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Theme and Variations

Welcome to Theme and Variations, a set of hour-long podcasts that explore how composers put together variations on themes that they or others have written. I will be adding one every couple of weeks from April 2024. They appear as clickable links to listen to via this site..

Theme and Variations 1: Ode to Theme and Variations (with the emphasis on Beethoven)


(based on a parable that Jesus told)

The Earth was minding its own business, travelling elliptically around the sun as it had done for billions of years, when it was set upon by some human beings. They pumped poisons into the Earth, the rivers and the seas, and the sky. They heedlessly and avariciously used its many resources, often destroying each other while progressively decimating their fellow earthly creatures – the fish in the sea, the birds of the sky, the wild animals, all the reptiles that crawl upon the earth, the plants of the plains, mountains, forests and jungles, and the tiny creepy-crawlies that helped the plants to reproduce.

The Earth became feverish and very ill.

One Christian heard about the situation. “The end times are coming!”, he or she said, and passed by on the other side.

Another Christian read about the situation. “God will keep me and my family safe. We will pray!”, and passed by on the other side.

“Fake news!”, snorted another Christian, turning away.

“Forgive me, O Lord, for I and all my household are sinners!”, cried another Christian and passed out completely on the spot.

The Earth’s fever was accelerating to the point of no return.

Which of those Christians was a friend to the Earth?

Where is a good Samaritan when you need one? What would a good Samaritan do?

Can We Dance??

This is a set of radio programmes originally broadcast on Fine Music Radio in Cape Town.

Click below the picture to stream the programme.

Duration 53 minutes.

Duration 51 minutes.

Easter Day 2019

Chris Hani 1993. Sri Lanka 2019.

Darkness tries to extinguish Easter light.

Guns blaze, bombs flash,
using light to bring death
                     on Resurrection Day

Hate spits its fire into the Easter dawn;
Hellfire, to burn down pillars of hope;
To bring nation-building crashing down,
To smother hope in the smoke of destruction.

hope cannot  die
hope will not die 
light cannot be extinguished
light will not be extinguished

Hate, hellfire, destruction, death – all are broken!

This is the victory of Easter
This is the power of Easter

Hold the line.

An interesting juxtaposition

Where are we headed as humanity? I rather enjoy books that look back, look the present in the eye and look forward. Jared Diamond’s books are a good read, giving pause. Collapse gives climate change a grim context. Alvin Toffler’s Futureshock I read when I was a teenager. I only remember the ‘Mozart on the run’ chapter now: we were playing music at ever faster speeds, he told us.

I have just completed reading Yuval Harari’s Homo Deus, having found it on my son’s bookshelf last year. A fascinating read, the book analyses trends in early 21st century science, thought and especially digital developments. There are twin theses: humans are not special, and we are moving towards a world (a galaxy?) in which humans (merely a set of algorithms) are either unnecessary or a means to an end for silicon – based artificial intelligence (AI) for which consciousness is an optional extra. Harari does not say that this de-humanised future is inevitable; he points to its possibility and implications for the present.

The book is large so I did not take it on my overnight trip for child health-related meetings in Johannesburg. I opened my Free Books app and started to read The Machine Stops by EM Forster that I had previously downloaded. There we are ‘in the Machine’, satisfied on a diet of all that we want (if we hadn’t been weeded out at birth), including tablets to establish emotional equilibrium and peace of mind. Humans live on their own, underground sequestered from each other. The surface is no longer fit for human habitation – climate change or pollution? We were happy with the Machine. We even give it god-like properties.

Climate change, elites working with AI to survive, then taken over by AI. 1909, 2016 – an artist and a social commentator/analyst/future gazer imagine and see a lot in common. Only connect.

For me as a Christian, I relish the double- even triple-think that going into Forster’s and Harai’s territory requires. AI would understand. Double-think, of course, is an invention of George Orwell in another dystopia – 1984. Perfectly legitimate and approved of by the authorities.

Alleluia, sing to Jesus (Hyfrydol) – F major

A wonderful Welsh tune used not only for Alleluia, Sing to Jesus.

These B flat trumpet parts are moderately difficult. The descant is Betty Pulkingham’s.

