Since pharmacologic habituation is not a problem with this approach, the possibility of malabsorption from the gastrointestinal tract or other metabolic aberrations may be considered as the cause of high-dose requirements. It has been observed, however, that even in the presence of total malignant bowel obstruction absorption does occur and pain can frequently be managed with orally administered narcotics, particularly if the obstruction is low in the gastrointestinal tract.7 In any event, since analgesia is encountered at a lower dose than toxicity, one may rely on the clinical response as a pragmatic and faithful indicator of the appropriate dose for that patient. Individual variation in the disposition of morphine is seen in patients of any age, but it is particularly marked in the very young and very old. However, respiratory depression is caused by opiates given in doses above the analgesic dose except in patients with poor respiratory reserve. Even so, the margin of safety is not wide, particularly when they are given intravenously.3 It follows that one should begin with small doses and work up quickly until the pain is controlled, while watching ventilation at each dose increase. This requires some experience and attention to detail of both doctor and nurse until the effective dose is found. In treating several hundred patients over the past 5½ years we have administered a narcotic antagonist on only two occasions when morphine was used as described: in one case following an error in the dose of narcotic given by a nurse, and in the second case, probably unnecessarily, to a somnolent, terminally ill cancer patient who had long-standing chronic respiratory insufficiency. In short, overdosage is not a problem. As to unsuccessful relief of pain, in our experience considerably less than 10% of patients with intractable pain have unsuccessful pain control when the morphine dose, given orally or, if that fails, given intramuscularly, is titrated carefully to the patient's need and given regularly as described. In Saunders'8 experience 1% (34 of 3362 patients) have had inadequate pain control.
The merit of our approach is not simply the economy and convenience Dr. Keeri-Szanto suggests, but also the documented excellent and reliable control of pain that it affords in an alert patient. We would be concerned if we had to offer a "trade-off" between some residual pain and a slight clouding of the sensorium, as Dr. KeenSzanto describes. In our experience it is possible, with few exceptions, to attain both continuous pain relief and a clear sensorium. Where demand analgesia with intravenously administered agents may have a useful role is in the rapid control of unpredictable episodic pain spasms, where the question is one of acute pain. The rapid effectiveness of the intravenous route in this situation commends it. This problem is, however, irrelevant to the efficacy of orally administered morphine given regularly in the treatment of chronic pain associated with advanced malignant disease.
"The Harvard Guide to Modem Psychiatry" To the editor: Dr. John D. Adamson has commented on my review of the book entitled "The Harvard Guide to Modern Psychiatry" (Can Med Assoc 1 120: 918, 1979). Dr. Adamson's concern about the book's value as the sole source of information for candidates for the Canadian specialty examinations in psychiatry is correct; indeed, in my review I suggested that the book be used by first-year residents only. No one knows for certain whether one should distinguish between endogenous and reactive depressions. Kierman is hardly the first person to suggest that one should not. The data demonstrating the utility of this distinction are open to criticism. Dr. Adamson's comment on the difference of the response between depressed persons taking imipramine and those taking amitriptyline, and much of his concern about Klerman's failure to discuss lithium BALFOUR M. MOUNT, MD, FRCS[C] carbonate, were covered in the Director, palliative care service chapter on chemotherapy by BalAssociate professor of surgery dessarini. This point illustrates that McGill University Montreal, PQ the text allows very little overlap, which I think is a virtue. References It is true that some patients with manic depression remain continu1. MOUNT BM, AJEMIAN I, Scorr JF: ously ill, but it is a matter of Use of the Brompton mixture in treating the chronic pain of malignant opinion whether this small group disease. Can Med Assoc 1 115: 122, should be mentioned in such a 1976 2. BERKOWITZ BA, NGAI SH, YANG JC, short chapter. Klerman did err in et al: The disposition of morphine in failing to mention diurnal mood surgical patients. Clin Pharmacol Ther variation as a useful diagnostic 17: 629, 1975 sign in depression. 3. VERE DW (ed): Pharmacology of It is difficult to understand how morphine drugs used in terminal care, one could produce a shorter textin Topics in Therapeutics, vol 4, Pitbook, as suggested by Dr. Adamman, London, 1978, p 75 4. Twx'caoss RG: Clinical experience son, and also introduce more facts. with diamorphine in advanced malignant disease. mt I Clin Pharmacol 9: 184, 1974
5. Twx'cRoss RG, WALD SJ: Long-term use of diamorphine in advanced can-
cer, in Advances in Pain Research and
MORTON S. RAPP, MD
Associate professor Department of psychiatry University of Toronto Toronto, Ont.
