r t i c i p a t e d in athletics or h a v e done h a r d m a n u a l labor. S u r g e r y should not be u n d e r t a k e n e a r l y in the a v e r a g e case, as it does not stop the disease process, ~s b u t it is to be used a f t e r the active p r o g r e s s of the disease kas been controlled b y the p r e l i m i n a r y medical t r e a t m e n t and before w e i g h t - b e a r i n g has placed such a strain u p o n the lesion as to pr'oduee or increase a d e f o r m i t y . The entire course of t r e a t m e n t m a y require f r o m three to five years. The same e o m b i n a t l o n of medical a n d surgical t r e a t m e n t is proving' successful in t r e a t m e n t of tuberculosis of the w e i g h t - b e a r i n g joints, p a r t i c u l a r l y the hip, the results being a m a r k e d reduction in the length of hospitalization and in the p e r c e n t a g e of recurrence. The details of t r e a t m e n t v a r y , and when t h e r e is extensive b o n y involvement, the results a r e not as good as in less a d v a n c e d eases ~9 but the I.ational use of s u r g e r y is being a d v o c a t e d even b y some who have f o r m e r l y b e e n s t r o n g l y ~n f a v o r of n o n o p e r a t i v e t r e a t m e n t } ~ The diagnosis of congenital dislocation of the hip should be made early if r e d u c t i o n is to be accomplished in the simplest a n d most satisf a c t o r y m a n n e r . The condition is u s u a l l y discovered a f t e r the child has b e g u n to walk, p e r h a p s in the first h a l f of the second year, at which time the m o t h e r seeks medical advice on account of a limp. The condition is painless a n d often is ascribed to an e x a g g e r a t i o n of the toddling gait until its persistence causes comment. The recognition of the defect should be a responsibility of the medical profession r a t h e r t h a n of the p a r e n t s or neighbors. An e x a m i n a t i o n soon a f t e r b i r t h in m o s t cases and always well within the first six months wilt either p e r m i t a definite diagnosis or show sufficient a b n o r m a l i t y to indicate a r o e n t g e n o g r a m . E v e n in the n e w b o r n the suggestive signs are an a s y m m e t r y of the gluteal creases a n d the skin folds on the inner surfaces of t h e thighs, e x t e r n a l r o t a t i o n of the affected thigh w h e n in a position of rest, limitation of abduction, and shortening of t h e thigh s h o w n best with the knees flexed} ~ I f t r ' e a t m e n t is b e g u n during' the first six months, s e c o n d a r y changes in the capsule and in the position of the h e a d of the f e m u r having" not y e t developed, reduetio.n is n s u a t t y easily accomplished, often w i t h o u t the necessity of an anesthetic. I n the t r e a t m e n t of congenital clubfoot, it cannot be too emphatically s t a t e d t h a t correction m u s t be b e g u n d u r i n g the first days of

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life and carried on persistently and vigorously until m a r k e d e~ercorrection is obtained. P a r t i c u l a r a t t e n t i o n is necessary r e g a r d i n g the correction of the equinus position of the os calcis 22 to avoid the production of a " r o c k e r foot"' in which the correction is mainly in the forefoot, leaving the position of the posterior portion practically unchanged. L a t e r a l roentgenograms m a y be necessary b u t in infants are often difficult to interpret. Comparison with a normal foot should be made. L a c k of correction of this portion of the foot is responsible f o r m a n y u n s a t i s f a c t o r y results and so-called relapses. 23 W h e n the condition is p e r m i t t e d to persist into early childhood, it often becomes s o resistant t h a t manipulative correction is impossible and extensive resection of the ligaments and capsule is necessary to permit r o t a t i o n of the tarsal bones into correct position. The removal of portions of the tarsus is inadvisable before early a d u l t life on account of interference with growth and development. A f t e r a position of overcorrection is obtained, persistent and t h o r o u g h supervision is necessary, often involving periods in plaster and special attention to corrective shoes d u r i n g the developmental years of childhood if r e c u r r e n c e is to be avoided and the best ultimate result obtained. The relation of generalized osteitis fibrosa, or yon Recklinghausen's disease, to p a r a t h y r o i d hyperplasia or tumor' is g r a d u a l l y emerging f r o m the present wave of endocrine enth~siasm as a f a i r l y fixed and stable conception. I t is to be borne in mind, however, t h a t skeletal changes occur in dysfunction of the thyroid, pituitary, pancreas, and suprarenals as well as that of the p a r a t h y r o i d s ~4 and that the surgical aspects of m a n y osteomalacic diseases 25 have not been determined, t h e r e f o r e it is p a r t i c u l a r l y essential t h a t indications be clear a=d definite before p a r a t h y r o i d s u r g e r y is recommended. A m o n g the general symptoms ~ m a y be mentioned, nausea, vomiting, cramps, muscular hypotonia, thirst, altered renal functions and bone pains. There are often f r a c t u r e s and deformities of the long bones due to cysts or t u m o r formation, and calculi and lime deposits m a y occur in the kidneys, lungs, stomach, and myocardium. A t u m o r in the neck is r a r e l y palpable in children. The blood picture of high calcium and low p h o s p h o r u s is characteristic, and the u r i n a r y calcium on o r d i n a r y :diet is six or eight times the normal. The skeletal changes as shown by r o e n t g e n o g r a p h y are never localized b u t are general and should be contrOlled b y comparison with a similar s t u d y of a normal child of the same age. S u r g e r y is complicated b4f the possible existence of a b e r r a n t parathyroids, the advisability of preserving a sufficient a m o u n t of functioning gland tissue, and the lack of relationship between the size of the gland or t u m o r and the symptoms. Close postoperative supervision is necessary on account of the possibility of the occurrence of t e t a n y ; calcium or p a r a t h y r o i d substitution t h e r a p y m a y be required. The differential diagnosis and t r e a t m e n t are difficult, b u t in suitable cases the results are satisfactory and the prognosis good. In the early stages of infantile paralysis, rest is the greatest f a c t o r i~i r e c o v e r y F This is the stage of cell inflammation and damage dur~ ing which the cells should be p r o t e c t e d b y reducing nerve impulses to a minimum. 2s There should be no manipulation or irritation. The daily nursing care should be conducted in the gex~tlest possible manner and confined to absolute essentials. The affected muscle groups Should be relieved of tension, postural protection by a plaster of Paris

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shell being p r e f e r a b l e to splints. A f t e r the disappearance of muscle tenderness, which m a y take six or eight weeks, light massage, muscle training~ and exercise of the affected muscle groups i.n w a r m w a t e r m a y be cautiously begun. I t is p a r t i c u l a r l y i m p o r t a n t t h a t the patient, the family, and friends be specifically i n s t r u c t e d at this stage that the ideas and methods of athletic training are p a r t i c u l a r l y disastrous and t h a t overexercise or the slightest f a t i g u e does not build up muscle power but causes actual weakening and delays recovery. Continued support, avoidance of strain and s t r e t c h i n g of affected muscles, and carefully supervised, g r a d u a t e d exercises are essential d u r i n g this stage. W h e n a w a r m pool is available exercises with w a t e r support are most beneficial. F r a c t u r e s of the arm are comparatively f r e q u e n t in children and those involving the elbow joint are p a r t i c u l a r l y prone to result in more or less serious disturbance of hmetion. The position of acute flexio~ following reduction is deservedly popular, but little stress has been placed upon t h e accompanying p r o n a t i o n or supination of the forearm. F a i l u r e to obtain a normal carrying angle is usually due to the use of the flexion-supination position instead of flexion-pronation. 29 Late or poor reductioJa causes excessive callus formation, and acceleration of d e v e l o p m e n t in ossification centers or other epiphyseal disturbance 8~ with r e s u l t a n t malfunction. In condylar fractures, manipulation and closed reduction is difficult and uncertain. E a r l y or immediate open r e d u c t i o n with wire nail fixation, if necessary, gives a high p e r c e n t a g e of excellent results. In f r a c t u r e of the neck of the radius, manipulation r a r e l y effects satisfactory reduction. 3~ Open reduction permits accurate replacement of f r a g m e n t s and of the epiphysis. l~esection of the head is r a r e l y necessary in children and results in axt unstable elbow with an increase of the c a r r y i n g angle. In these h.aetures there is often no crepitus, and a sign which is occasionally valuable is a r e f e r r e d pain a t the lower end of the radius when pressure is made over the head. The idea t h a t skeletal traction in children is contraindicated because of d a n g e r of osteomyelitis or i n j u r y to ePiphyseal lines deserves little consideration w h e n moder~ aseptic technic and t h e K i r s c h n e r wire type of traction are used. s2 This method should not be used routinely nor in all cases, but it is valuable where there are multiple fractures, t e n d e r , or injured skin surfaces, m a h n i o n , or delayed reduction. The Orr t r e a t m e n t of osteomyelitis has received wide publicity during recent years and has p r o v e d one of the outstanding contributions to the care of this disabling and r e f r a c t o r y disease. As is always true with any d e p a r t u r e f r o m the usual in the practice of medicine, this method has been subjected to a most searching s c r u t i n y and analysis by the profession. One study 38 would indicate t h a t the success of the m e t h o d depends upon the development of a bacteriophage. A f t e r careful p r e p a r a t i o n of the osteomyelitie cavity, packing and immobilization, the a p p r o p r i a t e bacteriophage is i n t r o d u c e d t h r o u g h an indwelling tube, t h e application being r e p e a t e d once or twice weekly without disturbing the packing. An autogenous bacteriophage as well as polyvalent stock preparations may be necessary to combat resistant strains of bacteria. The cast is removed and dressings changed every two months; in most cases healing takes place in a b o u t eight months. About 3 per cent of the cases resist the bacteriophage treatment. Vaseline of v a r y i n g consistency instead of vaseline gauze is used for