Alleluia sing to Jesus – Trumpet Alleluia sing to Jesus – Trumpet Alleluia sing to Jesus – Trumpet

Rhodes and me

This is talk I gave to the Department of Paediatrics at the University of Cape Town last year as part of a series in which we grapple with issues of transformation in South Africa, in the university and in our department.

Now it’s typical, isn’t it? You have hardly started a transformation process to deal with the current consequences and sequelae of past injustices predicated on race and in muscles a white male, whose voice he feels, must be heard. Given half a chance he will probably use his assumed centuries of privilege to start telling you what to do.

How this came about – the justification, if required – is either offensive to all or a reasonable part of the process that is within the aims of our departmental initiative. I perceived that, as with South African society in general, a certain amount of the response to the initiation of the Transformation process had gone off screen. A sense of threat and hurt was being expressed by some of those the process has identified as beneficiaries of that past injustice. So as a previously and currently advantaged white male, I asked the Transformation Committee if I could join the Voices programme. An additional motivation was that I had been having a personal eye-to-eye with Cecil John Rhodes and his legacy, and the long legacy he now represents for a couple of years before the shit hit the statue. I had been turning “all Rhodes lead to“ into a musical as part of that engagement with what that means for me. So here we are….Speaking for myself, and no-one else.

Power & privilege – shorthand and proxy for Race in this context. I plan to face that squarely while acknowledging (as we as a Department have agreed) that it cannot be the only item of the Transformation agenda. Race itself is a proxy for so many aspects of Power & Privilege that I will acknowledge its value as shorthand in this talk, and hope that others will understand this reasoning, uncomfortable though it be.

Power & Privilege – Not so far from Pride and Prejudice.

This talk could be ‘Power and privilege, but….’ – an attempted justification for who and where I am.

Or, ‘Power and privilege, how you see me’ – but then there is no point in me being the Voice.

Approaching this task/opportunity/responsibility, I decided the following:

It will be ‘Power & Privilege, so……’. I will describe my P&P – probably revealing my Pride & Prejudices on the way – and explore the implications.

I have made the following additional decisions in approaching this task:

My past has bequeathed me the power of a very large vocabulary and a word-smithing gift in a language that has a massive hegemonic impact. Rhodes recognised this as one basis for his broad planet-annexing vision for England. The dangers of manipulating with, confusing with, hiding behind such facility I saw as real; the danger of falsity, of not being myself if I changed language persona to a group of colleagues I also recognised. So I decided to be who I am while staying aware of the dangers; language is powerful and it can shut people down or out.

The irony in my first paragraph today will not recur. Ironic humour is a standard means of messaging in my culture, but its capacity to be mis-directed and misunderstood is so great that I have not allowed it breath.

The other decision was to pronounce the word British as Breeteesh. This is Robert Mugabe’s pronunciation of the word. I use it here not to ridicule him (he’s arguably also one of Rhodes’s legatees), but to give voice to the troubled context of my charmed journey in life. The parallel voice in today’s Voices input.

In this talk, Rhodes is sometimes a shorthand for British imperialism or white supremacy. Context should tell you when I’m referring to the man.

I also need to express an anticipatory apology for unintended hurt, heavy-footedness, and offence that I may cause. Transformation talk takes us into awkward territory; often unspoken but deeply felt shoals lurk in the waters. Words spark fires, as St James tells us; the Bee Gees bleated that ‘it’s only words’. Oh, no it is not!

Generally my writing tone tends to lightness; please do not mistake that for lack of application or seriousness. So here we go: Westwood through Rhodes-tinted spectacles.

Ulodzi! – That’s the working name of the musical – was going to end with Cecil John Rhodes dying under a hot tin roof in his hut in Muizenburg, Dr Jameson at his side. We hear the arrhythmic beating of his failing heart. In comes a young Sol Plaatje – he who chronicled the devastation wrought to indigenous African peoples by the 1913 Land Act. He starts to dance around the deathbed. Gradually in the band the rhythm of Cecil John Rhodes’ irregular Sino-atrial node is taken over by the young beating rhythms of Africa. Sol spins. Sol stamps. Sol shouts. The drumming rhythms rise, Rhodes dies, the roof opens up to high blue African skies. Africa’s rhythm is now the only rhythm. It spreads from the south-western tip of the continent. Rhodes has died! Africa lives! Long live Africa.

