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Practical Considerations in the Management of Pediatric Surgical Problems
Practical Considerations in the Management of Pediatric Surgical Problems JOHN L. KEELEY, M.D., F.A.C.S. *
THE impetus given to pediatric surgery during the past twenty years by the efforts of Ladd,I Gross,!' 2 Potts,3 Donovan,4. fi Miller,6 Penberthy and Benson,1 Haight and Towsley,8 Chaffin and Snyder,9 and many others has resulted in a vastly improved understanding of many specific problems in this field. One might, therefore, rightfully question the need, even the desirability, of a communication such as this. There are, however, some recommendations the elaboration of which will be in keeping with the practical purposes of this volume. It will be obvious at once that the surgeon who has had training in modern pediatric surgical centers has little to gain from reading further. For the man who must operate on infants and children in a general hospital the following text may crystallize some of his own thoughts, freshen his memory concerning past problems or provide additional information useful in the management of his future patients. MEASURES TO AID IN DIAGNOSIS
It may be trite to state that the solution of any problem in clinical medicine begins with diagnosis and diagnosis begins with history. Some pediatric surgical conditions, such as omphalocele, exstrophy of the bladder and imperforate anus are immediately detected upon inspection. However, many others, such as the obstructive lesions of the alimentary tract, may be unsuspected for a time depending on their severity and site. Since these may have vomiting, abdominal distention and obstipaFrom the Department of Surgery, Stritch School of Medicine, Loyola University, Mercy and Cook County Hospitals, Chicago.
* Professor of Surgery and Assistant Chairman of the Department, Stritch School of Medicine, Loyola University; Senior Attending Surgeon, Mercy Hospital; Attending Surgeon, General and Thoracic Surgery, West Side'~Veterans' 'Administration Hospital; Attending Surgeon, Cook County Hospital,. Consultant in Surgery, South Shore Hospital. 305
306
John L. Keeley
tion as symptoms in common it is essential to evaluate each. Prompt emesis of unchanged formula after taking small amounts plus associated cyanosis suggests esophageal atresia with tracheo-esophageal fistula. Attempts to pass a catheter into the stomach, a film to demonstrate the position of the catheter and another following the injection of a cubic centimeter or two of Lipiodol are logical steps in the study of such a patient (Fig. 88, A, B, C). Persistent vomiting of bile-stained material from the first day of life is usually found in atresias below the level of the ampulla of Vater.
Fig. 88. Catheter meeting obstruction in esophageal atresia and coiling :in oropharynx. Lateral and anteroposterior views after instillation of Lipiodol. Gas shown below the diaphragm (C) ;indicates a tracheo-esophageal fistula and therefore a lower esophageal segment reaching the region of the bifurcation of the traehea. End-to-end anastomosis between the upper pouch and the lower segment was accomplished without tension.
Other causes of obstruction in this area with similar emesis are annular pancreas and duodenal compression associated with incomplete rotation of the intestines and colon. In all three the stomach and parts of the duodenum are distended with air and therefore easily shown on a plain x-ray film (Fig. 89, A, B, C). In jejunal atresia a portion of that segment will be shown also (Fig. 89, A). Not uncommonly the obstruction of the duodenum associated with malrotation will be incomplete and small gas shadows will be seen in the lower intestinal tract (Fig. 89, C). An enema with contrast media will show the position of the cecum to be in the epigastrium or the right upper quadrant (Fig. 89, D), thus differentiating malrotation from the other two. Emesis due to obstructive lesions low in the intestinal tract comes on later, that is after a day or two, and is accompanied by obvious generalized abdominal distention. One must keep in mind the possibility that
Management of Pediatric Surgical Problems
307
emesis may be due to cerebral disturbances and careful inquiry regarding labor, instrumentation, onset of respirations and possible hypoxic pe~ riods must be made. The degree of abdominal distention is a fair indication of the severity of the obstruction and its level. The configuration of the abdomen will
Fig. 89. A, Stomach, duodenum and short jejunal segment outlined by gas in case of jejunal atresia. B, Stomach and part of duodenum outlined by gas in case of annular pancreas. The "double bubble" shadow is well shown to the right of the vertebral column. C, Gaseous distention of the stomach and part of the duodenum in a case of malrotation. Note the small amounts of gas scattered in the lower abdomen indicating incomplete obstruction in the duodenal area. D, A barium enema in the same patient showing the clockwise loop from the hepatic flexure to the cecum which remains in the right upper quadrant. This establishes the CIl,URA of the duodenal obstruction.