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packLng various t y p e s of cavities. The use of i r r a d i a t e d vaseline has given no b e t t e r results t h a n the use of the plain. Mention is m a d e of the use of b a c t e r i o p h a g e superficially in ceIlulitis and i n t r a v e n o u s l y in staphylococcic septicemia. T h e h e m o l y t i c staphylococcus is p a r t i c u l a r l y suspeetible to b a c t e r i o p h a g e therapy24, 3s In this connection it will be i n t e r e s t i n g to follow the d e v e l o p m e n t of' the ~se of' n u t r i e n t p e p t o n e b r o t h as a local ~applieation a~ a n d b y interstitial injection a7 to s t i m u l a t e - t h e reticuloendothelial system as a n d the use of i r r a d i a t e d blood a9 b y a u t o t r a n s f u s i o n in staphylococcic septieemim 4~ The success of the m a g g o t t r e a t m e n t of osteomyelitis h a s led to a similar critical analysis ~a for the purpose o~f eliminating the obvio~usly d i s a g r e e a b l e f e a t u r e s while r e t a i n i n g tile beneficial ones. I t was discovered t h a t p r o d u c t s of m a g g o t a c t i v i t y stimulate the retieuloendothelial system and inactivate the leueoeidin pr'odueed by the bacteria, This action is duplicated b y the use of 0.25 per' cent picric acid in 8 p e r cent glycerine, which inactivates the bacterial, toxin, and b y an aqueous suspension of calcium carbonate, w h i c h is a p o w e r f u l s t i m u l a n t of the local physiologic p r o t e c t i v e mechanism. A p p l i c a t i o n s are m a d e daily or' on a l t e r n a t e days, and r a p i d i m p r o v e m e n t is r e p o r t e d w i t h complete cure in f r o m one to six months. The usual surgical t r e a t m e n t is of course necessary. The s t i m u l a t i o n of the defense m e c h a n i s m b y a specific toxoid 42 in eases of osteomyelitis and local infections due to the staphylococcus has received a considerable a m o u n t of f a v o r a b l e notice. As yet, however, the p r o d u c t i o n of the toxoid is s o m e w h a t limited and a critical estimate of its value m u s t be withheld u n t i l m o r e r e p o r t s are available, BURNS

T h e use of 10 p e r cent tannic acid in the e a r l y t r e a t m e n t of b u r n s ~a i n s t e a d of t h e 5 p e r cent solution f o r m e r t y r e c o m m e n d e d is said to eliminate tile necessity of excision of' b u r n e d tissue. The s t r o n g e r solution p e n e t r a t e s and coagulates d o w n to sound tissues b e t t e r and m o r e r a p i d l y t h a n the weaker. E p i t h e l i a l i z a t i o n does not t a k e plaee u n d e r the c o a g u l u m in t h i r d d e g r e e burns, a n d skin g r a f t i n g should be used as soon as the general condition will permit, especially on the flexor surfaces of joints. All g e n e r a l s u p p o r t i v e and r e s t o r a t i v e m e a s u r e s should be used a n d in severe eases special nursing care is essential. Some question has been raised as to the possibility of deep necrosis f r o m the p r e s s u r e of the h a r d e o a g u l u m p r o d u c e d b y tannic acid 4~ a n d the substitution of a 1 p e r cent aqueous solution of gentian violet r e c o m m e n d e d , t~eports of this t r e a t m e n t seem favorable. ~5 I t is claimed t h a t the dye is specific f o r g r a m - p o s i t i v e b a c t e r i a and, in addition to its g r e a t e r antiseptic value, has no effect on living ceils. I t s a firm, dry, a d h e r e n t b u t pliable covering and is analgesic. On a c c o u n t of the lack of t o x i c i t y t h e r e is ~o d a n g e r of using too much. The m e t h o d of use and p r o t e c t i o n f o r the eyes are the same as for tannic acid, and the same rules are to be observed r e g a r d i n g maceration a n d r e m o v a l of the c o a g n l u m p r e p a r a t o r y to skin grafting. The results as r e g a r d s epithelialization seem to be similar to t h o s e obt a i n e d b y the tannic acid t r e a t m e n t . The m e t h o d on the whole presents some slight refinements over the tamale acid treatment, but the m o s t radical difference would a p p e a r to be a m a t t e r of color.

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CONDITIONS

Successful treatment of intracranial tumors is so dependent upon early diagnosis that possible early symptoms should be constantly in the minds of those who come in contact with children. Prominent among these are persistent vomiting and headache. 46 The child often shows a change of disposition becoming listless, drowsy, or irritable. D i s t u r b a n c e s of equilibrium and vision are usually l a t e r s y m p t o m s alt h o u g h changes in the fundus of the eye occur early in certain tumors. The persistence of a n y s y m p t o m s which m a y indicate an i n t r a c r a n i a l t u m o r should be the signal for a careful ophthalmoscopic and spinal pressure s t u d y followed b y a t h o r o u g h neurologie examinatio~ including v e n t r i c u l o g r a p h y if indicated. The possibility of multiple tumoI.s ~ should be b o r n e in m i n d if the neurologic findings seem confused, for the condition, a l t h o u g h rare, has been reported. The more common use of the o p h t h a l m o s c o p e *s will aid in b r i n g i n g cases to the neurosurgeon at a s t a g e w h e n prognosis is more hopeful. V e n t r i c u l o g r a p h i c i n t e r p r e t a t i o n has been s o m e w h a t clarified by a s t u d y 49 in which the v c n t r i e u l o g r a m s are c o r r e l a t e d with an a c c u r a t e cast of the v e n t r i c u l a r system, and as a result an i m p r o v e m e n t has been m a d e in the t e r m i n o l o g y used. The clinician should be present w h e n a v e n t r i c u l o g r a m is t a k e n as p o s t u r e is e x t r e m e l y i m p o r t a n t and suggestions as to the possible location and t y p e of the lesion will enable the r o e n t g e n o l o g i s t to obtain m o r e a c c u r a t e findings. The use of t h o r o t r a s t in the d e m o n s t r a t i o u of v a s c u l a r abnormalities in the b r a i n 5~ or elsewhere s~ is i n t e r e s t i n g a n d is r e p o r t e d to be free f r o m u n t o w a r d results. The use of a r a d i o o p a q u e liquid m e d i u m in the r a p i d l y m o v i n g blood stream, however, requires such a specialized technic if results are to be at all d e p e n d a b l e t h a t its use will be m u c h r e s t r i c t e d f o r some- time to come. CEI~VICAL CONDITIONS Branchial and t h y r o g l o s s a l cysts 52 should not be m i s t a k e n for cervical abscesses a n d incised. S e c o n d a r y infection results and renders l a t e r excision difficult. These cysts are usually smooth, semifixed but ~ot i n d u r a t e d , m o d e r a t e l y tense, and painless. T h e y are not tender unless secondarily infected or pressing u p o n a d j a c e n t nerves. Branchial cysts lie at the anterior b o r d e r of the s t e r n o m a s t o i d muscle and t h y r o g l o s s a l cysts in the midline. Fistulas and sinuses, derived f r o m tL,e same e m b r y o n i c s t r u c t u r e s open e x t e r n a l l y in the same locations in the g r e a t m a j o r i t y of cases, a l t h o u g h i n t e r n a l openings occasionally occur? a B e f o r e s e c o n d a r y infection, the discharge f r o m these sinuses is a clear mucoid or a thin m i l k y fluid a n d r a r e l y profuse, the complaint being the e m b a r r a s s m e n t caused b y its a p p e a r a n c e r a t h e r t h a n discomfort. U p o n palpation, a cord can be. felt passing u p w a r d and i n w a r d t o w a r d t h e throat, a c c e n t u a t e d b y t r a c t i o n u p o n the skin at the fistulous orifice. Thyrog]ossal sinuses pass t h r o u g h the substance of t h e h y o i d bone, and b r a n c h i a l ones lie in close contact w i t h the v a g u s n e r v e and g r e a t vessels. Cartilage m a y be present at some point along the t r a c t or even occur as an isolated cartilaginous tumor, 5~ in which later instance removal is optional as such tumors, are painless and m a l i g n a n c y does not develop.

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The removal of branchial and thyroglossal cysts and sinuses requires thorough and careful dissection with attention to vag~as symptoms, such as cough and i r r e g u l a r i t y of the pulse. The excision must be complete or t r o u b l e s o m e recurrences follow. O t h e r lateral t u m o r s in t h e n e c k 55 are, cervical glands, dermoids, a n e u r y s m , h y g r o m a , and v e r y r a r e l y thyroid, p a r a t h y r o i d or carotid b o d y tumors. The only midline t u m o r which m a y require differentiation is a sebaceous cyst. Cystic h y g r o m a m a y be difficult to different i a t e f r o m b r a n c h i a l cyst b u t usually has a m u c h m o r e r a p i d g r o w t h a n d lies p o s t e r i o r to the s t e r n o m a s t o i d muscle. I f s u r g e r y is contrai n d i c a t e d and pressure s y m p t o m s r e q u i r e relief injection w i t h a selerosing solution of 5 per cent sodium m o r r h u a t e ~6 m a y p r o v e successful. I f at all possible, however, excision is the p r e f e r a b l e treatm e n t because of the necessity f o r complete r e m o v a l of the secreting surface and the possibility of an undesirable i r r i t a t i n g effect of the sclerosing solutio.n upon a d j a c e n t structures. The surgical r e m o v a l of tuberculous cervical glands 57 should be r e s e r v e d f o r early selected cases in which the process is well localized a n d the general condition good. All antituberculosis measures should be used b o t h b e f o r e and a f t e r excision. Such t r e a t m e n t is a definite a n d direct m e t h o d of r e m o v i n g a focus w h i c h m a y become active at a latex" date. I n c a r e f u l l y selected cases, results are 90 p e r cent satisf a c t o r y . F o r the t r e a t m e n t of m o r e a d v a n c e d cases, either w i t h or w i t h o u t sinus formation, x - r a y t r e a t m e n t as an a d j u n c t to general measures

