Pediatricians' attitudes affecting decision-making in defective newborns

A questionnaire designed to identify the factors that influence the resolution of ethical dilemmas was returned by 230 (57% of the total) Massachusetts pediatricians. The decision to recommend surgery for an infant with Down's syndrome with duodenal atresia when the parents had refused surgery was influenced by religious affiliation (P less than .01), religious activity (P less than .04), and sex (P=.05). Of those favoring surgery, 40.2% would pursue a court order. The decision to recommend surgery for an infant with severe meningomyelocele when the parents' position was not stated was influenced by age (P less than .01), religious activity (P less than .02), and specialization (P less than .008). When the parents' wishes were expressed, the majority of the pediatricians modified their decision in accord with these wishes. In response to general ethical questions, 79.6% of all pediatricians thought that parents should have the right to withold consent for surgery. Equal numbers thought that psychosocial reasons justified witholding lifesaving procedures. Among a variety of factors, they thought that willingness of the parents to care for the child would influence the decision to take heroic measures. There were 90.4% who thought that ethics should be part of medical education; 55.7% indicated this need throughout their careers.

Congenital anomalies associated with thoracic outlet syndrome. Anatomy, symptoms, diagnosis, and treatment

Personal evaluation of more than 2,300 patients for possible thoracic outlet syndrome (TOS) and knowledge gained from 980 TOS operations in 766 patients (operative incidence of 33.7 per cent of the patients examined) have shown that most patients with TOS have anomalous fibrous muscular bands near the brachial plexus that predispose them to neurologic irritation or compression involving the plexus. Anatomic analysis during operations for TOS, plus cadaver dissections, have disclosed seven distinct types of fibromuscular bands in addition to the less frequent bony anomalies long associated with neurovascular compression. One third of fifty-eight cadaver thoracic outlets dissected showed at least one of the seven muscular anomalies recognized at operations. These anomalies can be accurately related to the patients' symptoms, which are neurologic complaints in 99 per cent of the patients examined who ultimately have the diagnosis of TOS established. Neurologic symptoms are clearly explained by the anomalous bands irritating or compressing the brachial plexus and rarely have any effect on the subclavian vessels. These studies, and others before, have shown no correlation with impairment of circulation or positional radial pulse changes in almost all patients with true TOS. Also, arteriograms and nerve conduction studies generally have failed to be of value in establishing the accurate diagnosis. Reasons for these conclusions are explained, and the most reliable tests are described. The most effective means of relief of severe symptoms of TOS is to alter the mechanical irritation or compression of the brachial plexus by completely resecting the first throacic rib and all anomalous fibromuscular tissue around the plexus and subclavian vessels. If patients are are throughly evaluated with appropriate tests and highly selected for surgical treatment, gratifying relief will result in more than 90 per cent of patients, if the correct operation is performed with meticulous technic.

Congenital absence of the vagina. The Mayer-Rokitansky-Kuster-Hauser syndrome

We describe 14 patients with congenital absence of the vagina associated with a variable abnormality of the uterus and review the literature. Associated developmental anomalies of the urinary tract and skeleton are common. As a result of the analysis of two affected families, we believe that the disorder may represent the variable manifestation of a single underlying genetic defect that can be expressed alone or in any combination of vertebral, renal, and genital abnormalities. Some affected persons may have lethal manifestations such as absence of both kidneys, and some cases may result from multifactoral causes rather than a single gene defect. Whatever the cause, the defect involves mesodermal development and the mesonephric kidney, the latter resulting in abnormalities in the paramesonephros (uterus and vagina) and in the metanephric kidney. Both nonoperative and surgical treatments are generally successful in repairing the vaginal abnormality.

[Anterior-cleavage-syndrome (author's transl)]

The authors report on local and general changes in dysgenesis mesodermalis iridis et corneae Rieger on the basis of own observations and literature survey. This genetically caused inhibitory deformation is outlined with regard to the differential diagnosis of other anomalies in the angle part of iris. The conservative and surgical therapeutic experiences of other authors are contrasted with our own.

Trigonometric method of analysis of the upper part of the mouth cavity

A method of analysis of a cast of the upper part of the mouth cavity which allows a comparison of various forms thereof, by the use of five parameters is described. For their calculation, only five measurements between four pre-determined points are needed. With the great accuracy which the method ensures, it is possible to follow, at short time intervals, the changes brought about by jaw-orthopaedic and surgical procedures. Numerical and schematic graphical comparison permits a rapid evaluation of results achieved in the treatment of clefts. The character of the parameters elucidates the morphogenesis of clefts and indicates the most rational therapy.

Hepatic portoenterostomy: an assessment of its value in the treatment of biliary atresia

A series of 12 infants undergoing hepatic portoenterostomy for incorrectable-type biliary atresia is reviewed. There has been no evidence of a sustained postoperative increase in bile excretion or improvement in biliary cirrhosis in any patient. Survival statistics for the group as a whole are poor with a mean postop survival time of 11 months and a mean total survival time of 15.3 months. These survival times are worse than that previously reported for infants with untreated biliary atresia. Our disappointing results with hepatic portoenterostomy raise doubts concerning its value in the treatment of biliary atresia.

Congenital posterior angulation of tibia and fibula

Congenital posterior angulation of the tibia occurs less frequently than congenital anterior bowing. Concomitant deformities of the foot and contractures of the soft tissue usually exist. A review of the literature indicates that nonoperative treatment is usually successful in correcting the deformity. Tibial growth is frequently less than normal and epiphysiodesis of the opposite extermity may be necessary. Three patients are presented who have been followed up for 17 years, two years, and over one year. Improvement is occurring with nonoperative treatment.

The demands and limits of care--ethical reflections on the moral dilemma of neonatal intensive care

Decisions regarding the care of deformed and retarded infants pose difficult ethical and moral dilemmas for both physicians and parents. Ethical inquiry regarding such questions must be concerned with how we see and understand the dilemma for conceptualization of the problem often shapes the decisions that are made. The fundamental issue that provides the background for the kind and amount of care defective newborns should receive is the obligation parents have to care for their children. New medical technology has so extended the limits of care that the extent of parental (and societal) obligation is unclear. In dealing with the problem of defective newborns, the action of both physicians and parents is determined in part by concern to act in a manner congruent with assumed roles and identity. With no moral consensus regarding the care of defective newborns, the doctor is put in a precarious position. What is revealed is how dependent medicine is on its underlying moral community to give it moral direction in instances of ambiguity and uncertainty.