308
John L. Keeley
be helpful as the high obstructions cause only gastric, duodenal and limited jejunal distention which results in epigastric fullness and scaphoid configuration of the remainder of the abdomen. Abdominal dist ention may be more severe in an infant receiving oxygen by intranasal catheter. Information concerning bowel movements or lack thereof is valuable if regularly and accurately recorded. Examination of the stool by Farber's testlO may show the absence of desquamated epithelial cells and indicate atresia which has prevented these cells swallowed with amniotic fluid from traversing the intestinal tract. Regardless of the signs and symptoms, one of the most helpful diagnostic procedures in any sick infant is a plain x-ray film. Its value in obstructive lesions of the gastrointestinal tract has already been discussed. In addition, it will show both the chest and the abdomen, can be made early in the course of illness, and will often provide evidence which is conclusive. It will thus prevent a diaphragmatic hernia, tension pneumothorax or a balloon cyst of the lung from being overlooked, lesions which may be fatal due to eventual cardiorespiratory failure. It will also detect pneumoperitoneum and insure early operation for such unusual lesions as perforated peptic ulcer in the newborn. Areas of calcification in the abdomen suggest meconium peritonitis, the result of prenatal rupture of the bowel, usually just above an area of atresia. PARENTERAL THERAPY
Since most of the emergencies in the newborn require a period of parentera(fluid administration, means to accomplish this must be considered. Specific requirements and special techniques of administration are presented in detail in recent texts. 2 • 11 Requirements of fluids and electrolytes may be met by subcutaneous injections of appropriate amounts in the scapular areas or the lateral surfaces of. the thighs. Absorption of fluids thus administered may be hastened by the use of the spreading agent hyaluronidase. For the administration of blood, plasn'la and other replacement fluids and drug therapy the intravenous route is either the sole or the most effective means. TheuCut-down." Venipuncture may be done repeatedly in older childrenput a high degree of skill and constant practice are necessary to establish an infusion in a scalp vein or other small vein in an infant with~assurance that it will remain functioning during an entire surgical procedure. Therefore, it is usually desirable to do a "cut-down." Unfortunately this procedure is often delegated to one of the less experienced personnel and may often fail to function at a time when it is most urgently needed. In fact, this failure may be the most important factor contributing to the serious or precarious condition of a patient in the immediate postoperative period. It appears worthwhile, therefore, to discuss materials and methods for this procedure in detail.
Management of Pediatric Surgical Problems
309
A set-up for inserting an intravenous cannula or polyethylene tube is shown in Figure 90. One may choose his own favorite instruments but the procedure should not be started until they have been found to be in good repair and with sufficiently fine and accurately aligned points and sharp edges. These instruments should be small enough to use on a vein at the ankle or in the antecubital fossa of a premature infant. The most useful piece of equipment is the binocular loupe of the sort used in ophthalmologic surgery (Fig. 90). It will enable one to visualize accurately the only available vein despite the fact that it is often dis-
Fig. 90. Materials and instruments for performing a "cut-down." A 2 cc. ampule of local anesthetic should be sufficient in most cases. The gloves are pointing to the binocular loupe which is so important in utilizing tiny veins. It is placed with the sterile set-up here for illustrative purposes.
