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Thirty-one infants less than a year of age underwent surgery for correction of pernicious gastroesophageal reflux. Severe growth retardation from persistent vomiting was the single most important indication for surgery (25 patients). Recurrent aspiration penumonitis was another serious sequella of reflux and necessitated surgery in six patients. The diagnosis of gastroesophageal reflux was confirmed by barium swallow in all children, and in 17 a concomitant hiatal hernia was demonstrated. Patients selected for surgery were first treated conservatively unless they showed significant esophagitis or had a major portion of stomach in the chest. Babies treated early in the series had Allison repairs (7 transabdominal, 2 thoracic). Twenty-two subsequent patients have had Nissen fundoplication, and two gastropexies were performed. In 15 patients, significant gastric outlet obstruction required a complementary pyloroplasty. Four infants required a second surgical procedure because of recurrence. Two of the four patients had Nissen procedures with good results, one following a Boerema gastropexy and one following an Allison repair. The other two patients needed revision after fundoplication. There was no mortality. Twenty-eight children have been followed 6 months-8(1/2) years. All have excellent nutritional status and are following normal growth curves. Study of these patients indicates the need for early diagnosis and medical or surgical therapy for all infants with major gastroesophageal reflux.

BILIRUBIN metabolism and excretion in children with biliary atresia is complex and poorly understood. Jaundice may not be apparent until the infant is three or four weeks of age. Rarely, as in a case reported by Sterling,1 the jaundice disappears, and for weeks the serum bilirubin levels are normal. Usually, however, the serum bilirubin levels continue to rise for several weeks after birth and thereafter remain relatively stable. Like the normal infant, the child with biliary atresia is continuously producing bile pigment from the breakdown of hemoglobin. Since the serum bilirubin levels do not continue to rise one must assume . . .

There is constantly a better understanding of the variety of congenital malformations of the genitalia which comes under the heading of intersexual abnormalities. Prompt recognition of these anomalies can now lead to correct sex assignment shortly after birth, minimizing the anatomical, psychological and social problems for these individuals in later life. For female babies born with an enlarged clitoris, total clitorectomy has become an established procedure. It has been shown that the clitoris is not essential for adequate sexual function, but its preservation would seem to be desirable if this could be achieved while maintaining satisfactory appearance and function. Operations to reduce or cover the enlarged clitoris without removing it have been suggested in the past, 1–3 Certain drawbacks of these procedures have prompted our search for a surgical technique which would preserve the clitoris in its anatomical position, yet permit the reconstruction of normal female contours during the important growing years of childhood. An operation has been devised which we believe meets these requirements. Our experience with this procedure over the past five years and its postoperative evaluation in female patients is reported here.

IN the recent literature considerable attention has been paid to recognition and management of obstructions at the bladder neck in children. This condition is relatively uncommon when compared to the numerous other anomalies of the urinary system, but it is highly important to detect, since it can insidiously lead to extensive destruction of kidney and excretory tracts. It is now known that the institution of appropriate therapy can effectively ward off renal damage and minimize superimposed infection. The entity has been recognized and described for decades, but it has not come into focus until the past few years. In 1915 . . .

1. A method of gastric analysis has been developed for the study of newborn infants. Results obtained with this method have shown it to reflect more accurately the ongoing secretory activity of the stomach. Previous methods of sampling left significant and varying amounts of acidity behind in the stomach rendering much of the available data inconclusive. 2. For the first time, gastric function has been correlated with specific disease states in the infant. 3. The volume, pH, total acidity, chloride content, and pepsin activity have been found to vary independently of one another. 4. Pneumonia and bronchiolitis, two conditions producing compromised respiratory function, were characterized by decreased total acidity, a more alkaline pH, and decreased pepsin activity. 5. Infants with short gut after bowel resection displayed highly significant increases in total gastric acidity and rate of acid formation, and a lower gastric pH. 6. Infants with acyanotic congenital heart disease showed significantly decreased pepsin content and increased chloride concentration despite normal acidity. Conversely, the few infants with cyanotic congenital heart disease studied had decreased volume of gastric juice and rate of acid formation.

Twenty infants with intractable diarrhea, whose onset was before 3 months of age, were analyzed. Twelve had identifiable pathological entities sufficient to explain their protracted diarrhea. A systematic diagnostic scheme for such babies is presented. Eight of the 20 infants had no identifiable cause for diarrhea of such severity and refractoriness, and these babies were termed non-specific enterocolitis. Six of these latter eight babies died and at autopsy had widespread enterocolitis with destruction of the mucosa and inflammatory infiltration. The authors believe that in these latter cases, regardless of the initial cause of the diarrhea, certain vicious cycles came into play which perpetuated the diarrhea. Preliminary evidence suggests that colostomy and, perhaps adrenal corticosteroids, may be useful in the therapy of refractory enterocolitis, particularly if applied before the terminal stages of the disease.

