SHORT NOTES 
ON THE 
SURGIUI DISUSES OF CHILDREN. 
BY 
EDWARD BORCK, A.M., M.D., 
St. Louis, Mo. 
Presented to the Section on Diseases of Children, at the meeting 
of the American Medical Association, at Newport, R. I., 
June 25-28, 1889. 
[Reprinted from the Archives of Pediatrics, August, 1889. ] SHORT NOTES 
ON THE 
SURGICAL DISEASES OF CHILDREN. 
Mr. President and Gentlemen :-What little I have 
to communicate upon the surgical diseases of children is 
based upon personal practical observation. It may not con- 
tain any very new information, but, as we are all interested, 
it will add at least something to our collective treasure of 
knowledge and experience. As such I offer the following 
remarks, leaving out all theory, criticism, and quotations: 
I.-CONGENITAL. 
Harelip.-For a single, simple harelip, after having tried 
the various methods known, I operate now with the object of 
not losing or destroying any tissue if possible. I insert a 
very fine needle knife and pierce through the skin of the lower 
margin of one corner of the lip, sweeping the knife around to 
the opposite corner, thus leaving a complete and continuous 
bridge between the two parts of the lips. (See Fig. 1: dotted 
line indicates the incision.) I then pull it down (see Fig. 
2), and unite the wound with three or four fine cambric 
needles deeply inserted. Upon the needles a small piece 
of cork is put upon each side (see Fig. 3); a single 
figure-of-eight ligature to hold it in its place, and the 
whole is pencilled over with flexible collodion. In youths 
or adults I use small glass beads instead of cork, two or 
three on each needle. If swelling should occur I can break 
one or more beads and thus relieve the tension. I prefer 
to operate as soon as possible; the earlier the better for the 
unfortunate creature and the better success for the surgeon. 
The advantages of this plan are that the cork as well as the 
glass does not irritate the skin, and if any swelling should 2 
Bouck : Short Notes on the Surgical Diseases of Children. 
occur the ligature can be loosened without risk of separating 
the wound. The cork retracts slowly and enough to correct 
this Swelling. Not dividing the lower margin nor sacrificing 
any tissue, leaves me a complete natural bridge,-a great ad- 
vantage in cases where union by first intention is not obtained. 
It also fills up the gap better. The objections that one may 
Fig. 1. 
raise who never has tried this plan may be that it leaves a 
pendulum or a flap hanging down; but if you have patience 
and wait, that which at first may seem a little unsightly to 
the eye will in a few.months disappear; so to say, it will be 
appropriated or absorbed by the surrounding tissue. If, how- 
ever, there remains a small protrusion, it can easily be removed Borck : Short Notes on the Surgical Diseases of Children. 
3 
with the knife to suit the case, and a much better result is 
obtained. 
In double, simple harelip I operate on one side at a time. 
After a perfect or complete healing of the same I operate on 
the second. 
In simple, complete harelip running into the nostrils I 
operate in a similar way, paring the edges according to cir- 
cumstances, let the flap hang down, and remove the super- 
fluous portion, if any, some time after union has taken place. 
Hypertrophy of tonsils.-I have seen no permanent cure 
from any treatment whatsoever except the complete extirpa- 
tion of the tonsils, which is to my mind the only safe treat- 
ment. Sometimes a temporary relief may be obtained by 
other remedies, but generally we find ourselves disappointed. 
I prefer to take out all of the gland, or as much as possible,- 
either one or both, as circumstances demand. The slicing off 
of a small piece only, and depending upon the remaining por- 
tion becoming smaller by atrophy, has been to me a disap- 
pointment. I have not observed impotence in adults who 
have had their tonsils removed in childhood. I know a few 
whose tonsils I removed when they were children; they grew 
up and married, and their wives and children, and the off- 
spring, had all or most of the " ear-marks " of the tonsilless 
father; and I know more than one girl whose tonsils I 
removed that grew up, married, and became the mother of 
children. 
Phimosis-Circumcision.-The frequency with which one 
meets with this affection and its many different degrees is re- 
markable; indeed, so remarkable that the question may be 
asked, What is really considered a perfect, natural prepuce ? 