appointingly small. Opening the vein with a fine cataract knife or iris scissors can be done precisely with this visual aid and the insertion of a cannula or tubing larger than the caliber of the vein can be done because of the accuracy of the manipulations. Polyethylene tubing is available in various sizes but even the smallest size available may be too large for the best vein in a premature infant. Stretching the tubing will decrease its diameter and a long bevel on the end will provide a point which can be accurately introduced and will dilate the vein to a larger size as the tube is passed proximally. The tubing should be introduced far enough so that the tip lies free in the lumen of the vein and thus avoid mechanical irritation to the vein wall
310
John L. Keeley
with resultant spasm. A cubic centimeter or two of procaine introduced through the tubing will usually relieve the spasm in a minute or two. ANESTHESIA
The choice of anesthesia depends upon the anesthetic skill available. In the past there has been some emphasis on local anesthesia with or without sedation for operations on infants. More recently longer and more extensive procedures are being done, making general anesthesia preferable. The advances in anesthesia and the increasing availability of medically trained personnel have been of inestimable importance in furthering not only pediatric surgery but other fields as well. It is, of course, possible to combine local anesthesia with tt e use of one of the gases for analgesia in a patient who is an exceptionally poor risk. The fact remains that the best and safest anesthesia for infants and children is open drop ether with plenty of oxygen introduced under the ether mask in a steady stream. Since relaxation is usually not a problem the anesthesia should be so light that the grasp reflex is still present. In a patient with a high fever, as in the occasional case of fulminating appendicitis, not only is it necessary to correct dehydration and acidosis before induction of anesthesia but sponging to bring down the temperature is a valuable aid and the application of several ice bags to the body surface during the course of the anesthesia will decrease temperature and metabolism. In fact, the application of ice bags should be routine during hot weather if the operating rooms are not air-conditioned. MATERIALS FOR PEDIATRIC SURGERY
The materials for pediatric surgery demand special attention. Drapes that are too heavy, and towels, laparotomy pads and sponges which are too large are handicaps which are minimal when compared to the disadvantages imposed on the surgeon if the instruments and the suture materials are selected on the same generous scale. An operation on an adult may be difficult without the proper instruments yet be accomplished safely, whereas the poor selection of materials for surgery in the newborn may be absolutely disastrous. It may be distressing to have the suture nurse offer what is considered fine suture material for adult surgery but it is much worse if she is unaware of the necessity and availability of the 5-0 and 6-0 sizes. The insistence upon appropriately small instruments and sufficiently fine suture material automatically imposes a careful and painstaking surgical technique which in itself safeguards the welfare of the patient, a fact long established by the disciples of the Halsted school of silk technique. NOTES ON POSTOPERATIVE CARE
Aspiration of vomitus is always a hazard in weak or premature infants or those inadvertently "overanesthetized." Constant vigilance to
Management of Pediatric Surgical Problems
311
avoid aspiration is necessary and suction to remove material from the pharynx should be immediately at hand. The use of oxygen postoperatively will improve the general condition of many of these patients and if there has been preoperative pulmonary disturbances or in cases where an endotracheal tube has been used or a thoracic operation has been performed, provision for a high concentration of moisture in the air will prevent drying of tracheobronchial secretions. The quantity of fluid in the containers used for intravenous administration should not be more at anyone time than the amount to be given in a six hour period. More infants are harmed by receiving too much fluid than by withholding it. It is better to discard the greater portion of the contents of a bottle than to make possible the disaster of" drowning" the patient. SUMMARY In reviewing some general problems in surgical management in infants and children, emphasis is placed on the history and significant findings in alimentary tract obstructions, and on the almost routine use of x-ray films in sick infants. Most of the congenital disturbances requiring early operation will be diagnosed early if prompt roentgenographic studies are made. Suggestions regarding fluid balance, anesthesia, the materials for pediatric surgery and postoperative care are presented. REFERENCES 1. Ladd, W. E. and Gross, R. E.: Abdominal Surgery of Infancy and Childhood. Philadelphia, W. B. Saunders Company, 1941. 2. Gross, R. E.: The Surgery of Infancy and Childhood. Philadelphia, W. B. Saunders Company, 1953. 3. Potts, W. J., Riker, W. L. and Lewis, J. E.: The Treatment of Inguinal Hernia in Infants and Children. Ann. Surg. 132: 566-576,1950. 4. Donovan, E. J.: Congenital Atresias of the Newborn. Ann. Surg. 103: 455-457, 1936. 5. Donovan, E. J.: Congenital Hypertrophic Stenosis. Am. J. Surg. 39: 377-381, 1938. 6. Miller, E. M.: Bowel Obstruction in the Newborn. Ann. Surg. 110: 587-605, 1939. 7. Benson, C. D. and Penberthy, G. C.: Hernia into the Umbilical Cord and Omphalocoele (Amniocoele) in the Newborn. Arch. Surg. 58: 833-844, 1949. 8. Haight, C. and Towsley, H. A.: Congenital Atresia of the Esophagus with Tracheo-esophageal Fistula. Surg., Gynec. & Obst. 76: 672-688, 1943. 9. Snyder, W. H., Jr., and Chaffin, L.: Appendicitis During the First Two Years of Life. Arch. Surg. 64: 549-560, 1952. 10. Farber, S.: Congenital Atresia of the Alimentary Tract: Diagnosis by Microscopic Examination of Meconium. J.A.M.A. 100: 1753-1754, 1933. 11. Hill, F. S.: Practical Fluid Therapy in Pediatrics. Philadelphia, W. B. Saunders Company, 1954. 30 N. Michigan Avenue Chicago 2, Illinois