is of value, as

The careful and t h o r o u g h use of general antituberculosis measures' will still r e m a i n the f u n d a m e n t a l l y sound a n d necessary t r e a t m e n t of tuberculosis in w h a t e v e r p a r t of the b o d y it m a y occur. S u r g e r y and local m e a s u r e s to i m p r o v e physiologic defense and resistance should be used w h e n e v e r indicated, b u t u n d e r no circumstances should t h e y be considered as m a j o r f a c t o r s in t r e a t m e n t , or allowed to o v e r s h a d o w the general regimen. Theories as to the cause of congenital torticollis h a v e often placed the responsibility u p o n muscle r u p t u r e or h e m o r r h a g e due to b i r t h t r a u m a or upon some congenital defect in e n e r v a t i o n or blood supply. A recent s t u d y 59 suggests t h a t it is caused b y venous o b s t r u c t i o n and constriction in the s t e r n o m a s t o i d muscle of one or two h o u r s ' d u r a t i o n d u r i n g labor. The constriction causes i n t r a v a s c u l a r clotting w i t h res u l t a n t localized fibrosis. The fibrotic t u m o r p r e v e n t s n o r m a l g r o w t h of the muscle w i t h relative shortening, a n d the d e v e l o p m e n t of increasing tortieollis. E a r I y s u r g e r y before s e c o n d a r y deformities occur is indicated. T h y r o i d disorders are seen f a i r l y f r e q u e n t l y in children, ~~ p a r t i c u . l a r l y in those sections o f the cou.utry which lie in the " g o i t e r b e l t . " Both congenital goiter and congenital cretinism occur. Colloid goiter in general does not need s u r g e r y a n d m a y be benefited b y iodine. Toxic goiter should be t r e a t e d s u r g i c a l l y if it is so large as to cause p r e s s u r e s y m p t o m s or if it does n o t r e s p o n d to medical t r e a t m e n t . Adolescent goiter is not a serious co.ndition, and usually there is a n o r m a l basal metabolic rate. E x o p h t h a l m i e goiter in children u n d e r ten y e a r s of age ~ occurs in girls in a b o u t 95 per cent of cases. Surg e r y is seldom indicated, b u t the m e d i c a l t r e a t m e n t is p r o l o n g e d and exacting. F o c a l and general infections a p p e a r to h a v e an etiologic

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significance and should be t h o r o u g h l y treated. Toxic loci, however, should not be removed during the height of the syndrome, because of toxic shock and the danger of h e m o r r h a g e due to disturbed calcium metabolism. NEUROLOGIC CONDITIONS

An operative treatment of spina bifida which gives a mortality of only 5 per cent in a series of sixty cases is well worth reportingY ~ If there is no leakage of spinal fluid, the operation is p e r f o r m e d as soon as the infant has r e g a i n e d its birth weight, but if there is drainage, as soon as the sinus is closed; the reason f o r early operation being that 80 per cent of these children die d u r i n g the first year if operation is not performed. Most of the sac is saved because of easier closure and minimal disturbance of nerve roots, not because of any absorptive characteristics of the sac. F r e q u e n t p r e o p e r a t i v e tapping, sudden release or change of pressure, and infection stimulate secretion. The t u m o r should not be p e r m i t t e d to increase greatly in size. Postoperative h y d r o c e p h a l u s begins before the operation or is due to infection r a t h e r than to failure to c a r r y out careful postural t r e a t m e n t after operation. Paralysis is not a contraindication to surgery, as careful freeing of the nerves will allow improvement in f u n c t i o n which may become v e r y good. Neither is a b r o a d base with wide bony defect a surgical eontraindication. Low postoperative m o r t a l i t y depends upon conservation of b o d y heat and blood, p r e v e n t i o n of rapid loss of spinal fluid, short, light anesthesia, and maintenance of nutrition. One can but wonder as the success which is reported from widely varying methods of surgical t r e a t m e n t of this serious condition. It would seem t h a t p e r h a p s the f u n d a m e n t a l principle of t r e a t m e n t or the true u n d e r l y i n g physiopathologic condition has not y e t been formulated. It is to be hoped t h a t the p r o c e d u r e s described will prove at least equally p r o d u c t i v e of good results as f o r m e r ones, as the change will be in the interest of simplicity and reduction of hospitalization. W i t h the constantly increasing knowledge of the function of the sympathetic nervous system and the widening of the fields of application of that knowledge, possibilities of t r e a t m e n t are. unfolding which p e r m i t relief of m a n y conditions which f o r m e r l y were of necessity endured or t r e a t e d blindly, with v a r y i n g degrees of poor results. The sympathetic nervous system controls and regulates the body fun'etions and activities which are without the field of consciousness, and we take these f u n c t i o n s for g r a n t e d until some i n t e r f e r e n c e with the perfection of its eo.ntrol makes us acutely conscious t h a t something is wrong. Aimless attempts at correction have often served only to aggroavate conditions. This complex system with its cooperative antagonist, the p a r a s y m p a t h e t i c system, is the great adjuster' by virtue of which the b o d y is able to w i t h s t a n d the manifold insults, both internal and external, to which it is constantly subjected. It regulates the temperature, controls the sensory thresholds, is the. guar'diaa of the various sphincters, controls the filling" and emptying of innumerable cavities and containers, releases reserve stores and forces when emergencies arise, mobilizes defense mechanisms, and so on t h r o u g h an almost endless series of automatic activities. W h e n it fails to function or functions erratically, trouble ensues. A few of' its" cells go wild and a f t e r two or t h r e e months of gastrointestinal disturbance, anemia, fever, and a r a p i d l y developing abdominal tumor; an i n f a n t or small

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child dies; tile diagnosis is ~leuroblastoma of the adrenal or a d j a c e n t sympathetic ganglia, a~ The diagnosis is occasionally made b y the presence of metastases in the membranous bones, but the prognosis is n e a r l y 100 per cent fatal, and operation seems to hasten the end. H i r s e h s p r u n g ' s disease occurs when t h e r e is a disturbance of balance of the sympathetic system, the filling meeha3~ism of the distal half of the colon being' overactive. S y m p a t h e t i c irritability or stimulation tightens the sphincter and exercises a brake action on colonic peristalsis with the resultant picture of h y p e r t r o p h y and dilation of ~he distal colon, spasticity of the sphincter, and massive fecal accumulation. The results following' section of the sympathetic zler-ces to the distal colon are proving most satisfactorY. 6~ The functional results are excellent in the great m a j o r i t y of cases and relapses are rare, the occasional unsatisfactory outcome being p r o b a b l y due to some unsevered, abnormally located n e r v e filaments. A r a t h e r puzzling observation is to the effect t h a t although the functional improvement has been r e p o r t e d to be a p p a r e n t l y permanent, no corresponding anatomic r e t u r n to normal has occurred. As a diagnostic measure to determine the probable operative result, spinal anesthesia or injection of the l u m b a r sympathetic t r u n k m a y be used. The same p r o c e d u r e is of value for preoperative emptying of the. colon. Section of the inferior mesenteric and presaeral nerves instead of the lumbar sympathetic t r u n k eliminates any effect on the v a s o m o t o r control of the legs. In eases of long duration, a considerable amount of training m a y be necessary to establish normal habits of evacuation. Co.ntrary to f o r m e r ideas the s y m p a t h e t i c system is capable of t r a n s m i t t i n g sensory impulses u n d e r certain conditions of interruption of somatic nerve supply. 6~ The significance of this action is not yet f u l l y apparent. As is usual with a new procedure, s y m p a t h e t e c t o m y is being tried in a great v a r i e t y of conditions, in some of which it is proving disappointing. 6s Its value in spastic paralysis, for which it was. originally developed, is r a t h e r limited. In a n o r m a l l y intelligent child with m o d e r a t e spasticity of the lower limbs, it relieves a certain a m o u n t of the tension and makes walking somewhat easier. There is a tendency, however, to lose the i m p r o v e m e n t after a few years. I t is of little value in spasticity of the u p p e r extremities. In chronic arthritis where pain rather' t h a n j o i n t change is the m a j o r symptom, relief is often p r o m p t and striking. Diagnostic injections will give a f a i r l y accurate indication as to the amount of relief which m a y be exp e c t e d from operation. Good results are r e p o r t e d in eases of Still"s disease when the operation is p e r f o r m e d fairly early29 P e r h a p s the most satisfactory and spectacular results in children are seen in the cold, cyanotic limbs of infantile paralysis. The color becomes pink almost immediately; t h e - s e n s a t i o n of w a r m t h and comfort is most g r a t i f y i n g ; ulcers, infections, and incisions heal quickly, and there is even a slight i m p r o v e m e n t in bone growth. These results are most m a r k e d immediately after operation but are still excellent six years later. I~T~STINAL TaACT Abdominal symptoms suggestive of appendicitis may be caused by a Meekel's diverticulum. ~s The pain is usually localized higher than the right lower quadrant and may even be in the right hypogastrium. In

