The victorious Allies initiated a policy of denazification and put many of the surviving Nazi leadership on trial for war crimes at the Nuremberg trials. How Green Were the Nazis?: The physical exam findings, persistence of the nodule, progressive growth and cosmetic appearance were the main indications for surgery. It is found in meat, vegetables, legumes, and whole grains. Retrieved 19 May A review of 27 cases. Identify chronic kidney disease CKD.
Outpatient repair is safer for those prematures above the 60 wk. The very low birth weight infant with symptomatic hernia can benefit from epidural anesthesia.
At times, the indirect inguinal hernia will extend into the scrotum and can be reduced by external, gentle pressure. Occasionally, the hernia will present as a bulge in the soft tissue overlying the internal ring. It is sometimes difficult to demonstrate and the physician must rely on the patient's history of an intermittent bulge in the groin seen with crying, coughing or straining. Elective herniorrhaphy at a near convenient time is treatment of choice. Since risk of incarceration is high in children, repair should be undertaken shortly after diagnosis.
Simple high ligation of the sac is all that is required. Pediatric patients are allowed to return to full activity immediately after hernia repair. Bilateral exploration is done routinely by most experienced pediatric surgeons. Recently the use of groin laparoscopy through the hernial sac permits visualization of the contralateral side. Testicular feminization syndrome TFS is a genetic form of male pseudohermaphroditism patient who is genetically 46 XY but has deficient masculinization of external genitalia caused by complete or partial resistance of end organs to the peripheral effects of androgens.
This androgenic insensitivity is caused by a mutation of the gene for androgenic receptor inherited as an X-linked recessive trait. In the complete form the external genitalia appear to be female with a rudimentary vagina, absent uterus and ovaries. The incomplete form may represent undervirilized infertile men. This patients will never menstruate or bear children. Early gonadectomy is advised to: Vaginal reconstruction is planned when the patient wishes to be sexually active.
These children develop into very normal appearing females that are sterile since no female organs are present. A hydrocele is a collection of fluid in the space surrounding the testicle between the layers of the tunica vaginalis.
Hydroceles can be scrotal, of the cord, abdominal, or a combination of the above. A hydrocele of the cord is the fluid-filled remnant of the processus vaginalis separated from the tunica vaginalis. A communicating hydrocele is one that communicates with the peritoneal cavity by way of a narrow opening into a hernial sac.
Hydroceles are common in infants. Some are associated with an inguinal hernia. They are often bilateral, and like hernias, are more common on the right than the left. Most hydroceles will resolved spontaneously by years of age. After this time, elective repair can be performed at any time. Operation is done through the groin and search made for an associated hernia. Aspiration of a hydrocele should never be attempted. As a therapeutic measure it is ineffective, and as a diagnostic tool it is a catastrophe if a loop of bowel is entrapped.
A possible exception to this is the postoperative recurrent hydrocele. The undescended testis is a term we use to describe all instances in which the testis cannot be manually manipulated into the scrotum.
The testes form from the medial portion of the urogenital ridge extending from the diaphragm into the pelvis. In arrested descent, they may be found from the kidneys to the internal inguinal ring. Rapid descent through the internal inguinal ring commences at approximately week 28, the left testis preceding the right. Adequate amounts of male hormones are necessary for descent.
The highest levels of male hormones in the maternal circulation have been demonstrated at week Thus, it appears that failure of descent may be related to inadequate male hormone levels or to failure of the end-organ to respond.
The undescended testes may be found from the hilum of the kidney to the external inguinal ring. The undescended testis found in 0. Testes that can be manually brought to the scrotum are retractile and need no further treatment. Parents should know the objectives, indications and limitations of an orchiopexy: To improve spermatogenesis producing an adequate number of spermatozoids surgery should be done before the age of two.
Electron microscopy has confirmed an arrest in spermatogenesis reduced number of spermatogonias and tubular diameter in undescended testis after the first two years of life. Other reasons to pex are: The management is surgical; hormonal Human Chorionic Gonadotropin treatment has brought conflicting results except bilateral cases.
Surgery is limited by the length of the testicular artery. Palpable testes have a better prognosis than non-palpable. Laparoscopy can be of help in non-palpable testis avoiding exploration of the absent testis.
Viens, MS University of Toronto. An umbilical hernia is a small defect in the abdominal fascial wall in which fluid or abdominal contents protrude through the umbilical ring. The presence of a bulge within the umbilicus is readily palpable and becomes more apparent when the infant cries or during defecation.
The actual size of the umbilical hernia is measured by physical examination of the defect in the rectus abdominis muscle, and not by the size of the umbilical bulge. The size of the fascial defect can vary from the width of a fingertip to several centimetres.
Embryologically, the cause of an umbilical hernia is related to the incomplete contraction of the umbilical ring. The herniation of the umbilicus is a result of the growing alimentary tract that is unable to fit within the abdominal cavity. Umbilical hernias are more prevalent in females than in males and are more often seen in patients with African heritage. The increased frequency of umbilical hernias has also been attributed to premature babies, twins and infants with long umbilical cords.
There is also a frequent association with disorders of mucopolysaccharide metabolism, especially Hurler's Syndrome gargoylism. Most umbilical hernias are asymptomatic; the decision to repair the umbilical hernia in the first years of life is largely cosmetic and is often performed because of parental request, not because of pain or dysfunction.
In the past, some parents use to tape a coin over the umbilical bulge, however, manual compression does not have an effect on the fascial defect. Treatment of umbilical hernia is observation.
However, surgical repair is recommended if the hernia has not closed by the age of five. The incidence of incarceration trapped intestinal loop is rare, even in larger defects. Females should especially have their umbilical hernia corrected before pregnancy because of the associated increased intra-abdominal pressure that could lead to complications. The procedure is simple and incidence of complication such as infection is extremely rare.
The repair is usually done as outpatient surgery under general anesthetic. Inguinal and umbilical hernia repair in infants and children. Surg Clinics of North Am 73 3: Swenson's Pediatric Surgery - 5th edition. The developing human - 4th edition. Philadelphia, WB Saunders, pp. Some observations on umbilical hernias in infants.
The comparative incidence of umbilical hernias in colored and white infants. J Natl Med Assoc The three most common abdominal wall defect in newborns are umbilical hernia, gastroschisis and omphalocele. Omphalocele is a milder form of primary abdominoschisis since during the embryonic folding process the outgrowth at the umbilical ring is insufficient shortage in apoptotic cell death.
Defect may have liver, spleen, stomach, and bowel in the sac while the abdominal cavity remains underdeveloped in size. The sac is composed of chorium, Wharton's jelly and peritoneum. The defect is centrally localized and measures cm in diameter. A small defect of less than 2 cm with bowel inside is referred as a hernia of the umbilical cord.
Epigastric localized omphalocele are associated with sternal and intracardiac defects i. Cardiac, neurogenic, genitourinary, skeletal and chromosomal changes and syndromes are the cornerstones of mortality. Cesarean section is warranted in large omphaloceles to avoid liver damage and dystocia.
After initial stabilization management requires consideration of the size of defect, prematurity and associated anomalies. Primary closure with correction of the malrotation should be attempted whenever possible. Antibiotics and nutritional support are mandatory.
Manage control centers around sepsis, respiratory status, liver and bowel dysfunction from increased intraabdominal pressure. The protruding gut is foreshortened, matted, thickened and covered with a peel. The IA might be the result of pressure on the bowel from the edge of the defect pinching effect or an intrauterine vascular accident. Rarely, the orifice may be extremely narrow leading to gangrene or complete midgut atresia.
In either case the morbidity and mortality of the child is duplicated with the presence of an IA. Alternatives depend on the type of closure of the abdominal defect and the severity of the affected bowel.
With primary fascial closure and good-looking bowel primary anastomosis is justified. Angry looking dilated bowel prompts for proximal diversion, but the higher the enterostomy the greater the problems of fluid losses, electrolyte imbalances, skin excoriation, sepsis and malnutrition. Closure of the defect and resection with anastomosis two to four weeks later brings good results.