THE impetus given to pediatric surgery during the past twenty years by the efforts of Ladd,I Gross,!' 2 Potts,3 Donovan,4. fi Miller,6 Penberthy and Benson,1 Haight and Towsley,8 Chaffin and Snyder,9 and many others has resulted in a vastly improved understanding of many specific problems in this field. One might, therefore, rightfully question the need, even the desirability, of a communication such as this. There are, however, some recommendations the elaboration of which will be in keeping with the practical purposes of this volume. It will be obvious at once that the surgeon who has had training in modern pediatric surgical centers has little to gain from reading further. For the man who must operate on infants and children in a general hospital the following text may crystallize some of his own thoughts, freshen his memory concerning past problems or provide additional information useful in the management of his future patients. MEASURES TO AID IN DIAGNOSIS
It may be trite to state that the solution of any problem in clinical medicine begins with diagnosis and diagnosis begins with history. Some pediatric surgical conditions, such as omphalocele, exstrophy of the bladder and imperforate anus are immediately detected upon inspection. However, many others, such as the obstructive lesions of the alimentary tract, may be unsuspected for a time depending on their severity and site. Since these may have vomiting, abdominal distention and obstipaFrom the Department of Surgery, Stritch School of Medicine, Loyola University, Mercy and Cook County Hospitals, Chicago.
* Professor of Surgery and Assistant Chairman of the Department, Stritch School of Medicine, Loyola University; Senior Attending Surgeon, Mercy Hospital; Attending Surgeon, General and Thoracic Surgery, West Side'~Veterans' 'Administration Hospital; Attending Surgeon, Cook County Hospital,. Consultant in Surgery, South Shore Hospital. 305
306
John L. Keeley
tion as symptoms in common it is essential to evaluate each. Prompt emesis of unchanged formula after taking small amounts plus associated cyanosis suggests esophageal atresia with tracheo-esophageal fistula. Attempts to pass a catheter into the stomach, a film to demonstrate the position of the catheter and another following the injection of a cubic centimeter or two of Lipiodol are logical steps in the study of such a patient (Fig. 88, A, B, C). Persistent vomiting of bile-stained material from the first day of life is usually found in atresias below the level of the ampulla of Vater.
Fig. 88. Catheter meeting obstruction in esophageal atresia and coiling :in oropharynx. Lateral and anteroposterior views after instillation of Lipiodol. Gas shown below the diaphragm (C) ;indicates a tracheo-esophageal fistula and therefore a lower esophageal segment reaching the region of the bifurcation of the traehea. End-to-end anastomosis between the upper pouch and the lower segment was accomplished without tension.
Other causes of obstruction in this area with similar emesis are annular pancreas and duodenal compression associated with incomplete rotation of the intestines and colon. In all three the stomach and parts of the duodenum are distended with air and therefore easily shown on a plain x-ray film (Fig. 89, A, B, C). In jejunal atresia a portion of that segment will be shown also (Fig. 89, A). Not uncommonly the obstruction of the duodenum associated with malrotation will be incomplete and small gas shadows will be seen in the lower intestinal tract (Fig. 89, C). An enema with contrast media will show the position of the cecum to be in the epigastrium or the right upper quadrant (Fig. 89, D), thus differentiating malrotation from the other two. Emesis due to obstructive lesions low in the intestinal tract comes on later, that is after a day or two, and is accompanied by obvious generalized abdominal distention. One must keep in mind the possibility that
Management of Pediatric Surgical Problems
307
emesis may be due to cerebral disturbances and careful inquiry regarding labor, instrumentation, onset of respirations and possible hypoxic pe~ riods must be made. The degree of abdominal distention is a fair indication of the severity of the obstruction and its level. The configuration of the abdomen will
Fig. 89. A, Stomach, duodenum and short jejunal segment outlined by gas in case of jejunal atresia. B, Stomach and part of duodenum outlined by gas in case of annular pancreas. The "double bubble" shadow is well shown to the right of the vertebral column. C, Gaseous distention of the stomach and part of the duodenum in a case of malrotation. Note the small amounts of gas scattered in the lower abdomen indicating incomplete obstruction in the duodenal area. D, A barium enema in the same patient showing the clockwise loop from the hepatic flexure to the cecum which remains in the right upper quadrant. This establishes the CIl,URA of the duodenal obstruction.