Therapy, vol 1, BoNICA JJ, ALBE-
FESSARD D (eds), Raven Pr, New York, 1976, p 653
Intussusception in infants and children by hydrostatic reduction 6. MELZACK R, OFIEsH JG, MOUNT BM: The Brompton mixture: effects on To the editor: We take issue with pain in cancer patients. Can Med several of the points made by Dr. Assoc 1 115: 125, 1976 7. MOUNT BM: Palliative care of the Joseph N.H. Du in his article on this terminally ill. Ann R Coil Physicians subject (Can Med Assoc 1 119: Surg Can 11: 201, 1978 1075, 1978). Although Dr. Du has 8. SAUNDERS C: Caring for the Dying. discussed most of the modern Presented at the Second International present-day concepts and treatment Seminar on Terminal Care, Montreal, of intussusception, there are several Nov 2, 1978 CMA JOURNAL/JULY 7, 1979/VOL. 121 21
* nicorette Prescribing Information
Indication: Nicorette Chewing Gum is designed to provide partial substitution for the nicotine in cigarette smoke, which is believed to be one of the principal factors in the perpetuation of the smoking habit. It is intended as a temporary aid in cushioning the patient against the psychopharmacological trauma of withdrawal. Its justification as part of the treatment of cigarette addiction lies in its being the least of three evils present in tobacco smoke. It is therefore importan that it should be regarded merely as an aid to the first stage of cigarette abstention, and that the ultimate aim should be the abandonment of all forms of smoking and all forms of nicotine chewing. Contraindications: Nicorette is contraindicated in pregnancy because of the known adverse effect of nicotine on the fetus. Nicorette is also contraindicated in breast feeding mothers, as nicotine is excreted in breast milk. Precautions: Nicorette may cause an exacerbation of symptoms in patients suffering from inflammation or disease of the oral cavity, gastritis, or peptic ulceration. Nicorette should be prescribed with care in patients with angina, coronary artery disease or peripheral vascular disease. Adverse Effects: Nicorette can sometimes cause, in the early days of treatment, apthous ulcers, throat irritation, excessive salivation and hiccups. However, these symptoms are usually more frequent and severe with the 4mg than the 2mg preparation. Excessive weight gain is sometimes associated with abstention of smoking. For this reason, a patient on Nicorette should be weighed at regular intervals, with modifications in diet as necessary.
Treatment of Overdose: 1. In a conscious, alert patient, prompt evacuation of the stomach should be performed. When evacuation is complete, activated charcoal may be administered by mouth if necessary. 2. In comatose patients, a clear airway must be established immediately. Other therapeutic measures are purely symptomatic and should be conducted according to the attending physicians assessment of the patient. When the patients clinical status stabilizes, consideration may be given to gastric lavage and the administration of activated charcoal.
Dosage and Administration: Dosage 2mg: One 2mg Nicorette piece to be chewed slowly in place of a cigarette when there is a craving to smoke. Up to 10 pieces per day is the usual recommended dosage although in exceptional cases, up to 20 pieces per day may be required. Dosage 4mg: One 4mg Nicorette piece to be chewed slowly in place of a cigarette when there is a craving to smoke which is uncontrolled by 2mg Nicorette. Up to 10 pieces per day is the usual recommended dosage although in exceptional cases, up to 20 pieces per day may be required. How Supplied: Nicorette is supplied as a 4mg (pale yellow) and 2mg (fawn colour) square of highly spiced chewing resin base and packaged in blister pack strips of 15 pieces and contained in boxes of 7 strips (105 pieces). Nicorette 2 mg-OIN 456586 Nicorette 4 mg-DIN 456594 Product monograph available on request.