Success or failure is related to the length of remaining bowel more than the specific method used. Initially do an Apt test to determine if blood comes from fetal origin or maternal origin blood swallowed by the fetus. If this coagulation profile is normal the possibilities are either stress gastritis or ulcer disease.
If the coagulation profile is abnormal then consider hematologic disease of the newborn and manage with vitamin K. The apt test is performed by mixing 1 part of vomitus with 5 part H2O, centrifuge the mixture and remove 5 ml pink. If the coagulation profile is abnormal give Vit K for hematologic disorder of newborn. If it's normal do a rectal exam. A fissure could be the cause, if negative then consider either malrotation or Necrotizing enterocolitis.
The stress includes prematurity, sepsis, hypoxia, hypothermia, and jaundice. These babies frequently have umbilical artery, vein catheters, have received exchange transfusions or early feeds with hyperosmolar formulas.
The intestinal mucosal cells are highly sensitive to ischemia and mucosal damage leads to bacterial invasion of the intestinal wall. Gas-forming organisms produce pneumatosis intestinalis air in the bowel wall readily seen on abdominal films. Full-thickness necrosis leads to perforation, free air and abscess formation. These usually premature infants develop increased gastric residuals, abdominal distension, bloody stools, acidosis and dropping platelet count. The abdominal wall becomes reddened and edematous.
There may be persistent masses and signs of peritonitis. Perforation leads to further hypoxia, acidosis and temperature instability. The acid-base status is monitored for worsening acidosis and hypoxia. The white blood cell count may be high, low or normal and is not generally of help. Serial abdominal films are obtained to look for evidence of free abdominal air, a worsening picture of pneumatosis intestinalis, or free portal air. Therapy consist initially of stopping feeds, instituting nasogastric suctioning and beginning broad-spectrum antibiotics ampicillin and gentamycin.
Persistent or worsening clinical condition and sepsis or free air on abdominal films require urgent surgical intervention. Attempts to preserve as much viable bowel as possible are mandatory to prevent resultant short gut syndrome.
Complicated NEC is the most common neonatal surgical emergency of modern times, has diverse etiologies, significant mortality and affects mostly premature babies. Consist of a right lower quadrant incision and placement of a drainage penrose or catheter under local anesthesia with subsequent irrigation performed bedside at the NICU.
Initially used as a temporizing measure before formal laparotomy, some patient went to improvement without the need for further surgery almost one-third. They either had an immature fetal type healing process or a focal perforation not associated to NEC? Some suggestion made are: PPD should be an adjunct to preop stabilization, before placing drain be sure pt has NEC by X-rays, persistent metabolic acidosis means uncontrolled peritoneal sepsis, do not place drain in pts with inflammatory mass or rapid development of intraperitoneal fluid, the longer the drainage the higher the need for laparotomy.
In the initial evaluation a history should be obtained for bleeding disorders, skin lesions, and aspirin or steroid ingestion.
The physical exam for presence of enlarged liver, spleen, masses, ascites, or evidence of trauma or portal hypertension.
Labs such as bleeding studies and endoscopy, contrast studies if bleeding stops. Common causes of Upper GI bleeding are: Esophagus a Varices- usually presents as severe upper gastrointestinal bleeding in a year old who has previously been healthy except for problems in the neonatal period. This is a result of extrahepatic portal obstruction portal vein thrombosis most commonly , with resulting varices.
The bleeding may occur after a period of upper respiratory symptoms and coughing. Management is initially conservative with sedation and bedrest; surgery ir rarely needed. Treatment consist of antacids, frequent small feeds, occasionally medications and if not rapidly improved, then surgical intervention with a fundoplication of the stomach.
This was thought to be uncommon in children because it was not looked for by endoscopy. It probably occurs more often than previously thought. Treatment initially is conservative and, if persistent, oversewing of the tear through an incision in the stomach will be successful.
They bleed when there is ectopic gastric mucosa present. Total excision is curative. Occasionally requires surgical intervention with local repair or ligation of hepatic vessels.
Anal fissure is the most common cause of rectal bleeding in the first two years of life. Outstretching of the anal mucocutaneous junction caused by passage of large hard stools during defecation produces a superficial tear of the mucosa in the posterior midline. Pain with the next bowel movement leads to constipation, hardened stools that continue to produce cyclic problems.
Large fissures with surrounding bruising should warn against child abuse. Crohn's disease and leukemic infiltration are other conditions to rule-out. The diagnosis is made after inspection of the anal canal. Chronic fissures are associated with hypertrophy of the anal papilla or a distal skin tag.
Management is directed toward the associated constipation with stool softeners and anal dilatations, warm perineal baths to relax the internal muscle spasm, and topical analgesics for pain control.
If medical therapy fails excision of the fissure with lateral sphincterotomy is performed. Meckel's diverticulum MD , the pathologic structure resulting from persistence of the embryonic vitelline duct yolk stalk , is the most prevalent congenital anomaly of the GI tract.
MD can be the cause of: Diagnosis depends on clinical presentation. Rectal bleeding from MD is painless, minimal, recurrent, and can be identified using 99mTc- pertechnetate scan; contrasts studies are unreliable. Persistent bleeding requires arteriography or laparotomy if the scan is negative. Obstruction secondary to intussusception, herniation or volvulus presents with findings of fulminant, acute small bowel obstruction, is diagnosed by clinical findings and contrast enema studies.
The MD is seldom diagnosed preop. Diverticulitis or perforation is clinically indistinguishable from appendicitis. Mucosal polyps or fecal umbilical discharge can be caused by MD. Overall, complications of Meckel's are managed by simple diverticulectomy or resection with anastomosis. Laparoscopy can confirm the diagnosis and allow resection of symptomatic cases. Removal of asymptomatic Meckel's identified incidentally should be considered if upon palpation there is questionable heterotopic gastric or pancreatic mucosa thick and firm consistency present.
Histology features a cluster of mucoid lobes surrounded by flattened mucussecreting glandular cells mucous retention polyp , no malignant potential. Commonly seen in children age with a peak at age As a rule only one polyp is present, but occasionally there are two or three almost always confined to the rectal area within the reach of the finger.
Most common complaint is bright painless rectal bleeding. Occasionally the polyp may prolapse through the rectum. Diagnosis is by barium enema, rectal exam, or endoscopy.
Removal by endoscopy is the treatment of choice. Rarely colotomy and excision are required. Wilms tumor WT is the most common intra-abdominal malignant tumor in children affecting more than children annually in the USA. It has a peak incidence at 3. WT present as a large abdominal or flank mass with abdominal pain, asymptomatic hematuria, and occasionally fever. Other presentations include malaise, weight loss, anemia, left varicocele obstructed left renal vein , and hypertension.
Initial evaluation consists of: The presence of a solid, intrarenal mass causing intrinsic distortion of the calyceal collecting system is virtually diagnostic of Wilms tumor. Doppler sonography of the renal vein and inferior vena cava can exclude venous tumor involvement. Metastasis occurs most commonly to lungs and occasionally to liver. Operation is both for treatment and staging to determine further therapy.
Following NWTSG recommendation's primary nephrectomy is done for all but the largest unilateral tumors and further adjuvant therapy is based on the surgical and pathological findings. Important surgical caveats consist of using a generous transverse incision, performing a radical nephrectomy, exploring the contralateral kidney, avoiding tumor spillage, and sampling suspicious lymph nodes. Nodes are biopsied to determine extent of disease. Stage I- tumor limited to kidney and completely resected.
Stage II- tumor extends beyond the kidney but is completely excised. Stage III- residual non-hematogenous tumor confined to the abdomen. Stage IV- hematogenous metastasis. Stage V- bilateral tumors. Further treatment with chemotherapy or radiotherapy depends on staging and histology favorable vs. Non-favorable histologic characteristics are: Prognosis is poor for those children with lymph nodes, lung and liver metastasis.