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2 p e r cent of the p a t i e n t s o p e r a t e d u p o n for appendicitis, the pathologic condition w a s f o u n d to be a M e e k e l ' s divertieulum, the a p p e n d i x being normall C o n t r a r y to the usual opinion, i n f l a m m a t i o n is n o t the most common cause of s y m p t o m s 6s arising f r o m a M e c k e l ' s diverticul u m ; h e m o r r h a g e r a n k s first, with intussusception second, and inflammation, o b s t r u c t i o n due to bands, volvulus, etc., third. Heter'otopie mueosa is f r e q u e n t l y present in these divertieula, gastric, jejunal, and p a n c r e a t i c tissue h a v i n g been found. Of these the gastric mucosa is responsible f o r h e m o r r h a g e since the glands secrete a n d the gastric r e g u l a t o r y m e c h a n i s m is absent. Ulceration caused not b y peptic digestion of the n m e o s a b u t b y the action of the hydr'oehlorie acid 7~ does not occur in the heterotop~c mucosa but in the ileae mucosa adjacent to it or at the neck of the divertieulmn. P a i n f r o m the ulcer follows t h e t a k i n g of food. Bleeding m a y be chronic or sudden and p r o f u s e the blood being of, the u p p e r intestinal t y p e r a t h e r t h a n of the c u r r a n t - j e l l y t y p e of intussusception: P e r f o r a t i o n is a serious complication, w h e t h e r occurring f r o m u l c e r a t i o n or f r o m inflammation, as p r o t e c t i v e p e r i t o n e a l adhesions do n o t ' o c c u r as r e a d i l y as in appendicitis; general peritonitis is the rtlle. W h e n the existence of a Meckel's diverticulum seems, reasonably probable, s u r g e r y is indicated. tIeter'otopie gastric mueosa m a y occur in d i v e r t i c u l a or enterogenous cysts o t h e r t h a n Mecket's, ~1 diverticula p r o j e c t i n g f r o m other p a r t s of the intestine and cysts being located in the a b d o m e n or mediastinum. The s y m p t o m s and signs of diverticula are similar to those ef 3/[eekel's. The cysts m a y be of sufficient size to cause pressure s y m p t o m s or to be seen in the r o e n t g e n o g r a m . U l c e r a t i o n m a y occur with subsequent h e m o r r h a g e , the. s y m p t o m s being' d e p e n d e n t u p o n the location of the cyst. P a i n is v a r i a b l e in location a n d intensity but often is r e f e r r e d to the navel or r i g h t u p p e r q u a d r a n t and associated with meals. The s y m p t o m s at times a r e suggestive of intussusception. F a c t o r s c a u s i n g intussuseeption in i n f a n t s 7~ are a b r u p t changes in d~et, cathartics, f o r e i g n bodies, and sudden d i s p r o p o r t i o n in caliber of the small a n d l a r g e bowel, to whieh m i g h t be a d d e d d i s t u r b e d balanee of the, visceral s y m p a t h e t i c nervous system. ~ A f o r t u n a t e situation existing in A u s t r a l i a m a y well be e m u l a t e d in other' countries; there the medical profession h a s become intussuseeption-eonscious w i t h the result t h a t late diagnosis is r a r e and the m o r t a l i t y r a t e e x t r e m e l y low. Reduction b y enema is v a l u a b l e in e a r l y eases. The t u m o r should a l w a y s be p a l p a t e d ; u n d e r pressure f r o m the enema it d i s a p p e a r s ; the loops of intestine i m m e d i a t e l y above become distended with fluid; the distention is general and s y m m e t r i c a l ; and the r e t u r n flow contains gas and feces. A s o m e w h a t similar p r o c e d u r e ~a consists in the reduction of the intussusception b y air pressure. The a i r is i n t r o d u c e d t h r o u g h the. anus a f t e r the a b d o m e n is opened a n d the mass is in the h a n d s of the s u r g e o n for p r o p e r control. The intussusception u,nro]]s well until the point or origin is r e a c h e d where edema m a y m a k e )nanual assistance necessary. Measures to p r e v e n t r e c u r r e n c e such as fixation of the cecum or ileum are unnecessary. I t is to be particul a r l y r e m e m b e r e d t h a t the enema t r e a t m e n t is d a n g e r o u s in late cases w h e r e portions of the bowel wall m a y h a v e been so devitalized as to r u p t u r e easily. I n irreducible cases, the m o r t a l i t y f r o m resection is so m u c h higher' t h a n w h e n i n t r a l u m e n a r slough and e v a c u a t i o n are p e r m i t t e d to t a k e place t h a t t~r'aser 4 is p r o m p t e d to r e m i n d us t h a t " N a t u r e ' s s u r g e r y surpasses the h a n d i w o r k of m a n . "

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In the treatment of intestinal obstruction, attention is being directed more to r e s t o r a t i o n of normal conditions b y assisting physiologic functions t h a n b y surgery. Studies show t h a t in high obstructions death is due to failure of secretio:ns from the u p p e r intestinal t r a c t to reach the lower TM and to the loss o f i m p o r t a n t blood electrolytes. ~5 There m a y b e either alkalosis or acidosis, and n u t r i t i o n is seriously impaired. S u r g e r y is often useless or contraindicated, and the condition m a y be relieved b y intravenous use of saline, R,inger"s solution, H a r t m a n n ' s solution, or glucose at a p p r o p r i a t e times as indicated b y blood chemi s t r y tests. ~6 Obstructio~ lower in the smali bowel causes m a r k e d loss of fluid b y increased secretion into the bowel, diminished absorption with demineralization, disturbed acid base balance, and n e u r o m u s c u l a r upset. H i g h enterostomy is not as effective as duodenal tube drainage. A f t e r low enterostomy is p e r f o r m e d or a duodenal tube. is in place, the bowel should be allowed to regain its normal function with a minimum of f u r t h e r interference f r o m the physician or nurse. Treatmerit directed t o w a r d restoration of peristalsis should be withheld until drainage is established, and in this connection it should be kept in mind t h a t intravenous h y p e r t o n i c saline stimulates peristalsis and glucose r e t a r d s it. W h e n obstruction is due to strangulation, s u r g e r y is obligatory and early diagnosis is essential to a favorable outcome. Resection is to be used only if absolutely necessary, and exteriorization is of doubtful practical value. In the t r e a t m e n t of paralytic ileus, ileostomy is usually a futile gesture., and drugs and h y p e r t o n i e sa]ixte have little value as peristaltic stimulants. Spinal or splanehnic anesthesia to paralyze the b r a k e action of the visceral sympathetics at times produces spectacular results, but it is of little, value in late toxic cases. Continuous drainage b y duodenal tube ~ is often a life-saving measu r e in simple, obstrnetion of the small intestine, p a r t i c u l a r l y of the adhesive type. I t is also excellent f o r improving the general condition p r e l i m i n a r y to operation. The insertion of the tube m a y take some time ; its position can be controlled b y x - r a y observations. There should be m a n y holes in the distal p o r t i o n of the. tube so that. the stomach as well as the duodenum will be drained. Hot. packs should be applied to the abdomen; fluid and n o u r i s h m e n t should be supplied b y intravenous injection of from. 3,000 to 4.;000 c.e. of saline and glucose daily; and peristalsis should be aided b y salivary stimulation b y ice, lemon juice, or chewing gum. In the relief of this f r e q u e n t l y f a t a l condition, the development of eontinnous duodenal drainage is the most outstanding recent advance. Continuous intravenous administration of fluid m a y be necessary in any condition where there is m a r k e d disturbance of fluid metabolism, TM an excellent solution for general use being 5 per cent dextrose in l~inger's solution. ~9 It protects the liver and kidneys, stimulates r e n a l activity, relieves dehydration, and supplies valuable n o n p r o t e i n constituents. I t is advisable to use insulin, from 8 to 10 units to each 25 grams of dextrose, to avoid the inhibiting effect on peristalsis. The choice of method w h e t h e r b y cannula or needle and the choice of the vein to be used will depend upon the individual preference and experience of the physician. A vein m a y become r e d d e n e d f o r an inch or two above the point of i n t r o d u c t i o n of the fluid a f t e r a few days. Such reaction is usually chemical r a t h e r t h a n bacterial, but it is an indication for change to a n o t h e r vein. I f glucose is being used alone,

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it should not be used continuously because it causes thrombosis, s~ The a t t e m p t to m a i n t a i ~ a solution at such a t e m p e r a t u r e in the container thas it will enter t h e blood s t r e a m at b o d y t e m p e r a t u r e is not only doomed to f a i l u r e b u t is unnecessary. The only p r e c a u t i o n necessary is t h a t the t e m p e r a t u r e of the entering solution should n e v e r b e m u c h above t h a t of the blood, and f o r all p r a c t i c a l p u r p o s e s r o o m t e m p e r a t u r e is satisfactory. In the g r e a t mass of l i t e r a t u r e r e l a t i n g to appendicitis, a t r e n d is b e c o m i n g a p p a r e n t to w i t h d r a w s o m e w h a t f r o m the position t h a t a p a t i e n t should be s u b j e c t e d to s u r g e r y as soon as the diagnosis of appendicitis is m a d e r e g a r d l e s s of the stage of the pathologic process at the time. A t h o r o u g h u n d e r s t a n d i n g of the p a t h o g c n e s i s of appendicitis 81 is n e c e s s a r y if the o p t i m u m time f o r surgical t r e a t m e n t is to be chosen. The f a c t t h a t a condition h a p p e n s to be surgical in n a t u r e is not a~ecessarily an indication for operation a n d the t r a d i t i o n which has m a d e the n a m e "appendicitis" a m a j o r surgical indication is outworn. I n the early stages w h e n the pathologic process is progressing and the a p p e n d i x is still the m a j o r focus of infection, its r e m o v a l is i n d i c a t e d even if p e r f o r a t i o n has o c c u r r e d a n d peritonitis is beginning. L a t e r when peritonitis or abscess is the m a j o r pathologic process, the r e m o v a l of an a p p e n d i x which has done its d a m a g e and r e t i r e d to a s e c o n d a r y position can do little if a n y good and in most instances will be a c t u a l l y h a r m f u l . T h e t r e a t m e n t of choice f o r an acute, violent, s p r e a d i n g peritonitis is not surgical t r a u m a , a n d the mere f a c t t h a t the process chanced to be initiated b y a p e r f o r a t i o n in the a p p e n d i x is n o t an a d e q u a t e r e a s o n f o r r e v e r s i n g the t r e a t m e n t of choice. Much of the confusion r e g a r d i n g the t r e a t m e n t of appendicitis has b e e n due to the failure to recognize the f a c t t h a t the t r e a t m e n t of appendicitis is not the t r e a t m e n t of peritonitis which m a y be a result of appendicitis, s2 The m o r t a l i t y f o l l o w i n g appendect o m y in the presence of general peritonitis varies f r o m 18 per cent to 50 p e r cent while t h a t following r a t i o n a l t r e a t m e n t of peritonitis is less t h a n ]0 p e r cent. F o w l e r ' s position tends to p r e v e n t distention, glucose in n o r m a l saline i n t r a v e n o u s l y reduces peristalsis and supplies fluid and nutrition. Other essential p a r t s of the t r e a t m e n t are h e a t to the abdomen, absolutely nothing b y m o u t h or b y rectum, sufficient sedation to give physical relaxation, e m p t y the stomach b y lavage, a n d use the duodena] tube f o r the relief of vomiting or u p p e r a b d o m i n a l distention. P a r a l y t i c ilcus, secoa~dary abscess, enterostomy, a n d fecal fistula are r a r e with this t r e a t m e n t . I t is difficult to accept loose s t a t e m e n t s r e g a r d i n g low resistance in children, f o r t h e y r e c o v e r f r o m other infections easily, s~ The mortality rises in p r o p o r t i o n to the time elapsed b e t w e e n the onset and operation in the acute cases. I n the l a t e r stages w h e n the process is localizing or has localized, delayed o p e r a t i o n is preferable. One e x p l a n a t i o n of the m a n y f a u l t y diagnoses of appendicitis is seen in the g r e a t n u m b e r and v a r i e t y of conditions, the s y m p t o m s of which have been said to resemble those of acute appendicitis. I n one lis~ no less t h a n f o r t y of these are e n u m e r a t e d , s~ I t is evident t h a t no clear conception of the actual picture of acute appendicitis based upon an u n d e r s t a n d i n g of the p a t h o l o g y could h a v e e~isted in the m i n d s of those who m a d e these comparisons. The t e n d e n c y to diagnose a n y condition which m a y be a c c o m p a n i e d b y d i s c o m f o r t in the lower a b d o m e n as acute appendicitis is the p r o b a b l e explanation.

