An infant with the rare association of colon atresia, total colonic Hirschsprung's disease, and tetralogy of Fallot is presented. While Hirschsprung's disease associated with atresia of the colon has been reported five times previously, this is the first case with associated congenital cardiac disease. As in previous reports, initial operations to relieve obstruction due to the colon atresia failed because of the unrecognized aganglionosis. This infant initially had an ileostomy performed as a newborn and then two failed attempts at closure of the ileostomy. In this case, as in four previously reported cases, histological examinations of resected colon from the initial operations were first reported as normal and only under the pressure of increasing clinical evidence was the pathology reviewed and the absence of ganglion cells appreciated. We stress the importance of suspecting the coexistence of Hirschsprung's disease and colon atresia when a functional obstruction is present after repair of the atresia.

We reviewed 187 cases of documented neonatal necrotizing enterocolitis (NEC) from 1976 to 1988. Of these patients, 111 infants underwent celiotomy for acute surgical complications. The following protocol of operative indications was employed: pneumoperitoneum, localized mass, abdominal wall erythema, portal venous air, and clinical deterioration, singly or in any combination. Clinical deterioration was defined as falling platelet count, rising or falling white blood cell count, left shift in the myeloid series, persistently or progressively low pH, and increasing frequency of apnea or bradycardia. Overall mortality was 15% (28 of 187). For the patients who underwent celiotomy, all had histologic confirmation of NEC. Ninety-five had localized disease, and 16 had diffuse disease. All of the former had resection and diverting enterostomy with 85 (89.5%) surviving; none with diffuse disease survived, P less than 0.0001. Forty-one infants with NEC weighed less than 1,000 g; 25 underwent surgery and 15 (60%) survived. Fifty-one of the 159 surviving neonates (32%) developed intestinal strictures. All neonates with strictures have had resection and successful reconstruction of their gastrointestinal tract. These indications and surgical principles resulted in a high degree of diagnostic accuracy and a low degree of surgical mortality.

Intraoperative radiation therapy (IORT) is a relatively new mode of cancer treatment which is being used with increasing frequency. IORT presents several challenges to the anesthesiologist, including patients who are debilitated from their disease or chemotherapy, operations involving major tumor resections, intraoperative interdepartmental transport of patients, and remote monitoring of patients during electron beam therapy. This report discusses the anesthetic management of ten children undergoing IORT. With adequate preparation and interdepartmental communication, complications can be avoided during these challenging cases.

One of the following procedures was carried out in 112, 200-gr, Sprague-Dawley rats: (A) sham operation, (B) hemisplenectomy, (C) 90% splenectomy, (D) total splenectomy and autologous spleen transplants in either omental, muscle, or subcutaneous pouch after total splenectomy, and (E) homologous splenic transplants after splenectomy. The rats were challenged intravenously with sheep, cat and guinea pig erythrocytes 6wk, 3 mo, and 6 mo postoperative. All totally splenectomized rats had significantly reduced primary responses, regardless of whether fragments of splenic tissue had been grafted or not. There was initial lowering of primary response in partially splenectomized animals but they responded significantly better than totally splenectomized rats. After 6 mo the primary response in the hemisplenectomy group was not significantly different from the nonoperated control group. The primary response in the 90% splenectomy group had improved significantly when compared to the total splenectomy group and normal controls. Total splenectomy and partial splenectomy did not appreciably reduce the ability to mount secondary and teritary responses.

Severe neonatal hypoglycemia with pathologic findings of diffuse nesidoblastosis of the pancreas is described in five children of both sexes from two families with unaffected parents. This appears to represent an autosomal recessive disorder of pancreatic development. Despite extensive testing, the diagnosis of hyperinsulinism was difficult in the index case of each family and delayed definitive treatment. Medical therapy with steroids and diazoxide was unsuccessful; pancreatectomy was required to treat persistent hypoglycemia. An abnormality of circulating glucagon found in one child with this disorder suggested that hyperinsulinism may not be the sole hormonal imbalance present, but rather that this disease is one of generalized disturbance of islet cell function. The history of severe, persistent neonatal hypoglycemia in an older sibling should lead the physician to investigate subsequent children for the presence of asymptomatic hypoglycemia.