They tend to occur in younger patients. Routine abdominal ultrasound screening every six months up to the age of eight years is recommended for children at high risk for developing WT such as the above-mentioned syndromes. It was originally thought that WT developed after the two-hit mutational model developed for retinoblastoma: When the first mutation occurs before the union the sperm and egg constitutional or germline mutation the tumor is heritable and individuals are at risk for multiple tumors.
Nonhereditary WT develops as the result of two-postzygotic mutations somatic in a single cell. The two-event hypothesis predicts that susceptible individuals such as familial cases, those with multifocal disease and those with a congenital anomaly have a lower median age at diagnosis than sporadic cases. It is now believed that several genes' mutations are involved in the overall WT pathogenesis.
Loss of whole portions of a chromosome is called loss of heterozygosity LOH , a mechanism believed to inactivate a tumor-suppressor gene. Children with the WAGR association shows a deletion in the short arm of chromosome 11 band 13 11p13 but a normal 11p15 region. Up to a third of sporadic WT have changes in the distal part of chromosome 11, a region that includes band p The region of the deletion has been named the WT1 gene, a tumor suppressor gene that also forms a complex with another known tumor-suppressor, p WT1 gene express a regulated transcription factor of the zinc-finger family proteins restricted to the genitourinary system, spleen, dorsal mesentery of the intestines, muscles, central nervous system CNS and mesothelium.
The important association of WT1 mutation and WAGR syndrome with intralobar nephrogenic rests immediately suggest that WT1 expression be necessary for the normal differentiation of nephroblasts. Inactivation of WT1 only affects organs that express this gene such as the kidney and specific cells of the gonads Sertoli cells of the testis and granulosa cells of the ovary.
WT1 has been shown to cause the Denys-Drash syndrome. Most of the mutations described in DDS patients are dominant missense mutations. A small subset of BWS has a 11p15 duplication or deletion. The region 11p15 has been designated WT2 gene and is telomeric of WT1.
This might prove that two independent loci may be involved in tumor formation. A gene for a familial form FWT1 of the tumor has also been identified in chromosome 17q. There also might be a gene predisposing to Wilms tumor at chromosome 7p, where constitutional translocations have been described. Mutation in p53 is associated with tumor progression, anaplasia and poor prognosis. Most WT are probably caused by somatic mutations in one or more of the increasing number of WT genes identified.
A few chromosomal regions have seen identified for its role in tumor progression. LOH at chromosome 16q and chromosome 1p has been implicated in progression to a more malignant or aggressive type Wilms' tumor with adverse outcome.
These children have a relapse rate three times higher and a mortality rate twelve times higher than WT without LOH at chromosome 1p. Patients with WT and a diploid DNA content indicating low proliferation have been found to have an excellent prognosis. Hyperdiploidy high mitotic activity is a poor prognostic feature of Wilms tumor, rhabdomyosarcoma and Osteosarcoma. Nephrogenic rests are precursor lesions of WT. Two types are recognized: Also the association between BWS and some cases of hemihypertrophy with abnormalities of more distant loci on chromosome 11p raises the possibility that the putative WT2 gene might be more closely linked to PLNR.
An advantage of genetic testing is that children with sporadic aniridia, hemihypertrophy or the above discussed syndromes known to be at high risk for developing WT can undergo screening of the germline DNA. This might identify if they harbor the mutation and need closer surveillance for tumor development.
Neuroblastoma NB is the most common extracranial solid tumor in infants. More than new cases are diagnosed annually in the United States. NB is a solid, highly vascular tumor with a friable pseudocapsule.
Most children present with an abdominal mass, and one-fourth have hypertension. Horner's syndrome, Panda's eyes, anemia, dancing eyes or vaso-intestinal syndrome. Diagnosis is confirmed with the use of simple X-rays stipple calcifications , Ultrasound, and CT-Scan.
Management of NB depends on the stage of disease at diagnosis. Localized tumors are best managed with surgical therapy. The Evans classification for NB staging comprised: Stage I - tumor confined to an organ of origin.
Stage II - tumor extending beyond an organ of origin, but not crossing the midline. Ipsilateral lymph nodes may be involved. Stage III - tumor extending beyond midline. Bilateral lymph nodes may be involved. Stage IV - remote disease involving skeleton, bone marrow, soft tissue or distant lymph nodes. A poor outcome is characteristic of higher stages, older patients and those with bone cortex metastasis. Other prognostic variables are: Neuroblastoma is a malignant tumor of the postganglionic sympathetic system that develops from the neural crest: In vitro three cell types have been identified: These cells are responsible for producing cathecolamines and vasoactive substances which help in diagnosis and follow-up therapy.
NB can behave seemingly benignly and undergo spontaneous regression, mature into a benign ganglioneuroma or most commonly progress to kill its host.
This disparate behavior is a manifestation that we are dealing with related tumors with differently genetic and biological features associated with a spectrum of clinical behaviors. Conclusive associations with environmental factors have not been proved in NB. Hereditary factors are important in NB since a few cases exhibit predisposition following a dominant pattern of inheritance. LOH of the short arm of chromosome 1 is also associated with an unfavorable outcome, suggesting that a tumor suppression gene may be found in this region.
The common region of deletion or LOH resides at the distal end of the short arm of chromosome 1 from 1p Loss or inactivation of a gene at this site is critical for progression of neuroblastoma. A few candidate genes from this site have been mapped.
Gain of chromosome 17 is associated with more aggressive tumors. N-myc protooncogene is found on chromosome 2p and its activation results in tumor formation. The amplified N-myc sequence is found on extrachromosomal double minutes DM or on homogeneous staining regions HSR involving different chromosomes in neuroblastoma N-type cell lines.
N-myc amplification is strongly associated with advance stages of disease, rapid tumor progression and poor outcome independent of the stage of the tumor or the age of the patient. NB tumors associated with N-myc amplification needs aggressive therapy. N-myc amplification associated with deletion of 1p is correlated with a poor outcome. Deletion of the long arm of chromosome 1 1q- is also a poor prognostic sign.
Though most NB cells are diploid, a good number of them are hyperdiploid or triploid. Neuroblast cells needs nerve growth factor NGF for proper differentiation.
NB tumor cells do not respond to NGF or do not express the receptor. High TRK-A levels correlate strongly with improved survival and plays a role in the propensity for tumors to regress or differentiate into a more benign nature. Alteration in the NGF receptor function or expression promotes tumorigenesis. In conclusion, high levels of TRK expression are associated with better prognosis, earlier stage, lower patient age and lack of N-myc expression. Neuroblastomas in newborns, cystic tumors, bilateral tumors in infants, and infants less than one year of age with neuroblastoma stage IV-S can undergo neuronal cell differentiation with spontaneous regression.
It is thought that high level of TRK-A found in this cases might explain differentiation and regression as high level of this glycoprotein is associated with a favorable prognosis. Regression might be associated with non-affected tumor cell apoptosis. Other biological markers associated with NB are the multidrug resistance-related protein MRP gene, telomerase activity and bcl-2 gene activity.
MRP shows a strong correlation with an advanced clinical stages and poor prognosis. High telomerase activity is associated with poor prognosis and high N-myc amplification. The bcl-2 gene produces a protein that prevents neuronal cell death apoptosis and promotes tumor progression. Bcl-2 expression is associated with a poor outcome.
Apoptosis in NB may result in tumor progression. The RET proto-oncogene is a protein tyrosine kinase gene Ret protein expressed in the cells derived from the neural crest. The activation of RET involves a chromosomal inversion of the long arm of chromosome 10 that juxtaposes the tyrosine kinase encoding domain of RET to the amino terminal sequences of at least three unrelated genes. Germline mutations in the RET gene have been associated with neuroblastoma, pheochromocytoma, multiple endocrine neoplasia MEN 2, familial medullary thyroid carcinoma MTC , radiation-induced thyroid papillary carcinoma, and recently Hirschsprung's disease.