38~

T H E J O U R N A L OF PEDIATRICS

T h e r e are of course a n u m b e r of conditions, the s y m p t o m s of which so closely resemble those of appendicitis t h a t differential diagnosis is e x t r e m e l y difficult and i.u some eases impossible, s~ b u t this n u m b e r is small as c o m p a r e d with forty. A p o l y v a l e n t serum m a d e f r o m several strains of tile colon g r o u p a n d anaerobic b a c t e r i a isolated f r o m bowel contents has been used in a small series of lat.e a p p e n d i e u l a r peritonitis cases, sG The m o r t a l i t y seems to be s o m e w h a t lower t h a n the a v e r a g e for this condition, but the series is considered too small to be conclusive. The. serum m a y be used intraperitoneally, intravexmusly, subcutaneously, or intramuscular~y, a n d it is r e c o m m e n d e d t h a t sensitization tests be made. I f such a s e r u m possesses a n t i t o x i c properties, it should p r o v e valuable in cases which are in need of t e m p o r a r y assistance d u r i n g the height of t o x e m i a ; but t h e r e should be no r e l a x a t i o n of the p r o v e d measures of t r e a t m e n t w i t h a t e n d e n c y to lean too h e a v i l y upon a possible .~eutralization of toxic products. The effect of i r r i t a t i o n a n d sear c o n t r a c t i o n upon the nerves of the a p p e n d i x m a y be seen in reflex d i s t u r b a n c e s in m a n y p a r t s of the body. s~ The period of i n f l a m m a t o r y r e a c t i o n is followed b y fibrosis in the submueosa, ss which m a y be so extensive as to cause cicatricial o b l i t e r a t i o n of the lumen. The c o n t r a c t i o n of the fibrous tissue upon n e r v e endings or u p o n severed ends of n e r v e s in an a p p e n d i e e a l s t u m p can p r o d u c e impulses c o m p a r a b l e to those o r i g i n a t i n g in the neurom a t a of an a m p u t a t i o n . Such impulses tra.nsmitted t h r o u g h the visceral s y m p a t h e t i c system m a y well cause gastrointestinal s y m p t o m s such as pylorospasm, constipation, diarrhea, disturbance of gastric s e c r e t o r y balance with ulcer production, spasticity of abdominal muscles, a n d general nervous a n d neurotic symptoms. Such a condition m a y explain the g r e a t d i v e r s i t y of s y m p t o m s ascribed to chronic appendicitis and also the occasional persistence of s y m p t o m s a f t e r appendectomy. A p p e n d i c i t i s in i n f a n t s b e t w e e n t w e l v e a n d eighteen months of age p r o b a b l y occurs with g r e a t e r f r e q u e n c y t h a n is commonly believed a n d p r e s e n t s u n u s u a l difficulties of diagnosis, s9 D u r i n g the periods of p a r o x y s m a l pain, the i n f a n t a p p e a r s v e r y ill but seems f a i r l y norm a l b e t w e e n them. Spontaneous p a i n is shown b y pseudotenesmus w h e n little or no stool is passed, a n d the presence of mucus is significant, Food will be t a k e n e a g e r l y f o r a short time and t h e n r e f u s e d w i t h a sudden scream. I n o r d e r to d e t e r m i n e the presence of tenderness, the i n f a n t should be p u t to sleep w i t h a sedative such as one of the b a r b i t u r a t e s and the left side p a l p a t e d first. The reaction to similar p a l p a t i o n on the r i g h t side is s h a r p and positive w h e n the a p p e n d i x is a c u t e l y inflamed. Coexisting pyelitis m a y complicate the picture. Distention is rare. An i n t e r v a l free f r o m s y m p t o m s m a y indicate perforation. The occasional f a i l u r e to localize tenderness to M e B u r n e y ' s p o i n t is due to the a b n o r m a l m o b i l i t y of tim cecum a n d the long a p p e n d i x characteristic of the age. A s t u d y of umbilical hernia 9~ brings out the fact t h a t in adults 16 p e r cent become s t r a n g u l a t e d , w i t h a m o r t a l i t y of 33 p e r cent. In children the o p e r a t i v e m o r t a l i t y i s p r a c t i c a l l y nil and only 11 per cent of u m b i l i c a l hernias require operation. I f the r i n g has not closed or shown s a t i s f a c t o r y r e d u c t i o n in size b y the age of eighteen months or if it still a d m i t s the tip of the little finger at two y e a r s of age, o p e r a t i v e closure is indicated. Excision of the umbilicus is unneces-

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sary. The tip of the little finger is a r a t h e r indefinite s t a n d a r d upon which to d e t e r m i n e the neeessity f o r surgery, and it would seem bett e r to set a definite age as, f o r example, t h r e e or f o u r years, a f t e r which nonsurgieal m e a s u r e s cannot r e a s o n a b l y be e x p e c t e d to succeed. I t m a y be s t a t e d definite]y that the. condition should not be p e r m i t t e d to exist b e y o n d childhood. The possibility of absorption of glueose b y r e c t u m in amounts sufficient to be of t h e r a p e u t i c value has been the subject of n u m e r o u s studies over a period of years. Recent o b s e r v a t i o n s in diabetic and nondiabetie p e r s o n s sl a p p e a r to p r o v e definitely that. it is absorbed in a p p r e c i a b l e quantities, a n d one ease of insulin shock was t r e a t e d successfully b y this m e t h o d of administration. The same conclusions have been r e a c h e d in a series of c a r e f u l l y controlled observations upon eolostomy patie.nts. 92 I n these p a t i e n t s conditions are ideal for such a s t u d y and the findings are r e m a r k a b l y exact and constant. On ~ceonnt of the location of the colostomy, the p o r t i o n of the colon studied was the distal segment which is the less a b s o r p t i v e half, b u t in spite of this f a c t absorptio.n v a r i e d f r o m 9 to 20 g r a m s in f r o m three to five hours. Other substances a b s o r b e d w e r e m e t h y l e n e blue, atropine, sucrose, a n d arseaqie. I n t h e t h e r a p e u t i c a d m i n i s t r a t i o n of glucose b y r e c t u m a b s o r p t i o n m a y well be expected to be m u c h g r e a t e r on account of the f a c t t h a t the solution can .pass easily into the t?roximal colon, one of the principal functions of which is absorption. G a l l b l a d d e r disease, f o r m e r l y t h o u g h t to be r a r e in children, is being r e p o r t e d w i t h increasing frequency. 93 B i l i a r y colic occurs as i,n a d u l t s ; there is tenderness over the gallbladder, r i g i d i t y of the. r i g h t rectus, p a i n at the umbilicus or in the u p p e r r i g h t q u a d r a n t , m o d e r a t e leucoeytosis, bile in the urine, and usually jaundice following" r e p e a t e d attacks. Chronic eholeeystitis m a y develop 94 f o r which eholeeysteet o m y is advised. I n infants the occurrence of a b d o m i n a l pain, fever, and leueocytosis is usually sufficient f o r a f a u l t y diagnosis of appendicitis, ss Stones m a y be f o r m e d before b i r t h and be associated with a congenital stenosis of the common duet. The bile in some instances is thick, the supposition b e i n g t h a t its increased consistency is due to muscular' i n a c t i v i t y during i n t r a u t e r i n e development. Opinions r e g a r d i n g the time. of election for the o p e r a t i v e t r e a t m e n t of eongenital d i a p h r a g m a t i c hernia v a r y . I f the i n f a n t s u r v i v e ; the firs~ month of life, when 75 p e r cent of the patients die, 9G the condition m a y continue t h r o u g h a d u l t life w i t h f e w symptoms, s t r a n g u l a t i o n being the chief danger. 97 C o n s e r v a t i s m as r e g a r d s s u r g e r y is counseled on the one h a n d and operation as soon as the general condition is good on the other. The operatioaa is r a t h e r a f o r m i d a b l e p r o c e d u r e but good results are r e p o r t e d in the f a v o r a b l e types. Diagnosis m a y be obscure f o r a time. but r o e n t g e n o g r a p h y is usually conclusive. The r o u t e of a p p r o a e h m a y be thoracic, abdominal, or a combination of the two, depending" upon the skill a n d p r e f e r e n c e of the surgeon. CJ:IEST AND LUNGS I n p u l m o n a r y abscess, ~s s u r g e r y is indicated if medical t r e a t m e n t fails. P n e u m o t h o r a x is aaot advised because of the d a n g e r of r u p t u r : ing the abscess into the pleural cavity. The medical t r e a t m e n t recomm e n d e d consists of rest, posture, and m e d i c a t i o n f o r a period of two or three months, a f t e r which such surgical p r o c e d u r e s as bronchoseopy,