I would answer, Whenever the prepuce is so formed that the 
opening is sufficient to uncover the gland, or at least the 
greater part of it. And now I would ask, With how many 
such formed cases have you met ? I have met very few that 
presented this condition. I observed closely every case when 
I was engaged in a pretty large obstetrical practice as a general 
practitioner years ago; admitting, however, that I operated 
comparatively seldom during that period, and then only in the 
most urgent cases, letting the greater part remain undisturbed, 4 
Borck : Short Notes on the Surgical Diseases of Children. 
like many other practitioners have done, and do now. What 
the beneficial or detrimental result of thus leaving to nature 
had in after-life in each and every case I cannot tell, but I do 
know that in some of the cases which I did not operate on I 
had an opportunity to correct, for some cause or another, this 
deformity during their childhood or later during their man- 
hood. 
To the question, When and how is the operation to be per- 
formed ? my answer would be to the first, Whenever indicated 
and as early as recognized. To the second, Operate in such a 
manner as to-accomplish the purpose well for which you oper- 
ate. Every case stands upon its own merit; no one certain 
operation-no one certain method-answers in each and every 
case. Good judgment must be used in each separate case; and 
the kind of operation or method of operation indicated for 
each case should be separately selected, for the promiscuous 
slicing off of a piece of the prepuce, and clumsily done, may 
produce an evil as great or greater than the one which we aim 
to correct. I am guided by the following, and operate accord- 
ingly : If the opening of the prepuce is very small-the pre- 
puce not too long-I make a simple incision with the knife 
upon the dorsal side, sufficient to uncover the gland com- 
pletely, and in the majority of such cases a small or compar- 
atively small incision will accomplish the object satisfactorily. 
In cases where the prepuce is extraordinarily long, with either 
a small or large opening, I prefer circumcision, removing 
more or less as the case may require. I use a flat forceps, 
made out of German silver, which I hand around for your 
inspection. You will observe that it has a channel which is 
intended for the knife to pass through. The prepuce is 
grasped with the forceps and the knife slides through the 
channel. I use ligatures occasionally and occasionally operate 
without ligatures, as the case may demand. I take plenty of 
time and try with the utmost care to make the operation as 
neat as possible and to leave a handsome and nice penis, so 
that the operation may be a credit to the surgeon, the member 
may be a benefit and comfort to the patient, and that others 
may derive pleasure therefrom. I need not mention all the 
defects and ailments for which this operation is recommended Borck : Short Notes on the Surgical Diseases of Children. 
5 
as relief or prevention; neither will I speak of the mischief 
that may be done by an imprudent operation ; it would take 
up too much time. I only wish to call attention to this im- 
portant observation, that in cases where there is but a small 
opening in the prepuce and the prepuce is short, the gland not 
uncovered or has never been uncovered until maturity, there 
the gland is always very small and atrophied, the penis is not 
wrell developed, oftentimes very short, and then unseemingly 
so in comparison with the other parts of the body. 
I operated upon a young, handsome, well-developed mar- 
ried man, the son of a physician, who had congenital phimosis, 
and who presented the above picture, and who informed me, 
like many others, that he never could enjoy the act of coition ; 
that erections were always accompanied with pain, almost to 
distress. He had no children. Circumcision relieved the 
gentleman ; in time the penis was better developed, and his 
family increased also. 
II.-ACQUIRED. 
Under the head of fractures and dislocations I will state 
that I find the latter, as a rule, easily reduced and kept in 
place; not often followed by unpleasant sequelae, with the ex- 
ception of dislocation of the head of the radius, which is the 
most difficult bone to replace into its proper position, and if 
success accompanies the attempt, it is as difficult to keep it 
there. The reasons why are obvious. 
I would also call your attention to my method of reducing 
dislocation of the vertebrae by suspending the patient by the 
head. (See case reported in Medical and Surgical Reporter, 
Philadelphia, Pa., January 31, 1885, vol. lii. No. 5.) 