RET analysis is a suitable method to detect asymptomatic children with MEN at risk to develop MTC allowing us to consider thyroidectomy at a very early stage of neoplasm development C-cell hyperplasia or prophylactically. High levels of neuron specific enolase and serum ferritin levels are associated with a poor prognosis in NB. Nm and ganglioside GD2 are still other tumor markers associated with poor outcome, active disease and tumor progression. It has a peak incidence before the age of five years, and a second surge during early adolescence.
Head, neck and pelvic malignancies are more prevalent in infancy and early childhood, while trunk, extremity and paratesticular sites are largely a disease of adolescents. RMS arises from a primitive cell type and occurs in mesenchymal tissue at almost any body site excluding brain and bone.
The predominant histologic type in infants and small children is embryonal rhabdomyosarcoma, occurring in the head and neck, genitourinary tract and retroperitoneum.
Embryonal RMS is associated with a favorable prognosis. Botryoid RMS is a subtype of the embryonal variety, which ordinarily extends into body cavities such as bladder, nasopharynx, vagina, or bile duct.
The alveolar cell type, named for a superficial similarity to the pulmonary alveoli, is the most common form found on the muscle masses of the trunk and extremities, and is seen more frequently in older children and young adults.
Alveolar RMS is associated with a poor prognosis. This unfavorable prognosis is the result of early and wide dissemination, bones marrow involvement and poor response to chemotherapy.
Clinical findings, diagnostic evaluation and therapy depend upon location of the primary tumor and are beyond the scope of this review. Head and neck RMS are most common and occur in the orbit, nasopharynx, paranasal sinuses, cheek, neck, middle ear, and larynx.
Most are treated by simple biopsy followed by combined therapy or preoperative chemotherapy and radiation followed by conservative resection.
Operations for extremity lesions include wide local excision to remove as much of gross tumor as possible. The trend in management is more chemotherapy with conservative surgical therapy. Survival has depended on primary site, stage of disease, and treatment given. Most RMS occurs sporadically. Other risk factors in the development of RMS include maternal use of marijuana and cocaine, exposure to radiation, and maternal history of stillbirth.
Alveolar and embryonal RMS are the most genetically studied sarcomas in children. In alveolar RMS novel fusion genes encoding chimeric fusion proteins have been identified. The t 2;13 activates the oncogenic potential of PAX3 by dysregulating or exaggerating its normal function in the myogenic lineage and affecting the cellular activities of growth, differentiation and apoptosis. PAX7-FKHR tumors tend to occur in younger patients, are more often in the extremity, are more often localized lesions and are associated with significantly longer event-free survival.
Still, a small subset of alveolar RMS does not contain either fusion mutation. Identification of fusion gene status by PCR is a useful diagnostic tool in differentiating RMS from other round cell tumors.
Embryonal RMS contains frequent allelic loss on chromosome 11 11p15 , a genetic feature specific for this type of tumor. Allelic loss is manifested by the absence of one of the two signals in the tumor cells indicating a genetic event such as a chromosome loss, deletion, or mitotic recombination that eliminates one allele and the surrounding chromosomal region.
The smallest affected region has been localized to chromosomal region 11p The presence of a consistent region of allelic loss is often indicative of the presence of a tumor suppressor gene inactivated in the associated malignancy. The mechanism for inactivation of tumor suppressor genes is postulated to be a two-hit scenario in which both copies of the gene are sequentially inactivated: This leads to over expression of the insulin-like growth factor II gene known to play a role in the development of embryonal tumors.
Notably, these distinct changes predominantly involved chromosomes 2, 12, and 13 in both subtypes. Both tumors share alterations in the p53 gene at the germline level contributing to increase susceptibility to other tumors characteristics of the Li-Fraumeni syndrome.
All this favors a multi-step origin of RMS tumors generating phenotypic changes of growth autonomy, abnormal differentiation and motility. More than one-half of the cancers overall and nearly one-third of the breast cancers were diagnosed before 30 years of age. Among females, breast cancer is the most common.
Germline mutations within a defined region of the p53 gene have been found in families with the Li-Fraumeni syndrome. Persistence of the mutation in the germline suggests a defect in DNA repair in the family member first affected. Asymptomatic carriers of p53 germline mutation needs closed evaluation and follow-up for early detection and treatment in case neoplasia develops. Hepatoblastoma HB is the most common primary malignant neoplasm of the liver in children mostly seen in males less than four year of age.
Diagnostic laparotomy will decide resectability. Markers associated to this tumor are: Only reliable chances of cure is surgical excision although half are unresectable at dx. Unresectable tumors can be managed with preop chemotx. Disadvantages of preop chemotx are: Tumor necrosis is more extensive in pt.
Osteoid present in tumors after chemotx may represent an inherent ability of the tumor to maturate and differentiate. Diploid tumors on DNA flow cytometry show a better prognosis.
Sacrococcygeal teratoma SCT is the most common extragonadal germ cell tumor in neonates with an incidence of one in , live births. SCT present as a large, firm or more commonly cystic masses that arise from the anterior surface of the sacrum or coccyx, protruding and forming a large external mass.
Histology consist of tissue from the three germ cell layers. SCT is classified as: Prenatal sonographic diagnostic severity criteria are: Large tumors should benefit from cesarean section to avoid dystocia or tumor rupture. Management consist of total tumor resection with coccyx recurrence is associated with leaving coccyx in place.
Every recurrence of SCT should be regarded as potentially malignant. Aggressive surgery is limited to avoid compromising reproductive capacity and endocrine function. Low incidence and need of mulitinodal therapy encourages referral to centers dealing with effective cancer therapy.
The most common histology is germ cell: This is followed by the sex-cord stroma tumors with a low incidence of malignancy.
They can cause feminization granulosa-theca cell and masculinization androblastoma. Ovarian tumors present with acute abdominal symptoms pain from impending rupture or torsion. They also cause painless abdominal enlargement, or hormonal changes. Preop work-up should include: The most important prognostic factor in malignant tumors is stage of disease at time of diagnosis. Objectives of surgery are: Radiotherapy is generally not effective, except in dysgerminoma.
The need to differentiate malignant from benign thyroid nodules is the most challenging predicament in management. After reviewing our ten-year experience with twenty-four pediatric thyroid nodules we found nineteen benign and five malignant lesions. Benign nodules were soft, movable, solitary and non-tender.
Malignant nodules were found during late adolecence, characterized by localized tenderness, a multigandular appearance and fixation to adjacent tissues. US and RNS were of limited utility since malignancy was identified among cystic and hot nodules respectively. Suppressive thyroid hormone therapy was useless in the few cases tried.
FNAB in eighteen cases did not limit the number of thyroid resections. This is the result of a higher number of patients with follicular cell cytology in the aspirate. No attempts should be made to differentiate follicular adenoma from carcinoma since capsular and vascular invasion cannot be adequately assessed by FNAB. The physical exam findings, persistence of the nodule, progressive growth and cosmetic appearance were the main indications for surgery. FNAB is a safe procedure that plays a minor role in the decision to withhold surgery.
Its greatest strength is to anticipate in case of malignancy that a more radical procedure is probably needed. In spite of presenting with advanced, multicentric and larger tumors children have a better survival than adults.
Clinical presentation is a solitary cervical mass or metastatic lymph node. Diagnostic work-up should include: Complications of surgery increase with decreasing age of patient: Prognostic factors associated to higher mortality are: Follow-up for recurrence with serum thyroglobulin level and radioisotope scans. Burkitt's lymphoma BL is a highly malignant tumor first described during the late 50's in African children jaw , endemic in nature, and composed of undifferentiated lympho-reticular cells with uniform appearance.
The head and neck region follows. The tumor can appear as a localized, diffuse multifocal, non-resectable or metastatic abdominal mass bone marrow and CNS.
It's considered the fastest growing tumor in humans with a doubling time around hrs. Chemotherapy is the primary treatment modality due to its effectiveness in rapidly proliferating cells. The role of surgery is to establish the diagnosis using open biopsy , stage the tumor, remove localized disease, relieve intestinal obstruction and provide vascular access.
