any doubt, however, we admit the child to hospital for the night. Dr. Du states that "there were no complications or recurrences of intussusception" in the patients who were sent home after a barium enema reduction. The recurrence rate for intussusception, which is 10% in our hospital and in most other children's hospitals, has got nothing to do with whether the child has been sent home or has stayed in hospital. If intussusception recurs within a few hours of reduction, then we strongly suggest that the first one was not adequately reduced. We have found that when intussusception does recur the parents usually recognize the signs and symptoms earlier and bring the child back to the hospital sooner. SIGMUND H. EIN, MD, FRCS[C] JAMES C. FALLIS, MD, FRCS[CJ
Division of general surgery and emergency department Hospital for Sick Children Toronto, Ont.
diologists, with only a few having great experience in it. Similarly, there must be a large number of physicians involved in the diagnosis and management of this condition. I can understand why there is a need for a rigid protocol. Since the Winnipeg Children's Hospital is the main referral centre in Manitoba it handles most of the cases of intussusception that occur in the province. We depend on two pediatric radiologists to perform all the barium enemas; therefore, with the passage of time they have gained considerable experience. In addition, most of the patients with intussusception are treated by qualified and experienced pediatricians (with referrals from general practitioners). Moreover, the cooperation from the surgeons and operating room staff is superb. As I stated in my article, "the operating room is available on a 24-hour basis and can be ready within an hour for emergencies." If the intussusception has been successfully reduced, admission to the hospital for observation is usually limited to 24 hours. The point I tried to make is that in the patients who were not admitted to the hospital after reduction there was no recurrence within the first 24 hours. I agree with Drs. Em and Fallis that common sense dictates the management of each case. The experience of the pediatrician and the radiologist, the cooperation of the surgeons and the operating room staff, and the nature of the patient's family all play a part in our decision-making. I have discussed the problem of the treatment of intussusception with our radiologic and surgical colleagues, and we believe that our results speak for themselves - in our series we had a mortality of zero for intussusception. J. Du, MD, FRCP[C], FAAP
To the editor: The Hospital for Sick Children in Toronto is a major referral centre for ill children, and, therefore, its experience is much more extensive than that of other centres. However, with due respect to Drs. Bin and Fallis, who have extensive experience in this field, "management of this condition is controversial, some advocating primary surgical treatment and others preferring barium enema reduction", as I stated at the beginning of my article. Drs. Bin and Fallis object to the fact that at the Winnipeg Children's Hospital the surgeons are not involved in the early stages of management of intussusception once the diagnosis is suspected or confirmed. In view of our experience, and with our high rate of success with reduction by barium enema (70% to 80%), it is difficult to comprehend Winnipeg clinic why Drs. Bin and Fallis consider inWinnipeg, Man tussusception to be a purely surgical condition. In a large centre such as the Hos- Spontaneous pneumothorax pital for Sick Children, the demand and pregnancy for barium enemas must be enor- To the editor: I read with interest mous and probably creates a need the article by Drs. Louis Burgener for radiologists to work on rotation and James Gerald Solmes about to handle the workload. Therefore, spontaneous pneumothorax and experience in reducing intussuscep- pregnancy (Can Med Assoc 1 120: tions must be diluted among the ra- 19, 1979). They commented on how
rare this occurrence is. However, I wonder if it is more common, but just not reported. I am a general practitioner in a city with a population of 10 000 and perform an average of about 50 to 60 deliveries per year. I had an encounter similar to that of Drs. Burgener and Solmes. An I 8-year-old gravida 1 woman came to me as a patient. She delivered a small but healthy boy Dec. 12, 1978. On Oct. 24, at approximately 34 weeks' gestation, she had been seen in the emergency room complaining of middle and upper left back pain radiating to the epigastrium. Physical examination and a chest roentgenogram showed a 70% pneumothorax on the left side. I treated the patient in the usual method with a #20 chest tube and a minimum of chest roentgenography (three posteroanterior films were made). After 2 days of underwater drainage the chest tube was removed. Intermittent monitoring of the fetal heart rate throughout the patient's stay in hospital showed no signs of fetal distress. Routine postpartum chest roentgenograms taken on Dec. 15 and inspiratory and expiratory films taken on Jan. 3 were normal. Tuberculin skin testing gave negative results. BOYD STEWART, MD
24 4th St. Weyburn, Sask. Juxtaglomerular cell tumour (reidnoma) with paroxysmal hypertension [correction] One of the authors of this brief communication (Can Med Assoc 1 120: 957, 1979) has advised us that the tumour mentioned in the opening sentence of their article should have been referred to as a renin-producing tumour of the kidney rather than a renal hemangiopericytoma. - Ed. The hypertensive patient [correction] In the first of this series of editorials on hypertension by Dr. David L. Sackett (Can Med Assoc 1 120: 1319, 1979) it was stated that copies of the task force report could be obtained from the Government of Canada Bookstore in Toronto. The name of the store is, in fact, the Ontario Government Bookstore. - Ed.