DOW PHARMACEUTICALS Dow Chemical of Canada, Limited 380 Elgin Mills Road. East nichmond Hill, Ontario L4C 5H2 Trademark of The Dow Chemical Company tTrademark of AB LEO, Helsrngborg. Sweden
F.1 P.AC
factors with Which we take exception. Dr. Du states that "if this condition is found but not reduced, a surgeon is consulted and a laparotomy is performed." We think this is placing the cart before the horse. We believe that intussusception is a surgical rather than a medical condition and we have been teaching this to the residents in pediatric surgery at the Hospital for Sick Children in Toronto for at least 10 to 15 years. We believe that a surgeon should be consulted when intussusception is diagnosed, so that he or she can be present at the attempt at barium hydrostatic reduction, if not to coordinate the complete treatment regimen from the time the diagnosis is made by the general practitioner or pediatrician. To call the surgeon to a darkened radiology examination room when intussusception has not been successfully reduced is unfair both to the surgeon and, of more importance, to the child. We have a standing rule at the Hospital for Sick Children, which is agreed upon by the departments of pediatrics, surgery and radiology, that any time a diagnosis of intussusception is made, the radiologist will not attempt barium enema reduction unless a surgeon is consulted in the management of the case and is present during the procedure. Dr. Du states that "before an enema is given roentgenograms of the abdomen are obtained with the child supine and upright, and signs of perforation or small bowel obstruction are looked for. If there is evidence of perforation, an enema will not be given." In the last 20 years we have noted only three perforations due to intussusception in more than 700 children with this condition, and the perforations were always noted at the time of the attempted barium enema reduction; in fact, the perforations may have been caused by the attempt at reduction, no matter how cautiously it was done. We have not found any evidence of a perforation due to intussusception prior to the attempted hydrostatic reduction. Dr. Du states: "If the patient has an obstruction of the small bowel or a long clinical history or appears seriously ill, a barium enema will be
24 CMA JOURNAL/JULY 7, 1979/VOL. 121
given and roentgenography performed to diagnose the condition, but hydrostatic reduction will not be attempted or will be attempted only with great caution." This statement is, for the most part, correct. We still proceed cautiously, though, when attempting a reduction if a complete small bowel obstruction is present. We have found that when the obstruction is caused by an ileoileocolic intussusception, it is very difficult, although not impossible, to reduce the intussusception with a barium enema. However, we realize that there is little chance of success with barium and, therefore, we do not push too hard or for too long. Moreover, we have found that a long clinical history does not necessarily contraindicate attempts at barium enema reduction. The same applies to recurrent intussusception and intussusception in older children. We believe that there is no contraindication to an attempted barium enema reduction for intussusception as long as the radiologist is familiar with the technique, a surgeon is present, the child is in a warm radiology examining room and, if necessary, intravenous and nasogastric tubes have been inserted and cross-matching has been done. The child's general condition, however, should dictate how many attempts at reduction can safely be made and for how long. In other words, common sense is the important factor. We no longer keep the barium receptacle about 1 m above the table in all cases. If, for example, the reduction is stopped at the ileocecal valve and the child's condition is good, and if the barium enema has not been going on for too long, then we may raise the bucket another 13 to 26 cm. Certainly, the further distal the intussusception is held up, the less hard we try, because the chance of reducing an intussusception with barium is greatly decreased as one approaches the rectum. We agree that if the child is well and is not dehydrated from vomiting, and if the parents are reasonable and reliable and the clinical course has been short, the child can be sent home after an uncomplicated barium enema reduction. If there is
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
The merit of our approach is not simply the economy and convenience Dr. Keeri-Szanto suggests, but also the documented excellent and reliable control of pain that it affords in an alert patient. We would be concerned if we had to offer a "trade-off" between some residual pain and a slight clouding of the sensorium, as Dr. KeenSzanto describes. In our experience it is possible, with few exceptions, to attain both continuous pain relief and a clear sensorium. Where demand analgesia with intravenously administered agents may have a useful role is in the rapid control of unpredictable episodic pain spasms, where the question is one of acute pain. The rapid effectiveness of the intravenous route in this situation commends it. This problem is, however, irrelevant to the efficacy of orally administered morphine given regularly in the treatment of chronic pain associated with advanced malignant disease.