This is a report of the gray scale ultrasound findings of pancreatic carcinoma occurring in a child. Although this tumor is rare, the preoperative diagnosis can be made if the physician is aware of this possibility. 99 mTc sulfur colloid radionuclide scan, liver spleen scan, gallium scan, and ultrasound examinations are helpful in distinguishing the site of origin of upper abdominal masses.

The following conditions were surgically created in fetal lambs at the gestational ages of 80 to 90 days: (1) preductal coarctation, (2) postductal coarctation, (3) pulmonic stenosis, and (4) constriction of the ductus arteriosus. Studies performed at the time of delivery showed the following: Preductal coarctation and postductal coarctation often are associated with a dilated ductus arteriosus that remains patent. Pulmonic stenosis often results in prestenotic and poststenotic dilatation that may include the ductus arteriosus. The fetal ventricles become hypertrophied in response to the increased pressure work imposed by the distal stenoses.

Etiology, clinical presentation, medical treatment, and surgical management of neonatal necrotizing enterocolitis are evaluated. With early diagnosis and vigorous therapy, survival should approach 75 per cent in nurseries where there is close liaison between neonatologist, surgeon, and consultants.

page 90 even though it could be easily produced in a quarter of a page or less. The complex table on page 228 still contains many of the artist's blue construction lines and is nearly undecipherable. Pages 192 and 193 are covered with a mass of figures carefully reproduced in columns designed to show the frequency ofcytotoxic antibodies among mothers with abnormal pregnancies. Even superficial examination reveals that the samples are so small that any numbers would be totally meaningless. Virtually all of the percentage figures cluster about 33.3, 50, 66.7, and 100 percent, since the groups rarely consist of more than four samples. Adding a significant figure to the right of the decimal point in such small series is the final irony. Clearly all of these errors of content and editing were not due to inordinate haste in production since the review copy was received approximately 2'? years after the symposium was held. This single volume contains examples of all of the undesirable features of a small symposium that has been committed to print without adequate focus, editing, or attention to production. Let us hope that the memory of Charles Mott is not predicated on this memorial volume. John D. Burrington Department of Surgery University of Chicago The Development of the Infant and Young Child: Normal and Abnormal. 6th ed. By R. S. Illingworth. London: Churchill Livingstone, 1976. Pp. 325. £4.95. This sixth edition is a considerable improvement over previous editions. The text and photos have been carefully updated and older material purged. The result is an attractively produced and readable manual for the student or clinician dealing with the normal or abnormal child. One of the strongest additions is a short chapter entitled "Developmental Testing and Its Value." In it the author carefully emphasizes the aims and limitations of testing. He states in italics "the purpose [of developmental examination] is to determine whether the baby is developing normally for his age and whether he has any mental, physical, neurologic or sensory handicaps, so that if possible appropriate treatment can be given." Infant testing cannot predict the child's future intelligence or chance of success. Mr. Illingworth struck a sympathetic cord with the reviewer in his railery against the term "brain damage" or "birth injury" when these terms are used to explain everything from a dull intellect to athetosis. These terms connote that someone, either obstetrician, midwife, or mother, battered the child's brain and caused his difficulties. This short, well-written section exemplifies the straightforward approach, free of the psychologist's jargon that keeps this book carefully focused on the factors proven significant in an infant's development. Another very helpful section addresses common mistakes and pitfalls in development evaluation and diagnosis. It stresses the importance of phasing the tests into the infant's normal play and sleep periods, the risk of ascribing retardation to laziness or lack of cooperation, and the importance of proper selection and interpretation of the tests. 1 62 Book Reviews There are few flaws to detract from this attractively produced and fairly priced volume. Had it been written in this country, there would perhaps be more discussion to the devastating effects of drugs and alcohol on the fetus. Instead these agents are simply listed in a detailed table of virtually all social, physical, toxic, and infectious agents known or thought to interfere with fetal development . There is also no special emphasis on the premature infant who has spent the first days or weeks of his life in one of our modern neonatal intensive care units where the infant has far more contact with machines and lights than with parents. While some of the photographs are old and have been printed in earlier editions, they have been carefully selected for content and clarity of reproduction . The photos in the section on "Assessment of Maturity" and "Reflexes and Reactions" are outstanding and these sections alone would be well worth the purchase price of this entire volume. The style throughout is straightforward and direct without being pedantic. In reviewing this book, I spent far more time than I had originally allotted. I came away with the feeling that I had discussed an...