386

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p n e u m o t h o r a x , pneumolysis, or t h o r a c o p l a s t y may be tried. It would a p p e a r t h a t there is little general a g r e e m e n t upon the t r e a t m e n t of this serious and disabling condition. B r o n c h o s e o p y should be used early to eliminate the possibility of a f o r e i g n body as an etiologic f a c t o r and to assist in removal of the contents of the cavity. Continuous postural drainage is often effective. The extremely disagreeable odor associated with most of these cases tends to minimize p r o l o n g e d bedside study. Nonopaque foreign bodies in air passages should always receive serious consideration in a n y case showing p r o t r a c t e d p u l m o n a r y symptoms2 9 I f seen early, the history is usually diagnostic. An asthmatic wheeze or other abnormal r e s p i r a t o r y noises suggest foreign body in the l a r g e r air passages. P a r t i a l obstruction causes reduced m.otility and emphysema while complete obstruction causes edema and collapse of the lung'. Vegetal bodies stimulate secretions markedly. In eases seen in the period immed}ately following the entrance of' the foreign body, the old r e m e d y of inversion and t h u m p i n g upon the back should be studiously avoided as impaetion of tile foreign body between the vocal cords m a y occur with r e s u l t a n t suffocation b e f o r e it can be ext r i c a t e d or a t r a e h e o t o m y p e r f o r m e d . Congenital p n e u m o t h o r a x is a r a r e condition, the cause of which is u n k n o w n 2 ~176 There is r e s p i r a t o r y embarrassment at b i r t h with cyanosis which m a y suggest a congenital h e a r t lesion; the x - r a y findings h o w e v e r are clear. The t r e a t m e n t which would seem l o g i c a l - aspiration of ~he a i r - - p r o v e d fatal in two cases. There was a sudden rush of air u n d e r pressure with collapse and death. Somewhat dif~ f e r e n t in behavior is congenital air cyst of the lung. T M There is i n t e r m i t t e n t cyanosis and dyspnea and the r o e n t g e n o g r a m shows a cyst outline. Repeated aspirations, removing 4,000 c.e. of air upon one occasion relieved the condition slowly. I n the discussion r e g a r d i n g the relative merits of open and closed d r a i n a g e in empyema, the eustora has been too p r e v a l e n t of r e p o r t i n g a series of cases all of which havc been t r e a t e d b y one of the two methods2 ~ The a t t e m p t has been made to force all cases to conform to one p r e d e t e r m i n e d t y p e of p r o c e d u r e regardless of individual differences, and, as a consequence, deductions and co.nelusions have been conflicting. Tt*e peaceful demise of this all too pointless diseussion will p r o b a b l y occur as a logical result of the increasing t r e n d t o w a r d b e t t e r knowledge of physiologic reactions, requirements of b o d y chemistry, pathogenesis of the disease, and the correlation of these factors in the s t u d y of the individual patient. Then will come the employment of open or closed drainage as individual conditions indicate. The realization of tile fact that the normal chest is a single cavity and t h a t the mediastinum is f r e e l y movable has b r o u g h t about a much more rational surgical t h e r a p y 2 TM ao~ The proportion of air going into a chest either t h r o u g h the t r a c h e a or t h r o u g h an exte)nal openhag depends upon the relation of the size of the trachea to t h a t of the opening. In the presence of an open thorax, i m p o r t a n t changes t a k e place during respiration. There is a comparative increase in the size of the affected pleural cavity ; there is a decrease in the amount of air entering" the lungs producing" a relative suffocation or anoxemia ; and there is shock from the motion of the mediastinum. To effect healing, the lung must e x p a n d and fill the pleural cavity a f t e r evacuation of the pus. This expansion takes place by the f o r m a t i o n of

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387

adhesions which creep slowly along the thoracic walls dragging the lung with them as t h e y progress, and not by the control of intrapulmonie or i n t r a p l e u r a l pressure. E m p y e m a is not an e m e r g e n c y and the operation of ehoiee should be done when tile pneumonia has subsided, when pleural adhesions have formed, and when the mediastinmn has become stabilized. The m o r t a l i t y r a t e is lower in the summer and in the w a r m e r sections of the country. I t is highest in the age group ~uder two years regardless of the m e t h o d of treatment. It is interesting to note t h a t the mortality follows the same age curve as in other s~rgieal infections in children, for example appendicitis. In general the closed method is b e t t e r for infants. They h a v e a lower vital capacity and should ha~ee close p e d i a t r i c supervision in the p o s t o p e r a t i v e as well as the p r e o p e r a t i v e period. Pa~eumothorax should be avoided. As r e g a r d s the infecting organism; pneumoeoeeus empyema is an end-produet and occurs secondary to the original p u l m o n a r y infection; streptococcus empyema, an accompanying eondition associated with other serious metastatic lesions, does not tend to localize, and the mediastinum remains unstable; staphylococcus empyema accompanies other staphyloeoeeie abseesses and is serious. The prognosis is based upon the following f a c t o r s : (1) age, (2) t y p e of infecting" organism, (3) virulence of the epidemie, (4) eomplieations or associated lesions, and (5) the general condition of the patient. GENITOURINARY CONDITIONS Malignant t u m o r s in children occur with g r e a t e r f r e q u e n c y in the k i d n e y t h a n in a n y other organ, 80 per cent occurring- in the first two years. The diagnosis of adenosareoma or Wilms's t u m o r 1~ is usually not made until the abdomen becomes enlarged, as pain is rare and u r i n a r y symptoms are usually absent. P y e l o g r a p h y is essential both for diagnosis and f o r information r e g a r d i n g the opposite kidney. B y the time the enlarged abdomen suggests the diagnosis, metastases have usually occurred and the prognosis is poor. R.eeurre.nee within a y e a r following n e p h r e e t o m y is the rule. I r r a d i a t i o n is of doubtful value as the radiosensitivity of these tumors is so variable. E m b r y o n a l adenoeareinoma 1~ is also practically symptomless. I f nephre.ctomy can be p e r f o r m e d before the capsule has been penetrated, the prognosis is fair. Neuroblastoma, a tumor' of the sympathetic nerve tissue of the suprarenal medulla is n e a r l y 100 per cent f a t a l within a few months. It occurs i~ infants and young children and is usually first a p p a r e n t t h r o u g h metastases. The expression " i n t r a v e n o u s u r o g r a p h y " should be supplanted by " e x c r e t o r y urography"~~ because of the development of substances f o r oral as well as intravenous administration. This diagnostic measure is of g r e a t v a l u e in lesions of the upper' u r i n a r y t r a c t and gives a f a i r l y accurate estimation of function. It is especially applicable to w o r k with children. Anomalies of the k i d n e y and uret.er f r e q u e n t l y cause obstinate pyuria, ~~ and a t h o r o u g h urologic examination should be made if careful medieal t r e a t m e n t does not p r o d u c e results within a month. Pyonephrosis occurring in one portion of a k i d n e y with double pelvis a a d u r e t e r can give a confused picture, including gastro-

388

TtIE

JOURNAL

OF P E D I A T R I C S

intestinal and u r i n a r y dysfunction with f e v e r and r e f e r r e d pains; the diagnosis will often depend upon the e x c r e t o r y urogram. Spina bifida occulta, causing enuresis or retention, is, at times an i m p o r t a n t fact in u r i n a r y d y s f u n c t i o n 2 ~ Pressure or traction on the nerves, due to f a t t y deposits, fascia, or fibrous tissue, may be of sufficient e x t e n t to require surgical relief. I f the symptbm is enuresis, operation m a y be postponed until a f t e r p u b e r t y , b u t retentfon is more serious on account of possible dilation of the u r i n a r y tract. All other causes should be carefully eliminated before advising' operation, and complete relief is obtained i~ only a b o u t 50 per cent of the cases. P e r s i s t e n t incontinence which is not a t r u e enuresis m a y be caused b y u r e t h r a l diverticula21~ Cystoscopy and c y s t o g r a p h y are necessary f o r diagnosis and surgical removal, or the use of sounds gives satisf a c t o r y results. B e f o r e renal s u r g e r y of a n y type is u n d e r t a k e n , a complete study of both sides is essential211 Some form of renal aplasia or hypoplasia is present o~ the side opposite the offending k i d n e y in an appreciable n u m b e r of cases, and u n d e r such conditions the t r e a t m e n t is necessarily conservative. The solitary k i d n e y is p a r t i c u l a r l y susceptible to disease. A welcome addition to the resources at our command for the treatment of hypospadias is due to the renewal of interest in Ombrhdanne'~s pouch operation212 Multiple stages are required, as is true of all forms of surgical correction of this deformity. The operations are perhaps easier for the general surgeon to p e r f o r m than the steps devised b y Blair ~13 there is less probability of lateral leakage with formation of accessory openings, b u t there' is slightly more risk of hair in the u r e t h r a and the appearance is at times so grotesque as to require cosmetic plastic surgery. The p r i m a r y object of the correction is, however, normal function, and this is attained in an unusually high p e r c e n t a g e of cases. Blair's p r o c e d u r e s make use of the available tissues m a m a n n e r which is physiologically more correct, and in the hands of this master plastic surgeon give, results which seem as n e a r physical and physiologic p e r f e c t i o n as is possible. The t r e a t m e n t of choice f o r hydrocele is. generally admitted to be excision, but w h e n this is contraindicated or seems inadvisable, sati s f a c t o r y results often follow the use of the injection of sclerosing solutions. T M This t r e a t m e n t is c o n t r a i n d i c a t e d in the presence of inf l a m m a t o r y reaction and has the d i s a d v a n t a g e of placing a destructive agent in uncontrollable p r o x i m i t y to i m p o r t a n t structures. Good results are r e p o r t e d following the use of 5 per cent s o d i u m m o r r h u a t e to which 0.5 per cent phenol is added f o r preservation, such an agent being definitely preferable to pure carbolic acid, which has been used at times in the past. One injection is usually sufficient although repetition m a y be necessary. The occurrence of undescended testis at birth has been variously estimated at from 10 to 30 per c e n t Y ~ The m a j o r i t y of these descend d u r i n g the first f e w weeks of life and additional ones up to the age of one year. A f t e r this h o w e v e r the chances of spontaneous descent are remote. Spermatogenesis m a y begin as early as the ninth y e a r but is r a r e l y complete before the f o u r t e e n t h , and operation m a y be