But it doesn’t, couldn’t end like that, or not yet. Here’s a hypothesis: I am living proof of that.

I am not going to try to disprove or prove that hypothesis today. I’m going to explore the questions that the British Rhodes and Boralong Sol Plaatje are asking me.

I’m nearly 60. Career-wise, a late phase. A senior paediatrician, nationally, provincially, academically. An inevitable look back: a view sharpened and refined, re-calibrated by the Transformation imperative. The retrospection will be followed by a current situation analysis, then a look forward.

Marc has read you my potted biography. I will plot the “favouring gale” that has “wafted” me “to a height that few can scale”, to quote Gilbert and Sullivan’s Lord High Executioner. Yes, I have flapped my wings but all the time under those wings were warm breezes, most but not all breathed by British imperialism and Rhodes.

My maternal grandfather’s Indian Army background, through Imperial contacts, facilitated my parents leaving British mainland (as Rhodes had intended people like them to do) to join colonial society in central Africa. The thing sought by my parents was sunshine and Central Africa, bought and fought for by Rhodes, had that. Inevitably my parents got so much more. Part of the design. Tony was the next generation of colonial society; colonial formal education (with pictures of the Founder in the Alfred Beit-endowed school hall) gave him the edge. It did by a good margin. He got one of the places reserved for Rhodesians (white Rhodesians) at UCT Medical School; apartheid South Africa opened its arms to its presumptive ally – me.

Dr Tony returns to Bulawayo in 1980 as an intern just as Zimbabwe was born. Down with the British; replace with the Zimbabwe flag. Rhodes’ statue in Main Street moves to the museum. But Rhodes is still there for me. I want to be a paediatrician; my wife is from Cape Town (she is classified white). It is so easy for me to come to better myself. We don’t see UDF marches and witdoeke as an impediment; the chances are that I will be safe. Anyway, I am only coming for higher training. Then we will return.

Some wonderfully generous zephyrs within the Department of Paediatrics UCT give me great learning opportunities, despite my colonial persona. Thank you.

Making economic decisions I see being made by young parents of all stripes even today, Jean and I put our children’s education ahead of our African contribution in Zimbabwe (good schools in southern suburbs, can’t afford the “good” ones in Bulawayo on an early 1990s Zimbabwe public doctors salary). I become an economic migrant.

Next thing Mr Rhodes turns up again. I’m offered a paediatrician post at this hospital. Recruitment: “Won’t you come to my office?” Interview: “Would you like this job?” Selection: “May I think about it, but yes please”.

If it is very important for me to say that I’m not biting the hand that fed me. In the decision some of us make, Mr Rhodes is much more present than we may think he is. My recognised merits are not all of my own making. Their expression has been facilitated by history. And that has continued to the present. Our children are beneficiaries of the continuing influence of this history.

Before I can assess the present, I have to go back again. I have had a parallel education that was certainly not typical 1960s/70s Rhodesian or colonial. Through the church we met and socialised with black Africans in our home, not a Rhodesian standard. We would never have been allowed to use the epithets others use so freely and intently to demean members of indigenous communities. Trevor Huddleston’s “Naught for your Comfort” was on my mother’s reading list for me. People tried to get my father to stand for Parliament in opposition Ian Smith’s Rhodesian front. But Doris Lessing-like radicalism was not to be found there. Nor here now.

Anglican connections when I was an undergraduate at UCT continued this attitudinal training. I demonstrated on Jammie steps – vaguely aware that Jameson had raided something at some time. (Sorry, irony crept in, but at least it was aimed at myself). In the late 1970s, my letters home were addressed to Zimbabwe. So I was ready in 1980, I thought, to be part of that country’s formal African life. Working in Zimbabwe under black consultants from there and from across Africa was formative, probably more subtly, re-formative. As was the first phase of white returnees and British doctors who were definitely not Breeteesh coming to a free Zimbabwe.

I’m going to telescope the last 20+ years in South Africa into the present. This is an acknowledgement of the limited change for many, many in South Africa and unfinished business that the Rhodes Must Fall movement is highlighting; and a tacit statement that I too may have been marking time in some important ways.