308
John L. Keeley
be helpful as the high obstructions cause only gastric, duodenal and limited jejunal distention which results in epigastric fullness and scaphoid configuration of the remainder of the abdomen. Abdominal dist ention may be more severe in an infant receiving oxygen by intranasal catheter. Information concerning bowel movements or lack thereof is valuable if regularly and accurately recorded. Examination of the stool by Farber's testlO may show the absence of desquamated epithelial cells and indicate atresia which has prevented these cells swallowed with amniotic fluid from traversing the intestinal tract. Regardless of the signs and symptoms, one of the most helpful diagnostic procedures in any sick infant is a plain x-ray film. Its value in obstructive lesions of the gastrointestinal tract has already been discussed. In addition, it will show both the chest and the abdomen, can be made early in the course of illness, and will often provide evidence which is conclusive. It will thus prevent a diaphragmatic hernia, tension pneumothorax or a balloon cyst of the lung from being overlooked, lesions which may be fatal due to eventual cardiorespiratory failure. It will also detect pneumoperitoneum and insure early operation for such unusual lesions as perforated peptic ulcer in the newborn. Areas of calcification in the abdomen suggest meconium peritonitis, the result of prenatal rupture of the bowel, usually just above an area of atresia. PARENTERAL THERAPY
Since most of the emergencies in the newborn require a period of parentera(fluid administration, means to accomplish this must be considered. Specific requirements and special techniques of administration are presented in detail in recent texts. 2 • 11 Requirements of fluids and electrolytes may be met by subcutaneous injections of appropriate amounts in the scapular areas or the lateral surfaces of. the thighs. Absorption of fluids thus administered may be hastened by the use of the spreading agent hyaluronidase. For the administration of blood, plasn'la and other replacement fluids and drug therapy the intravenous route is either the sole or the most effective means. TheuCut-down." Venipuncture may be done repeatedly in older childrenput a high degree of skill and constant practice are necessary to establish an infusion in a scalp vein or other small vein in an infant with~assurance that it will remain functioning during an entire surgical procedure. Therefore, it is usually desirable to do a "cut-down." Unfortunately this procedure is often delegated to one of the less experienced personnel and may often fail to function at a time when it is most urgently needed. In fact, this failure may be the most important factor contributing to the serious or precarious condition of a patient in the immediate postoperative period. It appears worthwhile, therefore, to discuss materials and methods for this procedure in detail.
Management of Pediatric Surgical Problems
309
A set-up for inserting an intravenous cannula or polyethylene tube is shown in Figure 90. One may choose his own favorite instruments but the procedure should not be started until they have been found to be in good repair and with sufficiently fine and accurately aligned points and sharp edges. These instruments should be small enough to use on a vein at the ankle or in the antecubital fossa of a premature infant. The most useful piece of equipment is the binocular loupe of the sort used in ophthalmologic surgery (Fig. 90). It will enable one to visualize accurately the only available vein despite the fact that it is often dis-
Fig. 90. Materials and instruments for performing a "cut-down." A 2 cc. ampule of local anesthetic should be sufficient in most cases. The gloves are pointing to the binocular loupe which is so important in utilizing tiny veins. It is placed with the sterile set-up here for illustrative purposes.