A clinical staging of patients with neuroblastoma is proposed. Such staging is desirable to aid in estimating the prognosis and to be able to evaluate the efficacy of differing therapeutic regimens by analyzing results obtained in comparable groups of patients. That the suggested staging is practical is illustrated by the ease with which 100 children with neuroblastoma, entered in previous studies by Children's Cancer Study Group A, were staged using the criteria described. Short-term survival data of this small sample demonstrated, in addition, that the proposed staging appears to be of help in estimating the prognosis. Also proposed is a list of investigations which aid in accurate staging.

The treatment of 27 infants presenting with omphalocele or gastroschisis was analyzed. Several different methods of therapy were available, but various treatment plans were chosen on an individual basis. The defects were classified according to the size of the anomaly, the presence or absence of sac rupture, and the presence of coexisting abnormalities. Infants with intact omphalocele sacs less than 5 cm in diameter were best treated by surgical closure of the musculofascial defect or by skin closure alone. Intact omphaloceles over 5 cm in diameter or those associated with other life-threatening anomalies were treated conservatively with local applications of mercurochrome. Ruptured omphalocele or gastroschisis required immediate surgical coverage. If skin closure was not possible, a plastic prosthesis of Silastic covered Marlex was useful as a temporary cover for the exposed intestine. Infectious complications from the exposed prosthesis were minimized by the use of 0.5% silver nitrate dressings. An overall survival rate of 70% was obtained using the most appropriate treatment plan for the particular anomaly.

The concept has been put forth that "brain death" constitutes the true death of the patient, regardless of supported cardiorespiratory function. This premise has not been uniformly accepted by the medical profession or the laity. The study presented evaluates opinions of 100 lay persons and 100 physicians as to their concept of death. In addition, a group of 70 freshman medical students were interviewed representing the transition from the lay to the medical orientation. Forty-six percent of the physicians, forty-two percent of the freshman medical students and sixty percent of the lay people did not consider brain death an adequate definition of cessation of life. It would appear that the classic concept of death is ingrained in the majority of the laity as well as a sizable percentage of the medical profession. This has important connotations for the field of organ transplantation and for individual situations which evoke crucial decisions about the cessation of artificial support of individuals in various clinical states. It is important that the medical profession as a whole assess the facts and standards which have been recommended from reliable sources on the subject of irrevocable death, so that some unification of thought will be realized. Only then can public education proceed, minimizing confusion, doubt, and misplaced hope.

Acute hepatic ischemia induced by hepatic artery ligation and mesentericcaval shunt resulted in hepatic failure and death within 72 hr in seven control pigs. Heterotopic hepatic transplantation from unrelated donor shoats was carried out 24 hr subsequent to hepatic ischemia in seven experimental animals. There was one technical fatality. The surviving six animals had gradual return of intrinsic liver function permitting safe removal of the hepatic allograft after 212-5 wk. Sequential 99m technetium scans of the dual-liver system were used to evaluate the relative integrity of the native liver and hepatic allograft, and consequently the timing of transplant excision. The results of this study suggest temporary auxiliary liver transplantation may warrant clinical trial in children with lethal, but potentially reversible, liver failure.

Elevated pH in the gastric contents of babies immediately after birth suggests the presence of alkaline amniotic fluid in the stomach of the fetus. After the stomach had been lavaged, a strongly acid secretion was immediately noted, implying that the secretory ability of the gastric mucosa is unimpaired immediately after birth. Therefore, no delay in the onset of oral feedings based on poor gastric functioning seems warranted. Infants born by Cesarean section and not subjected to abdominal compression by the birth process had an even more alkaline gastric residuum at birth, suggesting the presence of excessive amniotic fluid in the stomach of these babies. The recommendation that babies' stomachs be emptied immediately after Cesarean section seems justified to avoid an increased hazard from vomiting and aspiration. This has proved an innocuous and beneficial procedure in our hands.

The morbidity and mortality of cystic fibrosis are consequences of chronic endobronchial obstruction. To retard or reverse the pulmonary complications, we have evaluated bronchoscopy and bronchial lavage with acetylcysteine ∗ ∗Mucomyst, Mead Johnson Laboratories, Evansville, Ind. in the management of these children. Two groups have been treated: (1) a stable group in whom treatments were elective, and (2) those critically ill with advanced pulmonary insufficiency treated on an emergency basis. Our experience with 270 procedures in 100 patients forms the basis of this report.

EARLY in the surgical history of congenital pyloric stenosis, the operative approach was involved and often complicated. The infants who were brought to surgery were seriously depleted and many weeks past the age that the diagnosis is made today. Formal laparotomy was the standard procedure through a generous paramedian incision (Fig 1, A ). 1 Because of the debility of the tiny patient and the less sophisticated replacement therapy, wound dehiscence, evisceration, and death occurred all too frequently. To this distressing clinical problem, Robertson 2 brought a fresh look when he conceived the right-upper-quadrant, musclesplitting incision. This surgical incision was a counterpart in the upper abdomen of the McBurney incision in the right lower quadrant (Fig 1, B ). Recognizing wound healing as a major cause of death in these desperately ill infants, Robertson demonstrated that if the lateral abdominal musculature were split in fiber direction, the external and internal oblique muscles

Previous reports have suggested the usefulness of gastric division in premature infants or in critically ill infants with esophageal atresia and tracheoesophageal fistula. 1–3 Division of the stomach has also been applied in certain infants with complications of an esophageal anastomosis where it has proved a satisfactory alternative to cervical esophagostomy and abandonment of esophageal function. Although the advent of intravenous hyperalimentation has altered the critical need for early intestinal feeding in these infants, it has not supplanted use of the intact intestinal tract. This report relates our experience with gastric division in caring for infants with specific problems or complications relating to esophageal discontinuity.