So, to now, the present. I’ve asked myself a few questions. Mr Rhodes and Mr Plaatje I’m hoping to silence. I stand alone.

Am I a racist? I cannot assume that I am not. Am I a sexist? I cannot assume that. I am an not. Elitist? Myopically class conscious? I know that my upbringing in colonial and Apartheid central and southern Africa have made me an agile classifier, and hard on the heels of that, unless I’m very careful, is a stratifier. In there are the seeds of prejudices if given any quarter. So I have little doubt that there would have been not a few actions, omissions, assumptions along the way that would demonstrate prejudicial discriminatory-isms. Pervasive? I trust not, but here’s a story within our department that may illustrate some of the things I need to think about. In synch with the overall theme, I call it ‘Ralph and me’. When I was a registrar here pre-1994, I used to see Ralph coming to Respiratory Clinic for his session. So friendly but his anger at Apartheid’s bitter consequences was palpable to me. Later I went on outreach to Worcester where he was the sole paediatrician. So welcoming. Later still I was part of the interview panel for the post he took up under me in Ambulatory Paediatrics. My partner and colleague. After I left Red Cross and he stepped into the senior role, there was one issue regarding service provision that we found that we did not agree on. When I look back with Rhodes-tinted spectacles, I see two things: I may well have behaved like a supremacist, not giving quarter just because I’d been around longer and felt a right to my wisdom and authority. I also know for a fact that I did not engage at the right level because I was not certain that the things that Rhodes has given me would not poison the atmosphere. What right had I, who the system had favoured, to confront someone who had had a harder journey to where he was? What would happen to us if I did push through? I let things drift. I do not know what Ralph felt about our differences on that issue (and we only crossed swords on that one), but I cannot impute to him anything I have found in myself.

Second question. Am I an African? Some may see it as an H word, hubris. How can I a white person from Breetain answer that question? Others would see it as a long-since answered question that it is foolish to bring up. I consider that I can and must answer that question (with its resonances and sub-questions) myself if I am to be a prepared and thoughtful part of our shared re-designed future. But I have – with the opposite H word, humility – to put myself through a number of tests, and I believe that I am. Perhaps a superficial example. Can I love the music of Gustav Mahler (who probably never gave the needs of Africa a thought while the king of the Belgian was raping the Congo Free State) while not being able to name a Kwaito star and call myself an African? It depends how that love for Mahler is expressed. To adapt St Paul: if I give all my money to the Cape Philharmonic Orchestra but have not Africa in my heart, I am but a sounding gong and clashing cymbal. In other less poetic words, being an African in Africa is about a deep commitment to the people and continent, I believe. “Je suis Africain” I stated to a group of French MPs who visited Somerset Hospital under the auspices of Kidzpositive. I had restitution by a colonial power in mind. Was I a hubristic poseur? A self-deluding Romantic? Do I, like Shakespeare’s Portia, “protest too much”? Can the same words come out of Africanist Thabo Mbeki’s mouth and mine? I believe so.

“Words, words, words! I’m so sick of Words!” sang Eliza Doolittle. “Show me!” And that’s where I move from present to future. In looking forward I must not assume that because, in the new South Africa, I work for and with largely poor and needy children in the public sector as a white South African that this cancels out or assuages the consequences of my privileged past. If I think that, I am undertaking an accounting exercise. My medical, academic and policy-related work is or can be part of the post Rhodes and Race R-words – restitution, reparation, redemption of the past (Michael Lapsley’s phrase), redress, re-distribution. But those R words must walk the corridors with me; they must go home with me; they must pervade my choices (he who has been bequeathed choices in almost every sphere of his life). Choices in what I do with ‘my’ time, ‘my’ money must also be guided to a significant extent by those R words. Most of those “my’s” have been bought with a price. White guilt? White reality. White liberation, I would say. Our shared future demands these responses of me, work and play.

Here’s an example: I am both discouraged and angered that our government granted an unaffordable pay increase to civil servants. I further regret that the obvious re-distributive and restitutive step of giving smaller increases to people at the top (like me) has never been taken. What I can do is to take that tainted gain (and any other such gains, financial, skills and other – present and those stretching into my pre-history) and plough it and them personally into reparation and redress.