Complete resection whenever possible offers the patient improved survival. Is more readily accomplished in patients with localized bowel involvement operated on an emergency basis due to acute abdominal symptoms.
The only predictor of event free survival is extent of abdominal disease at diagnosis. Debulking cytoreductive procedures increases morbidity and delays initiation of chemotherapy worsening prognosis.
Bone marrow and CNS involvement are ominous prognostic signs. Neonatal Physiologic Characteristics Fluid and Electrolytes Concepts B. Variations in Individual Newborns Types of Newborns Infants Metabolic and Host Defenses Surgical Response of Newborns. Thyroglossal Duct Cyst D.
Branchial Cleft Fistula E. Malrotation and Volvulus D. Total Colonic Aganglionosis G. Chronic Intestinal Pseudo-obstruction L. Congenital Diaphragmatic Hernia Bochdalek Processus Vaginalis Remnants Upper GI bleeding Newborn B. Lower GI bleeding Newborn Upper GI bleeding Older child D. Idiopathic Perforation Bile Ducts. Labial Adhesions in Infants B.
Fetal Intestinal Obstruction C. Physiology of the Pneumoperitoneum B. Millions of Jews and other peoples deemed undesirable by the state were murdered in the Holocaust. Opposition to Hitler's rule was ruthlessly suppressed. Members of the liberal, socialist, and communist opposition were killed, imprisoned, or exiled. Christian churches were oppressed, with many leaders imprisoned. Education focused on racial biology , population policy, and fitness for military service.
Career and educational opportunities for women were curtailed. Recreation and tourism were organised via the Strength Through Joy program, and the Summer Olympics showcased the Third Reich on the international stage. Propaganda Minister Joseph Goebbels made effective use of film, mass rallies, and Hitler's hypnotic oratory to influence public opinion.
The government controlled artistic expression, promoting specific art forms and banning or discouraging others. Beginning in the late s, Nazi Germany made increasingly aggressive territorial demands, threatening war if they were not met.
It seized Austria and Czechoslovakia in and In alliance with Italy and smaller Axis powers , Germany conquered most of Europe by and threatened the United Kingdom. Reichskommissariats took control of conquered areas and a German administration was established in what was left of Poland. Jews and others deemed undesirable were imprisoned, murdered in Nazi concentration camps and extermination camps , or shot. Following the German invasion of the Soviet Union in , the tide turned against the Nazis, who suffered major military defeats in Large-scale aerial bombing of Germany escalated in and the Axis powers were pushed back in Eastern and Southern Europe.
Following the Allied invasion of France , Germany was conquered by the Soviet Union from the east and the other Allied powers from the west and capitulated in May Hitler's refusal to admit defeat led to massive destruction of German infrastructure and additional war-related deaths in the closing months of the war.
The victorious Allies initiated a policy of denazification and put many of the surviving Nazi leadership on trial for war crimes at the Nuremberg trials. The latter, adopted by Nazi propaganda as Drittes Reich , was first used in a book by Arthur Moeller van den Bruck. The German economy suffered severe setbacks after the end of World War I, partly because of reparations payments required under the Treaty of Versailles.
The government printed money to make the payments and to repay the country's war debt, but the resulting hyperinflation led to inflated prices for consumer goods, economic chaos, and food riots.
When the stock market in the United States crashed on 24 October , the effect in Germany was dire. They promised to strengthen the economy and provide jobs. Although the Nazis won the greatest share of the popular vote in the two Reichstag general elections of , they did not have a majority and therefore Hitler led a short-lived coalition government formed with the German National People's Party.
This event is known as the Machtergreifung "seizure of power". On the night of 27 February , the Reichstag building was set afire. Marinus van der Lubbe , a Dutch communist, was found guilty of starting the blaze. Hitler proclaimed that the arson marked the start of a communist uprising. Violent suppression of communists by the Sturmabteilung SA was undertaken nationwide and 4, members of the Communist Party of Germany were arrested.
The Reichstag Fire Decree , imposed on 28 February , rescinded most civil liberties, including rights of assembly and freedom of the press. The decree also allowed the police to detain people indefinitely without charges or a court order.
The legislation was accompanied by a propaganda blitz that led to public support for the measure. In March , the Enabling Act , an amendment to the Weimar Constitution , passed in the Reichstag by a vote of to The remaining major political parties followed suit: The founding of new parties was also made illegal, and all remaining political parties which had not already been dissolved were banned. In the following months, the Hitler cabinet used the terms of the Reichstag Fire Decree and later the Enabling Act to initiate the process of Gleichschaltung "co-ordination" , which brought all aspects of life under the control of the party.
These Commissars had the power to appoint and remove local governments, state parliaments, and officials and judges. In this way Germany became a de facto unitary state , with all state governments controlled by the central government under the NSDAP. The state governments were subsequently rendered subordinate to the Reich government. All civilian organisations, including agricultural groups, volunteer organisations, and sports clubs, had their leadership replaced with Nazi sympathisers or party members; these civic organisations either merged with the NSDAP or faced dissolution.
The celebrations were merely a pretext for the forcible takeover of Germany's trade unions. While many trade union delegates were in Berlin for May Day activities, SA stormtroopers demolished union offices around the country.
On 2 May all trade unions were forced to dissolve and their leaders were arrested. The Nazi regime also abolished the symbols of the Weimar Republic—including the black, red, and gold tricolour flag —and adopted reworked imperial symbolism.
The previous imperial black, white, and red tricolour was restored as one of Germany's two official flags; the second was the swastika flag of the NSDAP, which became the sole national flag in Hitler knew that reviving the economy was vital. Germany was still in a dire economic situation, as six million people were unemployed and the balance of trade deficit was daunting. Shortly after the NSDAP's seizure of power, the demands of the SA for greater political and military power began to cause anxiety among military, industrial, and political leaders.
Ernst Röhm , Stabschef Chief of Staff of the SA, regarded the SA as the vanguard of the Nazi seizure of power and supported a "second revolution" directed against German businesses, the finance industry, the Junkers , and even the senior staff of the German military.
Röhm envisioned the SA supplanting the Reichswehr Defense Force as the country's primary army, with himself and the leadership of the SA at its head. On 2 August , President von Hindenburg died. The previous day, the cabinet had enacted the "Law Concerning the Highest State Office of the Reich", which stated that upon Hindenburg's death the office of president would be abolished and its powers merged with those of the chancellor.
The new law altered the traditional loyalty oath of servicemen so that they affirmed loyalty to Hitler personally rather than the office of supreme commander or the state. Most Germans were relieved that the conflicts and street fighting of the Weimar era had ended. They were deluged with propaganda orchestrated by Joseph Goebbels , who promised peace and plenty for all in a united, Marxist-free country without the constraints of the Versailles Treaty.
Beginning in April , scores of measures defining the status of Jews and their rights were instituted at the regional and national level. They eventually declared them undesirable to remain among German citizens and society, which over time dehumanised the Jews.
Arguably, these actions desensitised Germans to the extent that it resulted in the Holocaust. Ethnic Germans who refused to ostracise Jews or who showed any signs of resistance to Nazi propaganda were placed under surveillance by the Gestapo , had their rights removed, or were sent to concentration camps. Following the passage of the Enabling Act and the NSDAP seizure of power in early , Hitler found Germany without allies and with a military still drastically weakened by the terms of the Treaty of Versailles.
France, Poland, Italy, and the Soviet Union each had motivations to object to Hitler's rise to power. Poland suggested to France that the two nations engage in a preventive war against Germany in March Fascist Italy meanwhile objected to potential German claims in the Balkans and on Austria , which Duce Benito Mussolini considered to be in Italy's sphere of influence.
Foreign policy under Hitler repeatedly stressed Germany's peaceful intentions to the rest of the world, while at the same time conducting a rearmament programme in secret without risking international sanctions or war. On 17 May , Hitler gave a speech before the Reichstag outlining his desire for world peace , while at the same time accepting an offer from American President Franklin D. Roosevelt for military disarmament, provided the other nations of Europe did the same.