"The Harvard Guide to Modem Psychiatry" To the editor: Dr. John D. Adamson has commented on my review of the book entitled "The Harvard Guide to Modern Psychiatry" (Can Med Assoc 1 120: 918, 1979). Dr. Adamson's concern about the book's value as the sole source of information for candidates for the Canadian specialty examinations in psychiatry is correct; indeed, in my review I suggested that the book be used by first-year residents only. No one knows for certain whether one should distinguish between endogenous and reactive depressions. Kierman is hardly the first person to suggest that one should not. The data demonstrating the utility of this distinction are open to criticism. Dr. Adamson's comment on the difference of the response between depressed persons taking imipramine and those taking amitriptyline, and much of his concern about Klerman's failure to discuss lithium BALFOUR M. MOUNT, MD, FRCS[C] carbonate, were covered in the Director, palliative care service chapter on chemotherapy by BalAssociate professor of surgery dessarini. This point illustrates that McGill University Montreal, PQ the text allows very little overlap, which I think is a virtue. References It is true that some patients with manic depression remain continu1. MOUNT BM, AJEMIAN I, Scorr JF: ously ill, but it is a matter of Use of the Brompton mixture in treating the chronic pain of malignant opinion whether this small group disease. Can Med Assoc 1 115: 122, should be mentioned in such a 1976 2. BERKOWITZ BA, NGAI SH, YANG JC, short chapter. Klerman did err in et al: The disposition of morphine in failing to mention diurnal mood surgical patients. Clin Pharmacol Ther variation as a useful diagnostic 17: 629, 1975 sign in depression. 3. VERE DW (ed): Pharmacology of It is difficult to understand how morphine drugs used in terminal care, one could produce a shorter textin Topics in Therapeutics, vol 4, Pitbook, as suggested by Dr. Adamman, London, 1978, p 75 4. Twx'caoss RG: Clinical experience son, and also introduce more facts. with diamorphine in advanced malignant disease. mt I Clin Pharmacol 9: 184, 1974
5. Twx'cRoss RG, WALD SJ: Long-term use of diamorphine in advanced can-
cer, in Advances in Pain Research and
MORTON S. RAPP, MD
Associate professor Department of psychiatry University of Toronto Toronto, Ont.
Therapy, vol 1, BoNICA JJ, ALBE-
FESSARD D (eds), Raven Pr, New York, 1976, p 653
Intussusception in infants and children by hydrostatic reduction 6. MELZACK R, OFIEsH JG, MOUNT BM: The Brompton mixture: effects on To the editor: We take issue with pain in cancer patients. Can Med several of the points made by Dr. Assoc 1 115: 125, 1976 7. MOUNT BM: Palliative care of the Joseph N.H. Du in his article on this terminally ill. Ann R Coil Physicians subject (Can Med Assoc 1 119: Surg Can 11: 201, 1978 1075, 1978). Although Dr. Du has 8. SAUNDERS C: Caring for the Dying. discussed most of the modern Presented at the Second International present-day concepts and treatment Seminar on Terminal Care, Montreal, of intussusception, there are several Nov 2, 1978 CMA JOURNAL/JULY 7, 1979/VOL. 121 21
* nicorette Prescribing Information
Indication: Nicorette Chewing Gum is designed to provide partial substitution for the nicotine in cigarette smoke, which is believed to be one of the principal factors in the perpetuation of the smoking habit. It is intended as a temporary aid in cushioning the patient against the psychopharmacological trauma of withdrawal. Its justification as part of the treatment of cigarette addiction lies in its being the least of three evils present in tobacco smoke. It is therefore importan that it should be regarded merely as an aid to the first stage of cigarette abstention, and that the ultimate aim should be the abandonment of all forms of smoking and all forms of nicotine chewing. Contraindications: Nicorette is contraindicated in pregnancy because of the known adverse effect of nicotine on the fetus. Nicorette is also contraindicated in breast feeding mothers, as nicotine is excreted in breast milk. Precautions: Nicorette may cause an exacerbation of symptoms in patients suffering from inflammation or disease of the oral cavity, gastritis, or peptic ulceration. Nicorette should be prescribed with care in patients with angina, coronary artery disease or peripheral vascular disease. Adverse Effects: Nicorette can sometimes cause, in the early days of treatment, apthous ulcers, throat irritation, excessive salivation and hiccups. However, these symptoms are usually more frequent and severe with the 4mg than the 2mg preparation. Excessive weight gain is sometimes associated with abstention of smoking. For this reason, a patient on Nicorette should be weighed at regular intervals, with modifications in diet as necessary.
Treatment of Overdose: 1. In a conscious, alert patient, prompt evacuation of the stomach should be performed. When evacuation is complete, activated charcoal may be administered by mouth if necessary. 2. In comatose patients, a clear airway must be established immediately. Other therapeutic measures are purely symptomatic and should be conducted according to the attending physicians assessment of the patient. When the patients clinical status stabilizes, consideration may be given to gastric lavage and the administration of activated charcoal.