So I hope to be guided by some words in thinking this through and acting.

H words: Hubris – out. Humility – in. The other silent H word, honesty – with myself and with colleagues and friends and everyone!

R words. I won’t spell them out again, but they all begin with R and E, thanks to the way the English language works.

The academic in me is screaming at this point because I have not had time to construct a neat ending to this talk. But this is probably just as well.

R is for Raw. So let me leave a raw, ragged and bleeding end to my Rhodes and Me talk. It may be a fitting metaphor.

Thank you.

Vomiting Verse

This the text of the lecture I used to give to (bemused?) 5th year medical students. Part of it appeared in the Student BMJ with a commentary in rhyme from the reviewer.


The subject for discussion

Is the little child who vomits,

Who throws up all her food with the

Trajectory of comets.

But first we must distinguish,

As you’re sure to come across it,

The differences between this and

The gently brought up posset.

The child who only possets

Never puts you in a spin

For she deposits but a drop

Or two upon her chin.

The vomiter however is

A child you can’t ignore

As her most recent meal ends up

Upon the kitchen floor.

A posseter you reassure;

A vomiter – find out more.

Why do children vomit?

Well, like you and me,

When the stimulus is there

It’s a reflex, don’t you see?

Signals from the gut

Or deep within the brain

Go to the medulla

To initiate a chain

Of events that are directed

By a centre that is known

By the sweet nonscanning title of

Chemo-emetic trigger zone.

What follows? Need I tell it?

The stomach will expel it.

It’s vital to remember that,

Like fits or halitosis,

  Vomiting’s a symptom and

  Is not a diagnosis.

I’ll say it once again

Though it might induce hypnosis:

Vomiting’s a symptom and

Is not a diagnosis.

So don’t be tempted just to give

The mother’s head a pat

And dose the kid with Stemetil

Or nostrums such as that.


A good history and examining

Will help you find the pieces

That fit together giving you

The cause of the emesis.

Thus a clinical approach will in all

Cases give the answer

Which may vary from a sore throat to

A cerebellar cancer.

Yes, causes may be minor

Like an earache or a cold

But miss a mass within the brain

And there’ll be strife untold.

The most helpful thing to aid you

As you search to find the reason

Is the age at which the child


Has now presented. In the season

Of the first week of the neonate

What they swallow during labour

Gastric irritation

May cause some irritation and

Get tossed out like a caber.

Liquor, blood, meconium

Upset the stomach lining

And make the baby puke

And vomit after dining.

Feeding  problems

Also difficulties feeding may

  Upset the infant gut.

These symptoms usually settle and

The baby then thrives, but

Don’t forget that in this period when

The baby very light is


She’s prone to get infections:

Septicaemia, meningitis.

Here the septic babe

May cry too much or go

Too quiet and apathetic,

Her temp is high or low.

Should these things occur,

Then you must be quick

To do your cultures and begin

An antibiotic.

Congenital gut anomalies 

Also at this time the gut is

New and is untried

And there may be an atresia or

Stenosis deep inside.

Many’s the congenital

Obstruction that may show

Soon after birth with vomiting.

So don’t be slow

To think of duodenal or other atres-

ia, meconium ileus or Hirschsprung’s disease.

If you’re in a bind

And just can’t find

Which part of the babe the trouble is in

There’s a chance it may

Be the DNA:

An inborn error of metabolism.

So at the end of the list

And not to be missed

Some rare faults exist

For the biochemist

Such as hyperammonaemia

Where blood ammonia’s high

And, if treatment isn’t given,

The baby may well die.


Vomiting’s a common symptom in the

First few months of life

And it causes much alarm to many a

Mother or a wife.

Feeding problems 

Commonly it’s met where feeding

Isn’t going well.

The baby’s swallowing air and is

Creating merry hell.

She eructates or burps

And the milk returns at speed.

The whole thing is repeated then

With each and every feed.

Or perhaps the hole that’s in the teat

Is made too big and wide;

Gulped air and milk distend her gut –

She can’t keep them inside.

Thus careful note you need to make

Of mum’s technique of feeding

So you can find the faults and change

Disaster to succeeding.