In , Hitler told his military leaders that was the target date for going to war in the east. When the Italian invasion of Ethiopia led to only mild protests by the British and French governments, on 7 March Hitler used the Franco-Soviet Treaty of Mutual Assistance as a pretext to order the Wehrmacht Heer to march 3, troops into the demilitarised zone in the Rhineland in violation of the Versailles Treaty.
These included tanks, planes, and the Condor Legion , which destroyed the city of Guernica during the war. The Nationalists were victorious in and became an informal ally of Nazi Germany. Schuschnigg scheduled a plebiscite regarding Austrian independence for 13 March, but Hitler demanded that it be cancelled. The Wehrmacht entered Austria the next day, to be greeted with enthusiasm by the populace.
The Republic of Czechoslovakia was home to a substantial minority of Germans, who lived mostly in the Sudetenland. Under pressure from separatist groups within the Sudeten German Party , the Czechoslovak government offered economic concessions to the region. The crisis led to war preparations by the British, the Czechoslovaks, and France Czechoslovakia's ally.
Attempting to avoid war, British Prime Minister Neville Chamberlain arranged a series of meetings, the result of which was the Munich Agreement , signed on 29 September The Czechoslovak government was forced to accept the Sudetenland's annexation into Germany.
Chamberlain was greeted with cheers when he landed in London, saying it brought "peace for our time". Austrian and Czech foreign exchange reserves were seized by the Nazis, as were stockpiles of raw materials such as metals and completed goods such as weaponry and aircraft, which were shipped to Germany.
The Reichswerke Hermann Göring industrial conglomerate took control of steel and coal production facilities in both countries. In January , Germany signed a non-aggression pact with Poland, which disrupted the French network of anti-German alliances in Eastern Europe. The British announced they would come to the aid of Poland if it was attacked. Hitler, believing the British would not actually take action, ordered an invasion plan should be readied for a target date of September The Germans reaffirmed their alliance with Italy and signed non-aggression pacts with Denmark, Estonia, and Latvia whilst trade links were formalised with Romania, Norway, and Sweden.
Germany's wartime foreign policy involved the creation of allied governments under direct or indirect control from Berlin. A main goal was obtaining soldiers from the senior allies such as Italy and Hungary and workers and food supplies from subservient allies such as Vichy France. Although Japan was a powerful ally, the relationship was distant, with little co-ordination or co-operation. For example, Germany refused to share their formula for synthetic oil from coal until late in the war.
Honouring their treaty obligations, Britain and France declared war on Germany two days later. Initially the intention was to deport them further east, or possibly to Madagascar.
But little other activity occurred until May, so the period became known as the " Phoney War ". From the start of the war, a British blockade on shipments to Germany affected the Reich economy. The Germans were particularly dependent on foreign supplies of oil, coal, and grain. On 9 April, Germany invaded both nations. Denmark fell after less than a day , while most of Norway was also under German occupation by the end of the month. Against the judgement of many of his senior military officers, Hitler ordered an attack on France and the Low Countries , which began in May after months of delay.
In spite of the provisions of the Hague Convention , industrial firms in the Netherlands, France and Belgium were put to work producing war materiel for the occupying German military. Officials viewed this option as being preferable to their citizens being deported to the Reich as forced labour. The Nazis seized from the French thousands of locomotives and rolling stock, stockpiles of weapons, and raw materials such as copper, tin, oil, and nickel.
Grand Admiral Erich Raeder had advised Hitler in June that air superiority was a pre-condition for a successful invasion of Britain , so Hitler ordered a series of aerial attacks on Royal Air Force RAF airbases and radar stations, as well as nightly air raids on British cities, including London, Plymouth , and Coventry. The German Luftwaffe failed to defeat the RAF in what became known as the Battle of Britain , and by the end of October, Hitler realised that air superiority could not be achieved.
He permanently postponed the invasion, a plan which the commanders of the Wehrmacht had never taken entirely seriously. On 22 June , contravening the Molotov—Ribbentrop Pact, 5.
In addition to Hitler's stated purpose of acquiring Lebensraum , this large-scale offensive—codenamed Operation Barbarossa —was intended to destroy the Soviet Union and seize its natural resources for subsequent aggression against the Western powers. The invasion conquered a huge area, including the Baltic republics, Belarus , and West Ukraine.
After the successful Battle of Smolensk , Hitler ordered Army Group Centre to halt its advance to Moscow and temporarily divert its Panzer groups to aid in the encirclement of Leningrad and Kiev.
The Moscow offensive, which resumed in October , ended disastrously in December. Four days later, Germany declared war on the United States. Food was in short supply in the conquered areas of the Soviet Union and Poland, with rations inadequate to meet nutritional needs.
The retreating armies had burned the crops and much of the remainder was sent back to the Reich. The harvest was good, and food supplies remained adequate in Western Europe. Germany and Europe as a whole was almost totally dependent on foreign oil imports. Soviet forces continued to push the invaders westward after the failed German offensive at the Battle of Kursk and by the end of the Germans had lost most of their Eastern territorial gains.
By targeting oil refineries and factories, they crippled the German war effort by late Hitler also ordered the destruction of transport, bridges, industries, and other infrastructure—a scorched earth decree—but Armaments Minister Albert Speer was able to keep this order from being fully carried out.
Suicide rates in Germany increased as the war drew to a close, particularly in areas where the Red Army was advancing. More than a thousand people out of a population of around 16, committed suicide in Demmin on and around 1 May as the 65th Army of 2nd Belorussian Front first broke into a distillery and then rampaged through the town, committing mass rapes, arbitrarily executing civilians, and setting fire to buildings.
High numbers of suicides took place in many other locations, including Neubrandenburg dead , Stolp in Pommern 1, dead ,  and Berlin, where at least 7, people committed suicide in Estimates of the total German war dead range from 5. At the end of the war, Europe had more than 40 million refugees ,  its economy had collapsed, and 70 percent of its industrial infrastructure was destroyed.
The Saarland temporarily became a protectorate of France under the condition that its residents would later decide by referendum which country to join, and Poland became a separate nation and was given access to the sea by the creation of the Polish Corridor, which separated Prussia from the rest of Germany, while Danzig was made a free city.
Germany regained control of the Saarland through a referendum held in and annexed Austria in the Anschluss of Some of the conquered territories were incorporated into Germany as part of Hitler's long-term goal of creating a Greater Germanic Reich.
Several areas, such as Alsace-Lorraine, were placed under the authority of an adjacent Gau regional district. Beyond the incorporated territories were the Reichskommissariate Reich Commissariats , quasi-colonial regimes established in some occupied countries. Areas placed under German administration included the Protectorate of Bohemia and Moravia , Reichskommissariat Ostland encompassing the Baltic states and Belarus , and Reichskommissariat Ukraine.
Part of Poland was incorporated into the Reich, and the General Government was established in occupied central Poland. With the issuance of the Berlin Declaration on 5 June and later creation of the Allied Control Council , the four Allied powers temporarily assumed governance of Germany. Germany was split into four zones, each occupied by one of the Allied powers, who drew reparations from their zone.
Since most of the industrial areas were in the western zones, the Soviet Union was transferred additional reparations. In , Germany finalised her border with Poland by signing the Treaty of Warsaw. The NSDAP was a far-right political party which came into its own during the social and financial upheavals that occurred with the onset of the Great Depression in Influenced by the Völkisch movement , the regime was against cultural modernism and supported the development of an extensive military at the expense of intellectualism.
Hitler ruled Germany autocratically by asserting the Führerprinzip "leader principle" , which called for absolute obedience of all subordinates. He viewed the government structure as a pyramid, with himself—the infallible leader—at the apex. Party rank was not determined by elections, and positions were filled through appointment by those of higher rank. Germans speak with mystification of Hitler's 'hypnotic' appeal".
