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The changing patterns of paediatric management of common disorders - Part 1

15 February 2016

The Late Datuk Dr N. Paramaesvaran

My favourite moment of the day is after lunch. I sit on my deck chair, on the balcony of my apartment, and look out at the shimmering blue sea, watch the flotilla of sleek yachts, the Manly ferry from Circular Quay, and  the majestic cruise ships, as they gracefully sail around the Sydney Harbour. I allow my mind to wander, and I often think of my 45 years of practising paediatrics, and how over the years, I had to struggle to adapt to the many changes of managing paediatric disorders. It was this that has prompted me to write this article, which I thought might interest the younger doctors, who are setting out to do paediatrics.

I joined the paediatric unit at the General Hospital Penang as a houseman on 1st August 1960. Dr. D. Bowler was my consultant, and Dr. Patmanathan my registrar. I was to alternate weekly night calls with Dr.Pathmanathan. After our first  morning ward round, both the consultant and Pathmanathan left me in charge and proceeded with their daily outpatient clinic. I had finished collecting all the blood samples (one of my duties as a houseman), and was in the treatment room (my little office and work room) with my microscope, looking at some blood slides when the nursing sister brought in a 11 month little boy who was screaming in pain. I noticed he was lifting his legs and pointing to his tummy. I asked the mother to sit down and carry him on her lap. He soon settled down. I warmed my hands (Prof Elaine Field used to emphasise the importance of this) and proceeded to examine him. As I palpated his abdomen, I felt a ‘sausage shaped’ lump under the liver margin! I remembered as a student under Prof. Wong Hock Boon in Singapore, I had done an assignment on intussusception, but I had never seen a case. I wondered if this could  be a case! I rang Dr. Bowler who  immediately came down from his office, examined the boy and patted me on the back. “You are spot on. It is a case of intussusception” He rang the surgeon, who confirmed the diagnosis, and soon the boy was sent to theatre and was successfully operated on. Note: the diagnosis was clinical and the patient was operated on successfully.

Since that experience, I had an obsession to rule out the possibility of intussusception, in young children admitted with acute abdominal pain. My interns were taught the gravity of missing the diagnosis. Over the years, there have been a few close calls, especially with children admitted to the ‘gastro’ ward as  cases of dysentery. I can still remember at least two cases I diagnosed during my morning round in the ‘gastro’ ward.

Surgical reduction was then the accepted  management for intussusception. In 1966, when I was training in U.K., at the Hospital of Sick Children, Great Ormond Street, I still remember Prof. Wilkinson, professor of paediatric surgery, telling us at a lecture, that in his opinion, surgical reduction was the treatment of choice. He was  critical of the Europeans for performing  barium enema reduction. Hence I came back from U.K. with the belief that surgical reduction was the gold standard for the management of intussusception, and I referred all my cases to the surgeon for reduction.

In 1977 when I joined the Gleneagles Medical Centre in Penang, and saw my first case of intussusception, Dr Chan, our radiologist, after looking at the plain X-Ray abdomen, suggested  barium enema to confirm the diagnosis and to reduce the intussusception. I agreed and we proceeded and he successfully confirmed the diagnosis and reduced the intussusception. He also started using ultrasound as a diagnostic tool before proceeding with the barium enema reduction.

From June 1977-March 1992 we saw 73 cases of intussusception and Dr.Chan attempted barium enema reduction in 70 cases. He was   successful in 59 of 70 cases with 12 recurrences in 6 cases. I remember we needed 3 attempts on our surgeon’s grandchild before it was successfully reduced. The final success rate was around 69%. I presented our findings  at our MPA Meeting in Penang in 1992. When Dr Chan left us, Dr Abdullah, our new radiologist, suggested using air. He pointed out that the Chinese had been very successful with this. We found this technique gave us a higher success rate.

Since the first recorded case of intussusception by Paul Barbette of Amsterdam, in 1674, and Cornelius Velse’s successful operation on a case in 1742, and Samuel Mitchell’s report of the first case of successful air enema reduction in 1836, polemic and bigotry has been raging for years between the proponents of surgical reduction and those who advocated barium/air enema reduction. This impasse has finally been unlocked and today, and most would  agree, ultrasound as a diagnostic tool and air enema reduction would be the treatment of choice. Laparoscopic surgery is now being increasing attempted when air or barium reduction fails.

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