Quite common too is GOR,

That’s gastro-oesophageal

Reflux where the babe returns

A portion of each meal.

She brings her milk up with no strain,

Of bile there’s not a trace,

But on the carpet there’s a stain;

Despair is in mum’s face.

But your job is to reassure.

“She’ll grow out of it”, you say

But check first that she’s growing well

And that her chest’s OK.

For reflux may result in a

Failure to gain weight

And, in others, food’s return

May make them aspirate.

A variation on this theme

Of GOR is seen when haem-

atemesis gives mum a fright. This

Brings to light oesophagitis:

Acid burn of the gullet

Needs antacid to dull it.


Also you will often see

An infant with otitis me-

dia, the common cold or such

Presenting ‘cos she vomits much.

Infections present commonly

With vomiting in infancy.

This aphorism’s worth repeating

Over and over if kids you’re treating:

Infections present commonly

 With vomiting in infancy.

Always thus you must consider

Maybe bugs will give a kid a

Gastro or a meningitis,

Chest infection, hepatitis.

Don’t forget the UTI

Lurking unsuspected by

Those not versed in little tricks,

Eg. the using of dipstix.

These causes – feeding, GOR, infection

Are the commonest in this section

Less common but now needing introduction

Intestinal Obstruction

Are some syndromes of intestinal obstruction.

Firstly and most common is a

Major diagnosis:

That’s infantile hypertrophic

 pyloric stenosis.

The cause of this phenomenon,

The pundits now assure us

Is that nitric oxide synthetase is

Low in the pylorus.

This is four times commoner

In boys than little girls.

It can run in a family. The

Firstborn often hurls

His milk across the room in

A projectile fashion.

It’s sudden and complete – he

Then wants his next ration.

The vomiting is not always projectile,

Don’t be caught,

But it occurs soon after feeds;

His mother’s overwrought.

The baby doesn’t thrive, he

May go slightly yellow

And it is quite obvious he’s a

Hungry little fellow.

The clue, apart from hist’ry, you will

Find if you can feel

A round mass, olive-shaped, as the

Baby takes a meal.

Here is how

To do it now:

The baby feeds on mother’s breast, re-

laxed (there is no hustle).

You gently get you fingers to the

Right of rectus muscle.

You’ll feel it then. Your eye may catch, as

It so smoothly pulses

Across the epigastrium, the

Gastric peristalsis.

The other helpful clue to

Make the diagnosis

Is a hypochloraemic hypokalaemic

Metabolic alkalosis:

For –

Although he’s dehydrated, it’s

Acid that he’s lost

And trying to correct, potassium into

Cells has crossed.

The diagnosis is confirmed with

Ultrasound or barium

And with a pyloromyotomy you’ll

Get your honorarium.

The name of the operation I’ll repeat now

Nice and slowly:

You cut the muscle lengthways –



In older infants it’s the in-

fections that are major


 Causes of the vomiting in

Children at this stage. A

Child of this age also tends to

Pick things up and swallow


All sorts of things that do no good.

Emesis may well follow.

A tablet, insect, leaves and sticks

Enter the oral cavity

So think of poison when she throws up,

Defying gravity.


The ruminator brings it up in

to his mouth, rechews it,

Swallows it again or, at

Times, will choose to spew it.

This can be normal but may show a

Child who’s life is boring;

Who’s parents do not stimulate or

Actively ignore him.


Likewise the infant who has had an

Early life of tension

At times of stress may make a mess;

Vomits to get attention.

If you have been sleeping

Please wake up and listen

As I introduce

Some important conditions.

Concentrate now! Do not doze

As words of wisdom I propose:

Surgical causes

In the first two years there occurs

  A vomit which the surgeon

Would maintain is his terrain.

One is an emergen-

cy, the midgut volvulus.

Here there will exist

A malrotation of the gut which

Gets into a twist.

The circulation to the bowel is

Compromised and should

This state continue long that

Bowel will be no good.

The child with this will vomit bile, goes

In and out of shock, but

Distension’s rare, the stomach’s soft, not

Much to point to rotgut.

To diagnose the midgut volvulus

Make it certain that

A child who brings up bile must have a

Barium meal and that stat.