The technique and scoring system of 24-hr pH esophageal monitoring has been modified to evaluate gastroesophageal reflux in infants and children. The data from two pediatric controls and five clinical cases are presented and compared to normal adult values. This test has better objectivity, precision, sensitivity, and reliability than contrast studies, endoscopy, esophageal biopsy, acid perfusion, or acid reflux tests. The 24-hr pH monitoring assists the evaluation of sphincter maturation, pulmonary disease, and the significance of body position. With more experience, this technique could identify children at risk of developing severe complications of reflux esophagitis and aid in the selection of candidates for surgical intervention.

Five children developed esophageal stricture from the ingestion of a Clinitest tablet. The sodium hydroxide contained in these tablets induced a short, dense stricture that was resistant to dilation and necessitated resection. In all patients primary esophageal resection with end-to-end anastomosis was technically possible. Four of the patients needed two or more dilations postoperatively and 1 still requires dilation. Prevention of accidental ingestion by use of a childproof container and parental education about the caustic nature of Clinitest are both essential to eliminate this child health hazard.

The patient with bronchial adenoma can present a puzzling diagnostic dilemma as well as challenging problems in anaesthetic management. Several aspects are reviewed in this report. Diagnostically these include chest roentgenographic findings and unique pulmonary function tests. Problems in anaesthetic management include possible development of acute carcinoid syndrome, as this tumour is usually of the carcinoid variety. In addition, the tumour may act as a ball valve, causing uneven ventilation of affected lung with expiratory air trapping. Several factors may necessitate prolonged bronchial blockage during anaesthesia. These include a friable mass which may bleed profusely upon manipulation, infected and atelectatic parenchymal tissue beyond the obstruction, copious volumes of purulent secretions, and one lung ventilation during resection.

Of 40 children suffering liver trauma, blunt trauma caused 92.5%, including 22 automobile accident victims. Associated injuries to chest, bone, head, retroperitoneal area, and kidney occurred in 67.5%. Shock, low hematocritis, and leukocytosis were frequent findings. Physical findings aided diagnosis, but radiography did not. Peritoneal taps, positive in 13 of 15 patients (86.7%), were useful diagnostically. Twenty-eight patients had liver lacerations, and seven had liver ruptures. Methods of surgical repair varied considerably, but T-tube choledochostomy did not affect results. Postoperative complications in ten of 35 survivors (28.6%) consisted of right pleural effusion, atelectasis, abscesses, and wound infections. Five patients (12.5%) died.

The most striking findings in a study of wound healing in the fetal lamb include: (1) healing in lamb fetuses prior to 120 days of gestation occurs without the presence of granulocytes; (2) there is virtually no scar formation in any healing wound presumably due to the relative absence of collagen in the fetal tissues; (3) open wounds contract very rapidly, even though they are moist and there can be no contraction of the coagulum; (4) open wounds do not form the normal slough of hyalinized collagen in the base; (5) very rapid healing of all wounds in spite of the low oxygen tension in the surrounding tissues; (6) the rapid healing cannot be explained by the germ-free environment.

1.1. Esophageal replacement or by-pass with a tube created from the greater curvature of the stomach has proved successful in 8 children ranging in age from 212 months to 16 years. Four of these replacements were performed for congenital esophageal atresia, three for lye stricture and one for peptic esophagitis.2.2. When possible, the upper anastomosis should be performed at the initial operation if there is no pre-existing cervical esophagostomy. Using this technique we have had no anastomatic leaks. Angulation of the tube in the neck was minimal.3.3. The tube serves as a relatively inert conduit and seems to retain its tone and empty quickly. There has been no problem with stasis.4.4. Reflux can be demonstrated radiographically, but has not caused symptoms. None of the patients regurgitate and all can lie down after eating.5.5. This type of esophagoplasty is ideally suited to the infant with associated colon or anal malformations and to those with a colonic blood supply unsuitable for support of a colon transplant.