There is still an inordinately high mortality rate in newborns who have lost large amounts of bowel from midgut volvulus, multiple congenital atresias or other mechanical problems requiring major resection of intestine. In 1952, Clatworthy 1 showed that some puppies can survive major intestinal loss because of their remarkable capacity to increase absorptive surface. Unfortunately, many infants as well as experimental animals succumb to intractable diarrhea and devastating inanition following major enterectomy before such intestinal compensation can occur. In 1960, Craig and Stewart 2 reported the unexpectedly bland course of a patient undergoing massive intestinal resection who had had a subtotal gastrectomy years before. It was postulated that the mechanism of survival was the control of gastric hypersecretion. In 1964, Frederick and Craig 3 demonstrated in laboratory animals and patients that operations which decreased gastric secretion favorably affected subjects undergoing major small bowel resection. In 1966, Avery and Randolph 4 showed that infants who have suffered major intestinal loss responded like adults with a marked increase of gastric acid. These facts suggest that an operation which limits gastric secretion might have a salutory effect on the mortality and on the growth of immature subjects deprived of a major part of their intestine. To test this hypothesis an experiment was designed to determine the effect of vagotomy and pyloroplasty on the growth and survival of puppies subjected to standardized enterectomy.

Incidental appendectomy is regarded by many as a worthwhile complementary procedure during laparotomy. Since the majority of cases of appendicitis occur in the childhood years, 1 incidental appendectomy seems especially desirable in pediatric patients. The fear of unnecessary contamination and possible infection has generated reluctance on the part of some surgeons to carry out complementary appendectomy. It is undoubtedly true that some bacterial contamination occurs with transection of the appendix. An ideal technic for elective appendectomy would completely eliminate contamination without increasing the dissection or prolonging the operative time. Total inversion of the appendix satisfies these criteria. Once denuded of its mesoappendix, the appendix can be turned inside out into the lumen of the cecum. If the blood supply is interrupted, the entire appendix will subsequently slough innocuously into the cecum. At no time is the lumen of the intestinal tract opened. During the past three years, 108 patients at the Children's Hospital in Washington, D. C. undergoing abdominal surgery for a variety of conditions, had incidental appendectomy by inversion of the appendix. The purpose of this paper is to report the application, technic, and results of this method of appendectomy.

A case of congenital agenesis of the trachea with esophagobronchial fistula is presented and the literature on the subject reviewed. A therapeutic plan is proposed for the management of this lesion in the immediate postnatal period.

Although there are other books dealing with the acute abdomen, this volume will be welcomed because it represents the experience of a major American general hospital widely known for its accident and emergency facilities. The Acute Abdomen is dedicated by the medical staff of the Wayne County General Hospital to the memory of Dr. Wayne W. Glas and contains much of the surgical thinking of the Department of Surgery which Dr. Glas directed for many years.

The introduction of antibiotics two decades ago made it appear that empyema would pass into history as a surgical and medical problem. However, there has been an increase in the incidence of childhood empyema in recent years. 1-3 Today, childhood empyema is a common complication of staphylococcal pneumonia; Koch and coworkers reported a 74% incidence of empyema in 83 cases of staphylococcal pneumonia in children. 4 Kevy and Lowe reported empyema associated with 10 of 11 cases of streptococcal pneumonia. 5 In spite of this increase in the incidence of childhood empyema, many surgeons who treat adult empyema are not familiar with the course of this disease in children. Empyema in children is almost always seen following a primary pulmonary infection. Since the introduction of antibiotics, empyema in adults is most often associated with malignancy or an operative procedure. In addition, the management and prognosis of childhood empyema differ from

This book is a collection of 12 papers from six neonatal surgical units. These papers were presented for a postgraduate course in pediatric surgery in Liverpool, England, in July 1970. They were subsequently revised and edited by the speakers for publication. The articles represent the current philosophy and methods of surgical management of various neonatal problems at different institutions. An historical overview of pediatric surgery as a specialty introduces the clinical material. No attempt is made to cover all categories of pediatric surgery, nor to describe all the recent advances, in even a specific field. Most chapters start with an abbreviated table of contents including selected references; a summary in French and German follows the English presentation. The articles vary in quality and value for the practicing surgeon. The chapter on advances in postoperative management of newborns is devoted primarily to the technique of parenteral hyperalimentation, with a brief consideration