To be complete,

I must repeat:

To diagnose the midgut volvulus

Make it certain that

A child who brings up bile must have a

Barium meal and that stat.

The other thing that’s surgical and

Vomits at inception

Is telescoping of the bowel that’s

Called intussusception.

This occurs at many sites, is

Often ileocolic.

The baby has a bloody stool and

Pain that’s diabolic.

These times of pain are episodes of

Gut contraction when

Ischaemia is occurring at the

Site of obstruction.

Apart from the history and the

Pain, the sign you try to find

Is a sausage-shaped abdominal lump

Either ill- or well-defined.

The management, I’ll briefly say, is

To attempt reduction,

Under X-ray control,

with careful introduction

Of air under pressure

In the colon with a pump:

And with a bit of luck

You’ll get rid of the lump.

Should this fail

It will entail

A surgeon’s knife

To end the strife.

Please make it a rule – if

Money you would earn – you

Must never, never miss an in-

carcerated hernia.

You’ll be alright

If in each mite

You carefully check

Each hernial site.


The older child she vomits less. The

Causes are not many.

Once more infections dominate and

Basically are any.


Some are less than obvious, re-

quire a little looking

To find the underlying germ, to

Ascertain what’s cooking.

Examples here are hepatitis

That is anicteric

And once again the UTI. And

Then there’s mesenteric

Adenitis that presents with

Pain that on the right is,

Similar to that found in

Acute appendicitis.


Don’t forget that little kids are

Greedy little devils

And often bring up after being at

Birthday party revels.


  Now, to those children with a fixation that is oral,

Here are some statements; each one with a moral:

The child that reaches for green peaches

Learns the lesson that this teaches.

Likewise she who chews dad’s pills

May go green about the gills.

Nausea and vomits follow

Kids who sundry poisons swallow.

Raised ICP

A group we must not fail to mention

  Have intracranial hypertension.

Infections, tumours – all may cause a

Puke with no preceding nausea.

So always probe for symptoms that

Point to trouble ‘neath the hat.

Headache, squint, a change in form, a

Fit, ataxia or head trauma.

Cyclical vomiting

Now, cyclical vomiting. I’ll

Try to give you a notion of it:

A child who’s well will, like hell,

Suddenly, profusely vomit.

She may get so dry

She may need I

V for rehydration

Yet in a day or so

She’ll want to go

Back to school and her education.

She’s well again, as right as rain

Yet she will be back

Puking like a drain, sunken-eyed again

In the midst of another attack.

The reason why this happens

I wish I could explain

But we know the child may go

On to suffer from migraine.

The recurrent nature of these bouts,

The rude health in between

Should rule out most of your doubts

And keep tests to the routine.

Psychological problems

  Some problems with the psyche

  And certain states of mind

  May make a child quite likely

To vomit be inclined.

A sight, a smell, excitement, joy,

The fear of a needle’s prick

May make a little girl or boy

Quite literally sick.

If an older child comes with vomiting

And the reason seems something of a poser

Just take note

Of the finger in the throat:

It’s a case of anorexia nervosa.

I’ll go on now we’ve been through

Causes and ages

And take a trip through all the

Clinical stages.


  History first. We want to know

More about the vomiting so


We ask a few questions. Quantity first.

Is it enough to cause a thirst?

Does it dehydrate the child?

Is this major or only mild?

What proportion of each feed

Is returned and at what speed?


  We’ve partly discussed this –

Projectile or posset?

Is it forceful or with ease

That she manages to toss it?


  And what’s in the stomach contents as they’re

Ejected or released?

Is it bile or blood or old food or what re-

mains of her last feast?

If blood, think first it’s swallowed

Eg. when a nipple cracks. This

Is like the older child who

Has an epistaxis.

But, as in older folk,

Vomiting blood may be no joke.

It may be from burst varices

Or bleeding peptic ulcer disease.

The presence of a green tint, bile,

Should make you think obstruction;

It may be paralytic il-

eus – needs drip and suction.

But it could be mechanical

Below ampulla of Vater

Where surgery is called for and

Medicine’s a non-starter.

Associated symptoms

Nausea we’ve discussed. It’s

Presence is suggestive

Of trouble that relates to part

Of the tract digestive.

In its absence, don’t be dull —

Think of trouble in the skull.