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p e r f o r m e d at a n y convenient time before puberty, p r e f e r a b l y from the ninth to the eleventh year on account of the small size and delicacy of the early childhood testis. W h e n the testicles cannot be found, the possibility of congenital absence is to be borne in mind. nG This condition cannot be differentiated f r o m complete cryptorchidism, until a f t e r puberty, and no a t t e m p t should be made to do so d u r i n g childhood. Secondary sex characteristics develop in the c r y p t o r c h i d but not in the anorchld. E n t h u s i a s m f o r the Torek operation f o r undeseended testis is steadily increasing. ~7 The excellence and p e r m a n e n c y of the end-results are so u n i f o r m l y s a t i s f a c t o r y that other methods of t r e a t m e n t are to be considered only in the mildest cases. Failures are due to technical errors. Torek considers it necessary to attach the testis directly to the fascia lata in order to take a d v a n t a g e of the blood supply which develops f r o m that structure. This is especially necessary if there is a t r o p h y or tension. I n extreme eases the testis m a y be b r o u g h t down kn successive stages, ~ls three months or more being allowed for l e n g t h e n i n g of the cord to take place between stages. W h e n the condition is bilateral, both sides m a y be t r e a t e d at one operation if time is a f a c t o r or such a course is otherwise desirable2 ~9 The technical difficulties of t h i s , p r o c e d u r e , however, are considerably greater t h a n when one testis is b r o u g h t down at a time. I~EFEREN CES I. Lanman, T.H.: Age of Choice for Operations of Choice in Infancy and Childhood) J. PEDZ~. 4: 107, 1934. 2. Myers~ T.: Surgery iu Relation to Pediatrics, Journal-Lancet 53: 409, 1933. 3. Sehulz, L : Suitable Time for Surgery in Children, Wisconsin M. J. 32: 820, 1933. 4. Fraser, J.: Twenty-l~ive Years of Progress in Pediatric Surgery: A Study in Contrasts, Glasgow M. J., August, September, 1933. 5. Saner, R. ]3.: Some Considerations in Treatment of Acute Suppuration, Lancet 2: 627, 1933. 6. Lilienthal, It.: Treatment With Irradiated Petrolatum~ Ann. Surg. 97: 927, 1933. 7. Jarman, R , and Abel, A . L . : Evipan: Intravenous Anaesthetic, Lancet 2: 18, 1933. 8. Miller, G.: Evipan: Preliminary Report on a New Intravenous Anesthetic, Canad. M. A. J. 29: 596, 1933. 9. Wood; P. M.: Coramine in Denarcotization an& Resuscitation: Preliminary Report, Am. J. Surg. 22: 86, 1933. 10. Campbell, M. ]~.: Caudal Anesthesia. in Children, J. Urol. 30: 245, 1933. i1. Herb, I. C'.: Present Status of Ethylene, J. A. M. A. 101: 1716, 1933. 12. Waldbott, G . L . : So-Called '~Thymie I ) e a t h " : Respiratory Sensitization to General and Local Anesthetic, Arch. Otolaryng. 17: 549, 1933. 13. Idem: So-Called '~Thymic I ) e a t h " : Pathologic Process in 34 Cases~ Am. J. Dis. Child. 47: 41, 1934. 14. Capper, A., and Schless, R . A . : The Thymus Gland and Thymie Symptoms, J. PEDI~T. 4: 573, 1934. 15. Henderson, ~ . S.: Arthrodesls in Joint Tuberculosis (editorial), Surg., Gynec. &l Obst. 57: 812, 1933. 16. Petter, C . K . : Rational Treatment of Bone Tuberculosis, J. Bone & J o i n t Surg. 15: 986, 1933. 17. Kite, J. tI.: Non-operative Versus Operative Treatment of Tuberculosis of Spine in Children: Review of 50 Consecutive Cases Treated by Each Method, South. M. J. 26: 918, 1933. 18. Freund, E.: Contribution to Question of Spinal F~sion in Tuberculous Spondylitis in Childhood, J. Bone & J o i n t Surg. 15: 752, 193~. 19. Miller, O . L . : Surgical Fusion of Tuberculous tIips in Children, Am. J. Surg. 20: 555, 1933.

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20. Bankhart~ A. S . B . : Treatment of Tuberculous Disease of the Hip Joint, Brit. J. Surg. 20: 551, 1933. 21. Freiberg, J. A.: Early Diagnosis and Treatment of Congenital Dislocation of tIip, J. A. h~. A. 102: 89, 1934. 22. lV[cCautey, 3-. S., Jr., and Xrida, A.: Early Treatment of Equlnus i n Congenital Club F'oot, Am. J. Surg. 22: 491, 1933. 23. Chollett, B. G. : Relapsed or Resistant Clubfoot of Early Childhood, 3-. A. M. A. 101: 1866, 1933. 24. Ballin, lV[.: Skeletal Pathology of Endocrine Origin, Ann. Surg. 98: 868, 1933. 25. Bromer, R. S.: Osteogenesis Imperfects, Am. 3-. Roentgenol. 30: 631, 1933. 26. Abel, A. L., Thomson, G., and Hawksley, L. IV[.: Generalized Osteitis Fibrosa: Case Successfully Treated by Removal of Parathyroid Tlumors, Lancet 2: 525, ]933. 27. Blount, W. P.: Early Orthopedic Treatment of Infantile Paralysis, Wisconsin lVI. J. 32: 693, 1933. 28. Jones, E . A . : Orthopedic Treatment of I n f a n t i l e Paralysis, New England J. l~ied. 209: 831, 1933. 29. Avellan, W.: Fractures of the Lower E n d of the Humerus in Children, Acts chir. Scandinav. (supp. 27) 73: 1, 1933. Abst. Internat. Abstr. Surg. 58: 148, 1934. 30. Speed, J. S., and Macey, H. B. : Fractures of Humeral Condyles in Children, 3-. Bone & J o i n t Surg. 15: 903, 1933. 31. Schwartz, R. P., and Young, F.: Treatment of Fractures of Head and Neck of l~adius and Slipped Radial Epiphysis in Children, Surg., Gynec. '&l Obst. 57: 528, 1933. 32. West, W . K . : Treatment of F r'~etures in Children by Use of Skeletal Traction, South. !VI. 3-. 26: 644, 1933. 33. Albee, F . H . : Trea• of Ostcomyelitis b y Bacteriophage, J. Bone & J o i n t Surg. 15: 58, 1933. 34. D'Here~le, F., and Rakieten, M . L . : Susceptibility of Hemolytic Staphylococci to Bacteriophage, 3-. A. M. A. 100: 1014, 1933. 35. Stout, B . F . : Bacteriophage Therapy, Texas State J. Med. 29: 205, 1933. 36. Feagles, H., et al.: Peptone Broth in Treatment of Raptured Appendix With Peritonitis, Northwest Med. 33: 249, 1934. 37. Tashian, S . H . " Pruritis Ani, Mobilization of Reticuloendethelial Cells as Aid to Cure, Northwest Med. 32: 106, 1933. 38. West, O . J . : The Reticuloendothelial System From P r a c t i t i o n e r ' s Viewpoint, Northwest Med. 32" 101, 1933. 39. Braun, A.: The Reinjection of I r r a d i a t e d Blood, Miinchen. reed. Wchnsehr. 80: 211~ 1933. Abst. Internat. M. Digest 22: 197, 1933. 40. Hancock, V. K,, and Knott, E . X . : I r r a d i a t e d Blood Transfusion in Treatment of Infeetions~ Northwest Med. 33: 200, 1934. 4]. Stewart, M . A . : New Treatment of Osteomyelitis: Preliminary Report, S u r g , Gynec. & Obst. 58: 155, ]934. 42. Dolman, C. E.: Treatment o f Localized StaphyIoeoeeie Infections With Staphylococcus Toxoid, J. A. IV[. A. 100: 1007, 1933. 43. Barnes, J . P . : Revdew of Modern T r e a t m e n t of Burns, Arch. Surg. 27: 527, 1933. 44. Peulek, R. M., Jr.: Treatment of Burns W i t h Especial Reference to Use of Gentian Violet, Tnternat. Clin. 1: 31, 1933. 45. Connell, J. H., et al.: Treatment of Burns W i t h Gentian Violet: Preliminary Report, 3-. A. IV[. A. 100: 1219. 1933. 46. Tidswell, F~.: Some Cerebral Tu'hlors; Experiences a t the Royal Alexandra Hospital for Children, 1Vi. 3-. Australia I : 280, 1933. 47. Carson, P. C., and Hellwig, C. A.: Multiple I n t r a c r a n i a l Tumors i~ Children; Suprasetlar Adamantinoma Associated W i t h Cerebral Glioma, Am. J. Dis. Child. 46: 119, 1933. 48. Davis, L.: Intracranial Tumors of Childhood, S. Clin. North America 13: 1019, 1933. 49. Torkildsen, A , and Penileld, W." Ventriculograpbic Interpretation, Arch. Neurol. & Psychiat. 30: 1011, 1933. 50. Egas Moniz- Cerebra] Angiography W i t h Thorotrast~ Arch. Neurol. & Psychiat. 29: 1318, 1933. 51. Yater, W. ~ . , and White, C. S.: Roentgenographie Demonstration of Arteriovenous Aneurysm by Means of Thorotrast, Am. 3-. M. Sc. 186: 493, 1933.