Fractures I treat in the most simple manner. My observa- 
tion has been that the more play and freedom you allow the 
little patient the better the result; that confinement of any 
kind does not suit children; it produces forced resistance and 
mischief. For instance, I treat fractures of the femur with a 
simple, single pasteboard splint, extending it from the crest of 
the ilium to below the knee, using a bandage and starch, and 
employing no extension or counter-extension; I leave the 
child alone upon a good mattress. After union has taken 
place I cut off the lower part of the splint a little above the 6 
Borck : Short Notes on the Surgical Diseases of Children. 
knee, so as to make a short femur splint, and again allow the 
little creatures the free use of their limbs. I am not afraid 
that they will abuse it. 
In fracture of the radius near the carpal joint, the best re- 
sult has been obtained by me with the straight splint upon the 
flexor side, from the elbow to the metacarpo-phalangeal joint, 
fingers free. After union has taken place, a light pasteboard 
splint is applied over the radial side for a short time for 
safety's sake, and free use of the arm and hand is permitted. 
The epiphyses.-Separation of the epiphyses-I mean here 
by fracture-I see much more frequently in late years than 
formerly, in all shapes and forms, at all stages; sometimes 
directly after the injury has occurred; at other times weeks, 
months, and years afterwards. My observation has taught me 
that separation of the epiphyses of the humerus and femur are 
the most frequent, and no matter at what time the injury is 
recognized, nor how carefully it is treated, the results are 
never very satisfactory. The separated epiphysis is partly or 
completely absorbed and therefore have only partial or no 
union at all, and the limb will have a dangling motion, 
though time may improve the usefulness of the limb; but the 
patient never recovers as well as after a fracture in other parts 
of the bone. 
Hip-disease.-In the second stage of hip-disease-that is, 
the stage of effusion-we have, among other symptoms, great 
pain. If the case goes from bad to worse,-that is, from the 
second to the third stage,-suppuration takes place, and as 
soon as the capsule is perforated the pain ceases. I have 
therefore been led in several cases to open the capsule by a 
subcutaneous incision during the second stage, with the most 
gratifying results. By this means I let the fluid run into the 
surrounding tissue, to be absorbed by nature. The pain ceases 
immediately; the patient is then put in as comfortable a posi- 
tion as possible; the limb is easily straightened by manipula- 
tion. The best method that I have employed is to put upon 
the patient a pair of wire breeches. No forced extension is 
employed. I will say that aspiration as a curative method 
has failed in my hands. 
Extension and counter-extension, employed upon the fanciful Boeck : Short Notes on the Surgical Diseases of Children. 
7 
theory that thereby the head of the femur is separated from 
the acetabulum, is useless. In a healthy joint it cannot be 
done. The two surfaces are in such close relation-move upon 
one another so accurately-that there is no room; the vacuum 
is so small, indeed, and the joint hermetically sealed; there- 
fore it cannot be pulled asunder. Separation of these two 
surfaces can only take place when disease has destroyed the 
ligaments and the capsule is opened. 
Club-foot.-I do not think that we surgeons up to the 
present time have accomplished all that might be accomplished 
for the successful treatment of club-foot, notwithstanding all 
the modern improvements for the treatment and cure of the 
various kinds of club-foot. There is not a single method, 
ever so much praised, that will answer for all cases belonging 
to one or the other class of club-foot. There is no apparatus 
that will answer for all cases. Each case requires a careful 
study, and though several cases may present the same features, 
each separate picture may be produced by a different cause, 
consequently the treatment applied to the one case may not 
answer for the other. Has not every surgeon seen cases of 
club-foot successfully treated by one or another method? and 
has not every surgeon seen the same case so successfully treated 
by him fall into a relapse again after a time? Most certainly. 
Then what is the cause of these relapses ? Has the fault been 
in our diagnosis or with our treatment ? That is the question 
to be answered. Now, it may be with one or the other, or it 
may be both, or there may be something else which, as yet, we 
do not know; but certain it is that these relapses do occur 
over and over again, and more often than we are willing to 
admit. I think that success greatly depends on the diagnosis. 