Dosage and Administration: Dosage 2mg: One 2mg Nicorette piece to be chewed slowly in place of a cigarette when there is a craving to smoke. Up to 10 pieces per day is the usual recommended dosage although in exceptional cases, up to 20 pieces per day may be required. Dosage 4mg: One 4mg Nicorette piece to be chewed slowly in place of a cigarette when there is a craving to smoke which is uncontrolled by 2mg Nicorette. Up to 10 pieces per day is the usual recommended dosage although in exceptional cases, up to 20 pieces per day may be required. How Supplied: Nicorette is supplied as a 4mg (pale yellow) and 2mg (fawn colour) square of highly spiced chewing resin base and packaged in blister pack strips of 15 pieces and contained in boxes of 7 strips (105 pieces). Nicorette 2 mg-OIN 456586 Nicorette 4 mg-DIN 456594 Product monograph available on request.
DOW PHARMACEUTICALS Dow Chemical of Canada, Limited 380 Elgin Mills Road. East nichmond Hill, Ontario L4C 5H2 Trademark of The Dow Chemical Company tTrademark of AB LEO, Helsrngborg. Sweden
F.1 P.AC
factors with Which we take exception. Dr. Du states that "if this condition is found but not reduced, a surgeon is consulted and a laparotomy is performed." We think this is placing the cart before the horse. We believe that intussusception is a surgical rather than a medical condition and we have been teaching this to the residents in pediatric surgery at the Hospital for Sick Children in Toronto for at least 10 to 15 years. We believe that a surgeon should be consulted when intussusception is diagnosed, so that he or she can be present at the attempt at barium hydrostatic reduction, if not to coordinate the complete treatment regimen from the time the diagnosis is made by the general practitioner or pediatrician. To call the surgeon to a darkened radiology examination room when intussusception has not been successfully reduced is unfair both to the surgeon and, of more importance, to the child. We have a standing rule at the Hospital for Sick Children, which is agreed upon by the departments of pediatrics, surgery and radiology, that any time a diagnosis of intussusception is made, the radiologist will not attempt barium enema reduction unless a surgeon is consulted in the management of the case and is present during the procedure. Dr. Du states that "before an enema is given roentgenograms of the abdomen are obtained with the child supine and upright, and signs of perforation or small bowel obstruction are looked for. If there is evidence of perforation, an enema will not be given." In the last 20 years we have noted only three perforations due to intussusception in more than 700 children with this condition, and the perforations were always noted at the time of the attempted barium enema reduction; in fact, the perforations may have been caused by the attempt at reduction, no matter how cautiously it was done. We have not found any evidence of a perforation due to intussusception prior to the attempted hydrostatic reduction. Dr. Du states: "If the patient has an obstruction of the small bowel or a long clinical history or appears seriously ill, a barium enema will be
24 CMA JOURNAL/JULY 7, 1979/VOL. 121
given and roentgenography performed to diagnose the condition, but hydrostatic reduction will not be attempted or will be attempted only with great caution." This statement is, for the most part, correct. We still proceed cautiously, though, when attempting a reduction if a complete small bowel obstruction is present. We have found that when the obstruction is caused by an ileoileocolic intussusception, it is very difficult, although not impossible, to reduce the intussusception with a barium enema. However, we realize that there is little chance of success with barium and, therefore, we do not push too hard or for too long. Moreover, we have found that a long clinical history does not necessarily contraindicate attempts at barium enema reduction. The same applies to recurrent intussusception and intussusception in older children. We believe that there is no contraindication to an attempted barium enema reduction for intussusception as long as the radiologist is familiar with the technique, a surgeon is present, the child is in a warm radiology examining room and, if necessary, intravenous and nasogastric tubes have been inserted and cross-matching has been done. The child's general condition, however, should dictate how many attempts at reduction can safely be made and for how long. In other words, common sense is the important factor. We no longer keep the barium receptacle about 1 m above the table in all cases. If, for example, the reduction is stopped at the ileocecal valve and the child's condition is good, and if the barium enema has not been going on for too long, then we may raise the bucket another 13 to 26 cm. Certainly, the further distal the intussusception is held up, the less hard we try, because the chance of reducing an intussusception with barium is greatly decreased as one approaches the rectum. We agree that if the child is well and is not dehydrated from vomiting, and if the parents are reasonable and reliable and the clinical course has been short, the child can be sent home after an uncomplicated barium enema reduction. If there is
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.
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