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52. Baumgartner, C. J.: Brachial and Thyroglossal Duct Cysts and Fistulas in Children, Surg., Gynec. & Obst. 56: 948~ 1933. 53. Bailey, K.: Clinical Aspects of Branchial Fistulae, Brit. J. Surg. 21: 173, 1933. 54. ~Iatthews, W . B . : Conge~dtal C'arti]aginous l~ests in Neck, Arch. Surg. 28: 59, 1934. 55: McNealy, R. S.: Cystic Tumors of Neck: Branchial and Thyroglossal Cysts, S. Clin. N o r t h America 13: 1083, 1933. 56. Harrower, g . G . : Treatment of Cystic Hygroma of Neck by Sodium Morrbuate, Brit. M. J. 2: 148, 1933. 57. ttanford, J. M.: Surgical Excision of Tuberculous Lymph Nodes of Neck. Report on 131 Patients With Followup Results, S. Clin. North America 13: 301, 1933. 58. Reeves, R . J . : Roentgen Ray Treatment of Tuberculous Cervical Lymph Nodes, South. IV[. J. 26" 558~ 1933. 59. Fitzsimmons, It. J.: Congenital Torticollis; Review of Pathological Aspects, New E n g l a n d J. IVied. 209: 66, 1933. 60. Cattell, R. B.: Thyroid Disorders in Childhood, New England J. Med. 209: 867, 1933. 61. Brain, L : Exophthalmic Goiter in Children of Ten and Under; Comments Based on Series of 102 Cases, Pennsylvania. M. J. 37: 45, 1933. 62. Kolodny, A.: Results of Surgery in Spina Bifida, J. A. M. A. 101: 1626, 1933. 63. Lewis, D., and Geschickter, C. F.: Tumors of Sympathetic ~ervous System; Neuroblastoma, Paraganglioma, Ganglioneuroma, Arch. Surg. 28: 16, 1934. 64. Mitchell, E. C., and Semmes, R . E . : Hirsehsprung's Disease: Its PathologicM Physiology and Apparent Cure of Two Cases Under Observation for Two and Three Years Following Sympathectomy, South. IV[. J. 26: 606, 1933. 65. Shaw, 1~. C.: Sympathetic System and P a i n Phenomena, Arch. Surg. 27: 1072, 1933. 66. ]~lothow~ P. G., and Swift, G. W.: Surgery of Sympathetic Nervous System; Review of 100 Sympathetic Ganglioneetomies, Am. J. Surg. 21" 345, 1933. 67. Robertson, D. E.: Sympathectomy in Children, Surg., Gynec. & Obst. 58" 312, 1934. 68. Boek, H. (Cologne): Iv[eckel's Diverticulmn, Zentralbl. f. Chir. 60" 1715, 1933. 69. Miller, l~. }t., and Wallace., R. ]:I. : Mecke] 's Diverticnlnm in Acute Abdominal Emergencies, Ann. Surg. 98: 713, 1933. 70. Dragstedt, L . R . : Ulcus Acidum of Meckel's Diverticulum, J. A. IV[. A. 101; 20, 1933. 71. Poncher, I~. G., and Milles, G.: Cysts and Diverticula of Intestinal Orgin, Am. J. Dis. Child. 45: 1064~ 1933. 72. Miller, E . M . : Acute Intussusception, Ann. Surg. 98: 706, 1933. 73. Montgomery, A. It.: intussusception, S. Clin. North America 13: 1117, 1933. 74. Best, R. R., Newton, L. A., and Meidinger, R.: Absorption in Intestinal Obstruction, Arch. Surg. 27: 1081, 1933. 75. Jenkins, H. P., and Beswiek, W. F.: Experimental ileus: Prolongation of Life for 70 Days A f t e r High I n t e s t i n a l Obstruction by Administration of Sodium Chloride and Nutritive Material Into Intestine Below Site of Occlusion, Arch. Surg. 26: 406, 1933. 76. Morton, J . J . : Treatment of Tntestinal Obstruction, New York State J. Med. 33: 1197, 1933. 77. Wangensteen, O. I-I., and Paine, J . R . : Treatment of Acute Intestinal Obstruction by Suction With Duodenal Tube~ J. A. M. A. 101: 1532, 193~. 78. Orr, T . G . : Management of Acute Abdominal Distention, Internat. J. Med. & Surg. 46: 109, 1933. 79. Horsley, J. S.: Intravenous Administration of Dextrose in R i n g e r ' s Solution, With Particular Reference to Its Use in Acute Abdominal Conditions, Ann. Surg. 98: 678, 1933. 80. Ramsey, 1% B.: Constant Intravenous Administration of Fluid, Venoclysis, S. Clin. N o r t h America. 13: 631, 1933. 81. Jackson~ E . W . : Treatment of Perforative Appendicitis With Pathology and Pathological Physiology as Basis, Kentucky M. J. 31: 471, 1933. 82. Potter, E. B , and Coller, F. A.: Treatment of Peritonitis Associated With Appendicitis, J. Michigan M. Soe. 32: 573, 1933.

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83. Maes, U., I.~oyee, F. F., and McFetridge, E. M.: Acute Appendicitis in Clfildhood With Critical Analysis of 250 Cases, Surg., Gynec. & Obst. 58: 32, 1934. 84. Easton, E. R.: Unusual Condition Simulating Acute A p p e n d i c i t i s - - V i n c e n t ' s Angina, Am. J. Surg. 22: 74, 1933. 85. FTaser, I.: Acute Appendicitis: Some lvlistakes of Diagnosis~ Brit. M. J. 1: 310, 1933. 86. Pries~ley, J. T.: Serum Therapy as A d j u n c t to Surgical Treatment of Appendicitis W i t h l~upture and Peritonitis: Preliminary Report s Proc. Staff. 1V[eet., Mayo C]in. 8: 753, 1933. 87. Freeman, L.: Obliterating Appendix as Cause of Disturbances Connected With Abdominal Nerves and Lymphatics, Colorado Med. 30: 320, 1933. 88. Williams, B. W , and Boggon, i~. I~.: Mechanics of Appendicitis, Lancet 1: 9, 1934. 89. Flusser, E.: Diagnosis of Appendicitis in Children Aged One to One and OneH a l f Years, Miinchen. reed. Wchnschr. 80: 609, 1933. Abst. Internat. S. Digest. 16: 118, 1933. 90. Miller, R. H., and Bartlett, M . K . : Umbilical Hernia, New England J. Med. 209: 565, 1933. 91. Collens, W. S., and Boas, L. C.: Absorption of Dextrose by Rectum, Arch. Int. Med. 52: 317, 1933. 92. Curry, F . S . : Studies on Absorption and Excretion in Segments of the Colon of Man, Proc. Staff Meet., Mayo Clin. 9: 386, 1934. 93. McClendon, S . J . : Gallstones in Children; Case Diagnosed by Roentgen Examination, Am. J. Dis. Child. 45: 584, 1933. 94. Sheldon, W., and Edwards, H. C.: Chronic Cholecystitis in Boy Aged Ten Years, Lancet 1: 82, 1934. 95. Shawan, It. K., and Long, E. C.: Gallbladder Disease in Young Children, Am. J. Surg. 2 t : 43, 1933. 96. Barrett, N. R., and Wheaton, C. E . W . : Pathology, Diagnosis and Treatmcnt of Congenital Diaphragmatic Hernia in Infants, Brit. J. Surg. 21: 420, ]934. 97. Abt, I . A . : Disorders of Diaphragm in I n f a n c y and Childhood, M. Clin. North America 17: 385, 1933. 98. Abrams, A. B.: Mesenteric Vascular Occlusion, J. M. Soc. New Jersey 30: 564, 1933. 99. Schenck, C . P . : Nonopaque Foreign Bodies in Food and Air Passages, Ann. Otol., Rhin. & Laryng. 42: 1128, 1933. 100. Barbour, P . F . : Congenital Pneumothorax, Kentucky M. J. 31: 499, 1933. 101. Croswell, C. V., and King, J . C . : Congenital Air Cyst of L u n g ; Report of Case, J. A. M. A. 101: 832, 1933. 102. Tomaiuoli, M.: Treatment of Acute E m p y e m a : I n s t r u m e n t for Closed Drainage, Am. J. Surg. 21: 289, 1933. 103. Bettman, R. B.: Treatment of Acute Empyema, S. Clin. North America 13: 1101, 1933. 104. Bohrer, J . V . : Acute Empyema in Children, Ann. Surg. 100: 113, 1934. 105. Harrah, F . W . : Embryonal Sarcoma of Kidney in Children, With Report of Two Cases, J. Urol. 29: 445, ]933. 106. lV[ostrom, tI. T., and West, J. C.: E m b r y o n a l Adenocarcinoma of Kidney in Childhood, Illinois 1VI. J. 65: 21, 1934. 107. Braasch, W . F . : Practical Application of Excretory (Intravenous) Urography, J. A. M. A. 101: 1848, 1933. 108. Campbell, M. F.: Hemipyonephrosis in I n f a n t s and Children; Treatment by tIeminephrectomy, Am.. J. Surg. 21: 85, 1933. 109. Mertz, H . O . : Relation of Spina Bifida Occulta to Neuromuscular D.ysfunctlon of TJrinary Tract, With Review of Six Cases Operated b y Laminectomy, J. Urol. 29: 521, 1933. 110. Campbell, M. F.: Diverticula of the Urethra, Y. Urol. 30: 113, 1933. 1!1. Gutlerrez, R.: Surgical Aspects of Renal Agenesis, With Special Reference to I~ypoplastic Kidney, Renal Aplasia and Congenital Absence of One Kidney, Arch. Snrg. 27: 686, 1933. 112. I~yle, H. 1LI. M.: Omhr6danne~s Pouch Operation for /~Iypospadias, Ann. Surg. 98: 513, 1933. 113. Blair, V. P., Brown, J. B., and tIamm, W. G.; Correction of Scrota] tIypospadias and of Epispadias,'Surg., Gynec. & Obst. 57: 646, 1933.

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114. Floyd, E., and Pittman~ J . L . : Injection of Hydrocelcs With l~lewer Sclerosing Solutions; Experimental Study~ J. M. A. Georgia 23: 63~ 1934. 115. Counseller, u S.: Cryptorchidism: Treatment and Results in 100 Cases, J. Urol. 30: 327, 1933. 116. Idem, and Walker, ~r A.: Congenital Absence of Testes (Anorchia), Ann. Surg. 98: 104, 1933. 117. Burdick~ C. G., and Coley, B . L . : ISndeseended Testicle: Comparison of End Results of Torek's Operation as Contrasted W i t h Former Methods of Operation, Ann. Surg. 98: 495, 1933. 118. Aria, A. E . W . : Advantages and Applicability 9.f Torek Orehiopexy for Undescended Testis, Am. J. Surg. 23: 133, 1934. 119. Walters, W., and Love, J. G.: Torek Operation for Cryptorehidism, S. Clin. North America 13: 948, 1933.