Top officials reported to Hitler and followed his policies, but they had considerable autonomy. Successive Reichsstatthalter decrees between and abolished the existing Länder constituent states of Germany and replaced them with new administrative divisions , the Gaue , headed by NSDAP leaders Gauleiters , who governed their respective regions. This led to a bureaucratic tangle of overlapping jurisdictions and responsibilities typical of the administrative style of the Nazi regime. Jewish civil servants lost their jobs in , except for those who had seen military service in World War I.
In August , civil servants and members of the military were required to swear an oath of unconditional obedience to Hitler. These laws became the basis of the Führerprinzip , the concept that Hitler's word overrode all existing laws. Most of the judicial system and legal codes of the Weimar Republic remained in use during and after the Nazi era to deal with non-political crimes. Thousands were arrested and confined indefinitely without trial. A new type of court, the Volksgerichtshof People's Court , was established in to deal with politically important matters.
In September , the Nuremberg Laws were enacted. These laws initially prohibited sexual relations and marriages between Aryans and Jews and were later extended to include "Gypsies, Negroes or their bastard offspring". The wording of the law also permitted the Nazis to deny citizenship to anyone who was not supportive enough of the regime. The unified armed forces of Germany from to were called the Wehrmacht. This included the Heer army , Kriegsmarine navy , and the Luftwaffe air force.
From 2 August , members of the armed forces were required to pledge an oath of unconditional obedience to Hitler personally. In contrast to the previous oath, which required allegiance to the constitution of the country and its lawful establishments, this new oath required members of the military to obey Hitler even if they were being ordered to do something illegal. In spite of efforts to prepare the country militarily, the economy could not sustain a lengthy war of attrition such as had occurred in World War I.
A strategy was developed based on the tactic of Blitzkrieg "lightning war" , which involved using quick coordinated assaults that avoided enemy strong points. Attacks began with artillery bombardment, followed by bombing and strafing runs.
Next the tanks would attack and finally the infantry would move in to secure the captured area. The decision to attack the Soviet Union and the decisive defeat at Stalingrad led to the retreat of the German armies and the eventual loss of the war. Röhm hoped to assume command of the army and absorb it into the ranks of the SA. Up to people were killed from 30 June to 2 July in an event that became known as the Night of the Long Knives. Initially a force of a dozen men under the auspices of the SA, the Schutzstaffel SS; Protection Squadron grew to become one of the largest and most powerful groups in Nazi Germany.
Himmler hoped it would eventually replace the existing police system. This holding company owned housing corporations, factories, and publishing houses. From forward, the SS was heavily involved in the persecution of Jews, who were rounded up into ghettos and concentration camps. The most pressing economic matter the Nazis initially faced was the 30 percent national unemployment rate.
Hjalmar Schacht , President of the Reichsbank and Minister of Economics, created in May a scheme for deficit financing.
Capital projects were paid for with the issuance of promissory notes called Mefo bills. When the notes were presented for payment, the Reichsbank printed money. Hitler and his economic team expected that the upcoming territorial expansion would provide the means of repaying the soaring national debt. On 17 October , aviation pioneer Hugo Junkers , owner of the Junkers Aircraft Works , was arrested, and within a few days his company was expropriated.
In concert with other aircraft manufacturers and under the direction of Aviation Minister Göring, production was ramped up industry-wide. From a workforce of 3, people producing units per year in , the industry grew to employ a quarter of a million workers manufacturing over 10, technically advanced aircraft annually less than ten years later.
An elaborate bureaucracy was created to regulate imports of raw materials and finished goods with the intention of eliminating foreign competition in the German marketplace and improving the nation's balance of payments. The Nazis encouraged the development of synthetic replacements for materials such as oil and textiles. Any profits in excess of that amount would be turned over to the Reich.
By , Farben regretted making the deal, as the excess profits by then being generated had to be given to the government. Major public works projects financed with deficit spending included the construction of a network of Autobahnen and providing funding for programmes initiated by the previous government for housing and agricultural improvements.
Envisioning widespread car ownership as part of the new Germany, Hitler arranged for designer Ferdinand Porsche to draw up plans for the KdF-wagen Strength Through Joy car , intended to be an automobile that everyone could afford. With the outbreak of World War II, the factory was converted to produce military vehicles. None were sold until after the war, when the vehicle was renamed the Volkswagen people's car. Six million people were unemployed when the Nazis took power in and by there were fewer than a million.
By early , the focus shifted from funding work creation schemes, towards rearmament. By , military expenditures accounted for 73 percent of the government's purchases of goods and services. The Nazi war economy was a mixed economy that combined a free market with central planning. Historian Richard Overy described it as being somewhere in between the command economy of the Soviet Union and the capitalist system of the United States.
Germany imported and enslaved some 12 million people from 20 European countries to work in factories and on farms. Approximately 75 percent were Eastern European. Poor living conditions led to high rates of sickness, injury and death, as well as sabotage and criminal activity. Foreign workers brought into Germany were put into four different classifications: Each group was subject to different regulations.
In addition, the Nazis issued a ban on sexual relations between Germans and foreign workers. By over a half million women served as auxiliaries in the German armed forces. They also took over jobs formerly held by men, especially on farms and in family-owned shops.
Very heavy strategic bombing by the Allies targeted refineries producing synthetic oil and gasoline , as well as the German transportation system, especially rail yards and canals. By November, fuel coal was no longer reaching its destinations and the production of new armaments was no longer possible. During the course of the war, the Nazis extracted considerable amounts of plunder from the territories and nations they conquered across Europe.
Historian and war correspondent William L. By February , the Reichsfinanzministerium Ministry of Finance had calculated that 48 billion Reichsmarks had been paid to Germany. By the end of the war, occupation costs were calculated by the Nazis to number 60 billion Reichsmarks, with France alone paying The Bank of France was also forced to provide 4.
The Nazis exploited other conquered nations in a similar way. After the war, the United States Strategic Bombing Survey concluded Germany had obtained billion Reichsmarks in the form of occupation costs and other wealth transfers from the whole of occupied Europe, including two-thirds of the gross domestic product of Belgium and the Netherlands.
Nazi plunder included private and public art collections, artefacts, precious metals, books, and personal possessions. Hitler and Göring in particular were interested in acquiring looted art treasures from occupied Europe,  the former planning to use the stolen art to fill the galleries of the planned Führermuseum Leader's Museum ,  and the latter for his personal collection. Göring, having stripped almost all of occupied Poland of its artworks within six months of Germany's invasion, ultimately grew a collection valued at over 50 million Reichsmarks.
France saw the greatest extent of Nazi plunder. Some 26, railroad cars of art treasures, furniture, and other looted items were sent to Germany from France.
Goods and raw materials were also taken. In France, an estimated 9,, tonnes 8,, long tons; 9,, short tons of cereals were seized and transported to Germany during the course of the war. The valuation of this loot is estimated to be The plunder of Poland for raw materials began even before Germany had finished its invasion of the country. Poland can only be administered by utilizing the country through means of ruthless exploitation, deportation of all supplies, raw materials, machines, factory instilations, ect.
Poland shall be treated as a colony. The Poles shall be the slaves of the Greater German Reich. Following Operation Barbarossa, the Soviet Union was also plundered. In alone, 9,, tons of cereals, 2,, tonnes 2,, long tons; 2,, short tons of fodder, 3,, tonnes 3,, long tons; 3,, short tons of potatoes, and , tonnes , long tons; , short tons of meats were sent back to Germany. By the time the last German troops left Soviet territory in , some 12 million pigs and 13 million sheep had also been taken.
The total value of Germany's plunder of the Soviet Union is estimated at 4 billion Reichsmarks. This relatively low number in comparison to the occupied nations of Western Europe can be attributed to the devastating fighting on the Eastern Front. Nazi Germany's racial policy was based on their belief in the existence of a superior master race. The Nazis postulated the existence of a racial conflict between the Aryan master race and inferior races, particularly Jews, who were viewed as a mixed race that had infiltrated society and were responsible for the exploitation and repression of the Aryan race.