QMA JOURNAL/JULY 7, 1979/VOL. 121 25
Division of general surgery and emergency department Hospital for Sick Children Toronto, Ont.
diologists, with only a few having great experience in it. Similarly, there must be a large number of physicians involved in the diagnosis and management of this condition. I can understand why there is a need for a rigid protocol. Since the Winnipeg Children's Hospital is the main referral centre in Manitoba it handles most of the cases of intussusception that occur in the province. We depend on two pediatric radiologists to perform all the barium enemas; therefore, with the passage of time they have gained considerable experience. In addition, most of the patients with intussusception are treated by qualified and experienced pediatricians (with referrals from general practitioners). Moreover, the cooperation from the surgeons and operating room staff is superb. As I stated in my article, "the operating room is available on a 24-hour basis and can be ready within an hour for emergencies." If the intussusception has been successfully reduced, admission to the hospital for observation is usually limited to 24 hours. The point I tried to make is that in the patients who were not admitted to the hospital after reduction there was no recurrence within the first 24 hours. I agree with Drs. Em and Fallis that common sense dictates the management of each case. The experience of the pediatrician and the radiologist, the cooperation of the surgeons and the operating room staff, and the nature of the patient's family all play a part in our decision-making. I have discussed the problem of the treatment of intussusception with our radiologic and surgical colleagues, and we believe that our results speak for themselves - in our series we had a mortality of zero for intussusception. J. Du, MD, FRCP[C], FAAP
To the editor: The Hospital for Sick Children in Toronto is a major referral centre for ill children, and, therefore, its experience is much more extensive than that of other centres. However, with due respect to Drs. Bin and Fallis, who have extensive experience in this field, "management of this condition is controversial, some advocating primary surgical treatment and others preferring barium enema reduction", as I stated at the beginning of my article. Drs. Bin and Fallis object to the fact that at the Winnipeg Children's Hospital the surgeons are not involved in the early stages of management of intussusception once the diagnosis is suspected or confirmed. In view of our experience, and with our high rate of success with reduction by barium enema (70% to 80%), it is difficult to comprehend Winnipeg clinic why Drs. Bin and Fallis consider inWinnipeg, Man tussusception to be a purely surgical condition. In a large centre such as the Hos- Spontaneous pneumothorax pital for Sick Children, the demand and pregnancy for barium enemas must be enor- To the editor: I read with interest mous and probably creates a need the article by Drs. Louis Burgener for radiologists to work on rotation and James Gerald Solmes about to handle the workload. Therefore, spontaneous pneumothorax and experience in reducing intussuscep- pregnancy (Can Med Assoc 1 120: tions must be diluted among the ra- 19, 1979). They commented on how
rare this occurrence is. However, I wonder if it is more common, but just not reported. I am a general practitioner in a city with a population of 10 000 and perform an average of about 50 to 60 deliveries per year. I had an encounter similar to that of Drs. Burgener and Solmes. An I 8-year-old gravida 1 woman came to me as a patient. She delivered a small but healthy boy Dec. 12, 1978. On Oct. 24, at approximately 34 weeks' gestation, she had been seen in the emergency room complaining of middle and upper left back pain radiating to the epigastrium. Physical examination and a chest roentgenogram showed a 70% pneumothorax on the left side. I treated the patient in the usual method with a #20 chest tube and a minimum of chest roentgenography (three posteroanterior films were made). After 2 days of underwater drainage the chest tube was removed. Intermittent monitoring of the fetal heart rate throughout the patient's stay in hospital showed no signs of fetal distress. Routine postpartum chest roentgenograms taken on Dec. 15 and inspiratory and expiratory films taken on Jan. 3 were normal. Tuberculin skin testing gave negative results. BOYD STEWART, MD
24 4th St. Weyburn, Sask. Juxtaglomerular cell tumour (reidnoma) with paroxysmal hypertension [correction] One of the authors of this brief communication (Can Med Assoc 1 120: 957, 1979) has advised us that the tumour mentioned in the opening sentence of their article should have been referred to as a renin-producing tumour of the kidney rather than a renal hemangiopericytoma. - Ed. The hypertensive patient [correction] In the first of this series of editorials on hypertension by Dr. David L. Sackett (Can Med Assoc 1 120: 1319, 1979) it was stated that copies of the task force report could be obtained from the Government of Canada Bookstore in Toronto. The name of the store is, in fact, the Ontario Government Bookstore. - Ed.
QMA JOURNAL/JULY 7, 1979/VOL. 121 25