appointingly small. Opening the vein with a fine cataract knife or iris scissors can be done precisely with this visual aid and the insertion of a cannula or tubing larger than the caliber of the vein can be done because of the accuracy of the manipulations. Polyethylene tubing is available in various sizes but even the smallest size available may be too large for the best vein in a premature infant. Stretching the tubing will decrease its diameter and a long bevel on the end will provide a point which can be accurately introduced and will dilate the vein to a larger size as the tube is passed proximally. The tubing should be introduced far enough so that the tip lies free in the lumen of the vein and thus avoid mechanical irritation to the vein wall
310
John L. Keeley
with resultant spasm. A cubic centimeter or two of procaine introduced through the tubing will usually relieve the spasm in a minute or two. ANESTHESIA
The choice of anesthesia depends upon the anesthetic skill available. In the past there has been some emphasis on local anesthesia with or without sedation for operations on infants. More recently longer and more extensive procedures are being done, making general anesthesia preferable. The advances in anesthesia and the increasing availability of medically trained personnel have been of inestimable importance in furthering not only pediatric surgery but other fields as well. It is, of course, possible to combine local anesthesia with tt e use of one of the gases for analgesia in a patient who is an exceptionally poor risk. The fact remains that the best and safest anesthesia for infants and children is open drop ether with plenty of oxygen introduced under the ether mask in a steady stream. Since relaxation is usually not a problem the anesthesia should be so light that the grasp reflex is still present. In a patient with a high fever, as in the occasional case of fulminating appendicitis, not only is it necessary to correct dehydration and acidosis before induction of anesthesia but sponging to bring down the temperature is a valuable aid and the application of several ice bags to the body surface during the course of the anesthesia will decrease temperature and metabolism. In fact, the application of ice bags should be routine during hot weather if the operating rooms are not air-conditioned. MATERIALS FOR PEDIATRIC SURGERY
The materials for pediatric surgery demand special attention. Drapes that are too heavy, and towels, laparotomy pads and sponges which are too large are handicaps which are minimal when compared to the disadvantages imposed on the surgeon if the instruments and the suture materials are selected on the same generous scale. An operation on an adult may be difficult without the proper instruments yet be accomplished safely, whereas the poor selection of materials for surgery in the newborn may be absolutely disastrous. It may be distressing to have the suture nurse offer what is considered fine suture material for adult surgery but it is much worse if she is unaware of the necessity and availability of the 5-0 and 6-0 sizes. The insistence upon appropriately small instruments and sufficiently fine suture material automatically imposes a careful and painstaking surgical technique which in itself safeguards the welfare of the patient, a fact long established by the disciples of the Halsted school of silk technique. NOTES ON POSTOPERATIVE CARE
Aspiration of vomitus is always a hazard in weak or premature infants or those inadvertently "overanesthetized." Constant vigilance to
Management of Pediatric Surgical Problems
311
avoid aspiration is necessary and suction to remove material from the pharynx should be immediately at hand. The use of oxygen postoperatively will improve the general condition of many of these patients and if there has been preoperative pulmonary disturbances or in cases where an endotracheal tube has been used or a thoracic operation has been performed, provision for a high concentration of moisture in the air will prevent drying of tracheobronchial secretions. The quantity of fluid in the containers used for intravenous administration should not be more at anyone time than the amount to be given in a six hour period. More infants are harmed by receiving too much fluid than by withholding it. It is better to discard the greater portion of the contents of a bottle than to make possible the disaster of" drowning" the patient. SUMMARY In reviewing some general problems in surgical management in infants and children, emphasis is placed on the history and significant findings in alimentary tract obstructions, and on the almost routine use of x-ray films in sick infants. Most of the congenital disturbances requiring early operation will be diagnosed early if prompt roentgenographic studies are made. Suggestions regarding fluid balance, anesthesia, the materials for pediatric surgery and postoperative care are presented. REFERENCES 1. Ladd, W. E. and Gross, R. E.: Abdominal Surgery of Infancy and Childhood. Philadelphia, W. B. Saunders Company, 1941. 2. Gross, R. E.: The Surgery of Infancy and Childhood. Philadelphia, W. B. Saunders Company, 1953. 3. Potts, W. J., Riker, W. L. and Lewis, J. E.: The Treatment of Inguinal Hernia in Infants and Children. Ann. Surg. 132: 566-576,1950. 4. Donovan, E. J.: Congenital Atresias of the Newborn. Ann. Surg. 103: 455-457, 1936. 5. Donovan, E. J.: Congenital Hypertrophic Stenosis. Am. J. Surg. 39: 377-381, 1938. 6. Miller, E. M.: Bowel Obstruction in the Newborn. Ann. Surg. 110: 587-605, 1939. 7. Benson, C. D. and Penberthy, G. C.: Hernia into the Umbilical Cord and Omphalocoele (Amniocoele) in the Newborn. Arch. Surg. 58: 833-844, 1949. 8. Haight, C. and Towsley, H. A.: Congenital Atresia of the Esophagus with Tracheo-esophageal Fistula. Surg., Gynec. & Obst. 76: 672-688, 1943. 9. Snyder, W. H., Jr., and Chaffin, L.: Appendicitis During the First Two Years of Life. Arch. Surg. 64: 549-560, 1952. 10. Farber, S.: Congenital Atresia of the Alimentary Tract: Diagnosis by Microscopic Examination of Meconium. J.A.M.A. 100: 1753-1754, 1933. 11. Hill, F. S.: Practical Fluid Therapy in Pediatrics. Philadelphia, W. B. Saunders Company, 1954. 30 N. Michigan Avenue Chicago 2, Illinois