A careful diagnosis between the physiological club-foot and 
congenital pathological club-foot of the infant is of the utmost 
importance; the first of which, according to my observation, 
every infant possesses in a greater or less degree, and which 
is always corrected as soon as the child begins to walk, and 
these are the cases that the child will outgrow. Now, if the 
apparent deformity of the physiological club-foot is subjected 
to the treatment of a congenital pathological club-foot, then 
surely there will be some mischief produced, and a permanent 8 
Borck : Short Notes on the Surgical Diseases of Children. 
deformity will remain in the future. When the child begins 
to walk, then the deformity will be increased and has to be 
corrected over again. Again, if a congenital pathological 
club-foot is looked upon as the natural physiological position 
of the feet, and left to itself to outgrow, we will be sadly dis- 
appointed again, for the deformity, if not corrected early, will 
increase rapidly and fearfully as soon as the child begins to 
use its feet in walking. It is more difficult then to correct 
the same; the more advanced the case the more severe treat- 
ment it takes. If no treatment is instituted the case grows 
worse and worse until at last no kind of treatment will correct 
the error. A correct diagnosis and as early a treatment as 
possible is essential for success. But different forms of treat- 
ment are required for the different forms of acquired or con- 
genital club-feet. For example, to try to cure a club-foot or 
genu-valgus which was caused by congenital paralysis by 
complicated mechanical appliances would be in vain, and it 
would be useless to attempt to correct such a deformity by the 
operation of tenotomy, osteotomy, and so forth; it would not 
alone be a failure, but a discredit to the surgeon. 
I pursue no one method for all cases. I adapt ray treat- 
ment to each individual case, and am well satisfied with the 
general result that I have obtained. 
Tracheotomy.-This operation is an unthankful one. Out 
of eight cases this year I have lost seven,-one of them died 
upon the table. It was a child only eight years old, the only 
daughter,-a handsome, bright child. All these cases I saw 
in the last stages of diphtheria or membranous croup, being 
called merely to perform the operation as a dernier ressort. 
The remaining cases all lived from two to twenty-four hours. 
They have occupied my mind, and I have asked myself the 
question, What can be the cause of all these fatal termina- 
tions? consoling myself at the same time that others have had 
no better luck. In my seven cases chloroform was adminis- 
tered and the operation done at night by gas or kerosene light. 
All care was taken by myself, and the necessary attention 
bestowed at the time and in the after-treatment by the watch- 
fulness of the attending family physicians. Now, whether 
the chloroform, or possibly the mixture of the gas or kerosene Bouck : Short Notes on the Surgical Diseases of Children. 
9 
with the chloroform, may have been a factor in these cases I 
cannot determine; but it occupies my mind at present for 
solution. The eighth case-a child four years old-suffered 
with membranous croup, and the dyspnoea was very great; 
the patient was almost cyanosed. I operated without chloro- 
form and quickly, on a bright day. This child recovered 
after careful treatment and attention by the family physician. 
About twelve years ago, during a season, I performed ten 
tracheotomies with five recoveries. It has not and may never 
again repeat itself. Tracheotomy for the removal of foreign 
bodies hardly ever terminates fatally. 
Diseases and injuries of the spine are very interesting 
studies, and under that head I will only say a few words 
about what is known as Pott's disease. The principles of the 
treatment of the trouble, though important, are very well un- 
derstood, but of the pathology of this affection I think we can 
still learn a good deal by more close investigation. The ques- 
tion is, What is the general cause? This seems, even at the 
present day, not quite settled ; the opinions are various, and a 
few cannot give up the old inherited theory of scrofulous diath- 
esis. My observation, studies, and investigation have taught 
me that in by far the majority of cases the cause of caries of the 
spine has been produced by mechanical injury. So with the 
diseases of joints, such as abscess, etc. The tubercular origin 
of such has not been, and cannot be, satisfactorily proven ; it 
is only a convenient theory. 
Mr. President, there are other interesting topics, such as 
congenital tumors, hernia, spina bifida, etc.; but I have 
already taken up my allotted time. One could write a good- 
sized monograph upon every single affection. The points 
which I have touched upon in this paper were brought for- 
ward for the purpose of eliciting discussion upon this interest- 
ing field of surgical diseases of children and thereby obtain- 
ing the views and opinions of others, in order that we might 
listen to the personal observations of so many distinguished 
gentlemen present here. 
I should like to have said a few words upon laparotomy in 
children, but will reserve it for another occasion. I thank 
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