Discrimination against Jews began immediately after the seizure of power. Following a month-long series of attacks by members of the SA on Jewish businesses and synagogues, on 1 April Hitler declared a national boycott of Jewish businesses. The regime used violence and economic pressure to encourage Jews to voluntarily leave the country. Citizens were harassed and subjected to violent attacks. In November , a young Jewish man requested an interview with the German ambassador in Paris and met with a legation secretary, whom he shot and killed to protest his family's treatment in Germany.
Members of the SA damaged or destroyed synagogues and Jewish property throughout Germany. The Jewish community was fined one billion marks to pay for the damage caused by Kristallnacht and told that any insurance settlements would be confiscated. Emigrants to Palestine were allowed to transfer property there under the terms of the Haavara Agreement , but those moving to other countries had to leave virtually all their property behind, and it was seized by the government.
Like the Jews, the Romani people were subjected to persecution from the early days of the regime. As a non-Aryan race, they were forbidden to marry people of German extraction. Romani were shipped to concentration camps starting in and were killed in large numbers. Action T4 was a programme of systematic murder of the physically and mentally handicapped and patients in psychiatric hospitals that mainly took place from to , and continued until the end of the war.
Initially the victims were shot by the Einsatzgruppen and others; in addition gas chambers and gas vans using carbon monoxide were used by early Mentally and physically ill people were also targeted. Most of the victims came from disadvantaged groups such as prostitutes, the poor, the homeless, and criminals. Germany's war in the East was based on Hitler's long-standing view that Jews were the great enemy of the German people and that Lebensraum was needed for Germany's expansion.
Hitler focused his attention on Eastern Europe, aiming to defeat Poland and the Soviet Union and remove or kill the resident Jews and Slavs. The Generalplan Ost "General Plan for the East" called for deporting the population of occupied Eastern Europe and the Soviet Union to Siberia, for use as slave labour or to be murdered.
Around the time of the failed offensive against Moscow in December , Hitler resolved that the Jews of Europe were to be exterminated immediately. Some would be worked to death and the rest would be killed in the implementation of Die Endlösung der Judenfrage the Final Solution of the Jewish question. German citizens had access to information about what was happening, as soldiers returning from the occupied territories would report on what they had seen and done.
Evans states that most German citizens disapproved of the genocide. In addition to eliminating Jews, the Nazis planned to reduce the population of the conquered territories by 30 million people through starvation in an action called the Hunger Plan. Food supplies would be diverted to the German army and German civilians. Cities would be razed and the land allowed to return to forest or resettled by German colonists.
Poles were viewed by Nazis as subhuman non-Aryans, and during the German occupation of Poland 2. The German authorities engaged in a systematic effort to destroy Polish culture and national identity. During operation AB-Aktion , many university professors and members of the Polish intelligentsia were arrested, transported to concentration camps, or executed. During the war, Poland lost an estimated 39 to 45 percent of its physicians and dentists, 26 to 57 percent of its lawyers, 15 to 30 percent of its teachers, 30 to 40 percent of its scientists and university professors and 18 to 28 percent of its clergy.
Between June and January , the Nazis killed an estimated 2. Antisemitic legislation passed in led to the removal of all Jewish teachers, professors and officials from the education system. Frequent and often contradictory directives were issued by Interior Minister Wilhelm Frick, Bernhard Rust of the Reichserziehungsministerium Ministry of Education , and various other agencies regarding content of lessons and acceptable textbooks for use in primary and secondary schools.
Detailed National Socialist indoctrination of future holders of elite military rank was undertaken at Order Castles. Primary and secondary education focused on racial biology, population policy, culture, geography, and especially physical fitness. At universities, appointments to top posts were the subject of power struggles between the education ministry, the university boards, and the National Socialist German Students' League.
Religion in Germany . When the Nazis seized power in , roughly 67 percent of the population of Germany was Protestant , 33 percent was Roman Catholic , while Jews made up less than 1 percent.
Under the Gleichschaltung process, Hitler attempted to create a unified Protestant Reich Church from Germany's 28 existing Protestant state churches ,  with the ultimate goal of eradication of the churches in Germany. Persecution of the Catholic Church in Germany followed the Nazi takeover. Catholic schools were required to reduce religious instruction and crucifixes were removed from state buildings.
Pope Pius XI had the " Mit brennender Sorge " "With Burning Concern" encyclical smuggled into Germany for Passion Sunday and read from every pulpit as it denounced the systematic hostility of the regime toward the church. Enrolment in denominational schools dropped sharply and by all such schools were disbanded or converted to public facilities. He planned the "extermination of the foreign Christian faiths imported into Germany", and for the Bible and Christian cross to be replaced in all churches, cathedrals, and chapels with copies of Mein Kampf and the swastika.
Nazi Germany had a strong anti-tobacco movement as pioneering research by Franz H. Müller in demonstrated a causal link between tobacco smoking and lung cancer.
Government-run health care insurance plans were available, but Jews were denied coverage starting in That same year, Jewish doctors were forbidden to treat government-insured patients. In , Jewish doctors were forbidden to treat non-Jewish patients and in their right to practice medicine was removed entirely. Medical experiments, many of them pseudoscientific , were performed on concentration camp inmates beginning in Josef Mengele , camp doctor at Auschwitz.
Women were a cornerstone of Nazi social policy and the Nazis opposed the feminist movement, claiming that it was the creation of Jewish intellectuals, instead advocating a patriarchal society in which the German woman would recognise that her "world is her husband, her family, her children, and her home". Courses were offered on childrearing, sewing and cooking. Women were encouraged to leave the workforce and the creation of large families by racially suitable women was promoted through a propaganda campaign.
Women received a bronze award—known as the Ehrenkreuz der Deutschen Mutter Cross of Honour of the German Mother —for giving birth to four children, silver for six and gold for eight or more. Though the measures led to increases in the birth rate, the number of families having four or more children declined by five percent between and After the war started, slave labourers were extensively used.
The Nazi regime discouraged women from seeking higher education since Nazi leaders held conservative views about women and endorsed the idea that rational and theoretical work was alien to a woman's nature since they were considered inherently emotional and instinctive — as such, engaging in academics and careerism would only "divert them from motherhood".
The number of women enrolled in post-secondary schools dropped from , in to 51, in However, with the requirement that men be enlisted into the armed forces during the war, women comprised half of the enrolment in the post-secondary system by Women were expected to be strong, healthy and vital. The BDM's activities focused on physical education, with activities such as running, long jumping, somersaulting, tightrope walking, marching and swimming.
The Nazi regime promoted a liberal code of conduct regarding sexual matters and was sympathetic to women who bore children out of wedlock. Soldier's wives were frequently involved in extramarital relationships. Sex was sometimes used as a commodity to obtain better work from a foreign labourer. With Hitler's approval, Himmler intended that the new society of the Nazi regime should destigmatise illegitimate births, particularly of children fathered by members of the SS, who were vetted for racial purity.
Existing laws banning abortion except for medical reasons were strictly enforced by the Nazi regime. The number of abortions declined from 35, per year at the start of the s to fewer than 2, per year at the end of the decade, though in a law was passed allowing abortions for eugenics reasons. Nazi society had elements supportive of animal rights and many people were fond of zoos and wildlife. In , the Nazis enacted a stringent animal-protection law that affected what was allowed for medical research.
The Reich Forestry Office under Göring enforced regulations that required foresters to plant a wide variety of trees to ensure suitable habitat for wildlife and a new Reich Animal Protection Act became law in Evans , The Coming of the Third Reich The regime promoted the concept of Volksgemeinschaft , a national German ethnic community.
The goal was to build a classless society based on racial purity and the perceived need to prepare for warfare, conquest and a struggle against Marxism. In addition to taking control of tens of thousands of previously privately run recreational clubs, it offered highly regimented holidays and entertainment such as cruises, vacation destinations and concerts.
Sub-chambers were set up to control aspects of cultural life such as film, radio, newspapers, fine arts, music, theatre and literature. Members of these professions were required to join their respective organisation. Jews and people considered politically unreliable were prevented from working in the arts and many emigrated.