Associated symptoms

You need to find to sew up

The underlying cause that

Makes a little child throw up.

Diarrhoea would suggest the

Cause is enteritis.

Fever, stiff neck, crying point to

Likely meningitis.

A little trick- if a child is sick

As each new day is dawning

She may be in the grip of a postnasal drip

With a gut full of snot every morning


  Examination. There are two

Questions to select:

One: what caused the vomiting? and

Two: what’s its effect?

Hydration and nutrition

Two first: Check the child for the de-

gree of dehydration.

Is she still well nourished or

Showing emaciation?

A weak child may be short of

Ions: potassium, sodium, chloride

And may need their replacement intra-

venously supplied.


  Examination takes the form that

You’ve been taught so well:

All systems of the body may

Have a tale to tell.

Jaundice – that’s the liver;

Fever – that’s a bug;

Neonate, distension that could

Be meconium plug.


  The abdomen’s the focus of your

Int’rest like as not.

Can you palpate an organ?

Is there a tender spot?

Gaseous distension an

Obstruction would suggest

And peristalsis you can see will

Help you in your quest.

Don’t forget the rectal – it can

Help you when one sees

A low intussusception or per-

haps Hirschsprung’s disease.

Other systems

  Don’t ignore the ENT,

  Otitis you may miss

But I can’t talk of everything in a

Paper such as this.


Investigations are dictated very

Much by what you find

But here are some remarks which you

Ought to keep in mind.

Always test the urine; Acid

Base if weak or dry

Along with the electrolytes which

May be low or high.

X-rays may be plain or contrast,

Use mainly in obstruction –

Barium can go in the top or by

Rectal introduction.

Ultrasound has got a place for

Seeking out of masses

That may cause copious vomiting in

Little lads and lasses.

These days its use for intussus-

ception or pyloric

Stenosis, GOR is nothing

Short of meteoric.

Other tests you order will re-

late to your conclusion

As to where you think the trouble is – of

These there’s a profusion.

But all in all our main help is

Always to be found

  When hist’ry and examination

  Are complete and sound.

Now remember at the start

Of this great work of art

A sentence that I’d like you

To learn off by heart.

Open your eyes

And lift that drooping ptosis:

Vomiting’s a symptom and is

  NOT a diagnosis.


So – Management is One: General (re-

plenish body stores

of fluid and electrolytes);

Two: Specific (treat the cause).

Just one more thing: resist the urge,

Though mother may be keen,

To stop the kiddy’s vomit with a


For Stemetil or Valoid

Are toxic to a baby

Or child and could produce a

Dyskinesia maybe.

So treat the cause and you will win

And baby’ll keep her dinner in.

So ends this thesis

On childhood emesis.

Early morning Hungarian rhapsody

Yes, for once in this chronicle of change and loss, I can wax rhapsodical. It is 4.30 am. I am driving home after a spell in the hospital with a critically ill baby. FMR plays an uninterrupted playlist at that time of day. An orchestral version of Liszt’s most famous Hungarian Rhapsody begins with its firm C sharp minor chord. Pah-dah! I eagerly anticipate the sharp-bestrewn fast section that I have had great fun getting my fingers round on the piano. And here it is – the orchestra playing showers of sharps, violinists’ fingers racing up and down F sharp major scales. We are nearing the end and I am taking the 270 degree left turn from the N2 on to the M5 when it dawns on my crepuscular consciousness that the players would have been playing C minor and F major, the simpler keys of the orchestral version! One up for Westwood…..worth being up at that time. Pah-dah!

Flipping Chopin

My daughter is teaching herself to play Chopin’s Mazurka in A minor. The middle section is in F sharp minor. She was practising this section when I came in from a pleasant walk below Table Mountain. Not surprising to me was the G minor picture of her fingers on the piano keys that saw in my head. The music soundedin this key. I decided to experiment: I lookedover her shoulder at her fingers. Yes, Top note C sharp as I knew it must be – and as i looked the music I heard seamlessly changed to F sharp minor. No transposition; merely a change of sense. I looked away and within two seconds I was hearing G minor again.

When Ursula arrived at the A minor recap, it was in the ‘right’ key. I’ll talk to that paradox in another post.

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