Welcome back to our voyage called History of Pediatric Cardiology.

Getting back to the Congenital heart lesions, we have seen some of the works by Steno, Morgagni and others, which led to the development of interest in the field. In the 18th century, a Frenchman by name LeCat brought out a study on Atrial Septal Defects in AD 1747, with a quality that was unparalleled till then and set a trend for future. Also seen was a lively debate (which used to run toxic if opposite parties met!) on the origin of cyanosis – obstruction Vs admixture. Obstruction to the flow theory, vehemently supported by Thomas Peacock cited instances of cyanosis in the absence of septal defects. The other group which supported the admixture lesions was physicians like Gintrac, who quoted patients of pulmonary stenosis who had no cyanosis at all, thereby arguing in favor of admixture. None of the early proponents of each theory survived to see the truth.

(Ref: LeCat: Concerning the foramen ovale being found open in the hearts of adults. Phil trans 9:134-135, 1747
Gintrac E: Observations and Researches on Cyanosis or Blue Disease. Paris: lmprime et Fonderie de J. Pinard, 1824)

In the 19th century, interest in the theoretical congenital cardiology evolved further with some of the great brains of the century rendering their interest in these. Important among them were:

Farre JR: On malformations of the human heart. In, Pathological Researches. London, 1814
Meckel JF: On malformations of the heart. Virchows Arch Pathol Anat 1805:594-610; 1815:221-284
Gintrac E: Observations and Researches on Cyanosis or Blue Disease. Paris: lmprime et Fonderie de J. Pinard, 1824
Paget: On the congenital malformations of the heart. Edinburgh Med Surg 36:263-309, 1831

These publications in the first half of the 19th century were only a prequel to a grand 2nd half. AD 1858 saw a monumental work by name “Malformations of the Human Heart” published in London, authored by one of the most celebrated physicians of the time, Sir Thomas Bevill Peacock. The book contained beautiful illustrations of various congenital malformations, including such things as ventricular septal defects, pulmonary stenosis, and transposition of the aorta and pulmonary artery, making it a pleasure to read. Even a person of Maude Abbott’s caliber exclaimed about Peacock’s book as, "the first comprehensive study covering the whole field (of Pediatric cardiology)". About 17 years later, another celebrated physician, Carl von Rokitansky published his monumental from Vienna, named “Defects of the Cardiac Septa”. Having personally done some 30,000 autopsies, Rokitansky was probably the best-suited person of the period to write anything related to Pathological Anatomy. No wonder, he was later called as “Linnaeus of
pathological anatomy” by Rudolf Virchow himself. Rokitansky was also a very keen observer of latest and could appreciate the best of the era. He, in fact, had openly supported Ignaz Philipp Semmelweis in his work on Puerperal fever. The works of Peacock and Rokitansky added to the knowledge of the existing cardiac disease to a great extent and inspired generations of physicians to look at the subject with keener eyes.

Peacock was famous not just for his publications, but also for his ability to accommodate to the new technology available in the period. He noted a characteristic radiation of the murmur of pulmonary stenosis using the new tool, the stethoscope, to correlate physical findings with anatomy in congenitally malformed hearts. He thus became a pioneer in the use of this device for heart, others of the era being more interested in lungs. Peacock was also interested in etiology. He was first to observe that "malformations are certainly most common in males, though why it should be so seems incapable of explanation." He also observed the familial nature of cardiac defects, presaged a long period of analysis of genetic and familial aspects of heart malformations, a process that continues using vastly more sophisticated tools to the present day.

(Ref: Peacock TB. On malformations of the human heart. London: John Churchill, 1858.

Peacock TB. On some of the causes and effects of valvular disease of the heart [together with] On the prognosis in cases of valvular disease of the heart. London: John Churchill, 1865. Reprinted in: Fye WB, ed. Birmingham, AL: The Classics of Cardiology Library, 1990

Rokitansky : Defects of the Cardiac Septa. Vienna, 1875)

Next time, we shall see the further development of 19th century.

On a personal note, the week saw an acutely short staffed and over-stressed Surgical staff. It is not easy for a person to do/assist 5 cases a day. I hope they will draw their strength from the work itself!

How partial can be an AV canal defect? We have seen an isolated primum defect. How about an intact interatrial septum with common AV valve with inlet VSD? We had a tough time differentiating this with a Tricuspid atresia, as the MRV was hypoplastic. Great vessels were normally related. The management may not change, but the diagnosis is obviously, a matter to dwell upon.

I was discussing the differentials of AortoPulmonary windows and explained the need for looking at both semilunar valves as a differentiating factor from Truncus. What I saw in a child was much intriguing. There were 2 semilunar valves with large communication between Aorta and MPA. The MPA continued towards LPA and stopped there. No distal LPA! RPA took separate origin from the Aorta, just above the Aorto-pulmonary communication. Technically, it was an Aortopulmonary window with Hemitruncus! I had not seen this combination and my previous publication of 50 cases of Aortopulmonay window also did not feature this entity. I think I should bring it to the notice of Dr Robert Anderson.

Please put in your inputs. If you happen to see anything that is similar what I discuss every time, feel free to comment or email me.

Regards

Kiran

Welcome back to the wonderful voyage called History of Pediatric cardiology. Last time we saw the saga of Laennec and stethoscope. We shall continue with this further

There was no dearth of critics for Laennec. He concentrated so much on stethoscopic findings that he ignored the traditional percussion and auscultation techniques, which earned him the title of “Cylindromaniac”! It is true that his concepts of origin of heart sounds were complete mismatch, but we should understand that we are talking about the inception of the science. It is very easy to comment about past without having to undergo the trouble of pain involved in the labour. Saintington, Laennec’s biographer in AD 1904 gets severely critical of Laennec’s cardiology concepts. Probably, one should get soft in criticism of past, for, we are standing on the same shoulders whom we are talking about!

(Ref: Saintignon, H. (1904). Laennec, sa Vie et Son Oeuvre. J. B. Bailliere, Paris)

Irrespective of the fundamentals, stethoscopy had earned a great demand in Europe, as each patient wanted their doctor to use them. Gradually, physicians used stethoscope for heart and direct auscultation for lungs.

Claude Bernard had prophetically told once about the light of scientific truth dispelling the obscurities and discovery of new paths. A new era of physical diagnosis was laid on be Laennec’s stethoscope. Auscultation of heart got into new straits with many physicians exploring the vista and scaling new heights. The wooden stethoscope did not come in the way of Bouillaud to study his own heart sounds when he decided to attach a rubber tube to its end. This innovation helped in the flexibility of the device and paved the way for present day design. He was also the first to favour a valvar origin of heart sounds, by correctly attributing the S1 to AV valves and S2 to semilunar valves.

(Ref: Flint, Austin (1876). A Manual of Percussion and Auscultation, of the Physical Diagnosis of Diseases of the Lungs and Heart. Churchill, London)

Laennec was not the only one to get the origin of heart sounds incorrect. To-be Giants of field also erred at this level! Majendie attributed the S1 to ventricular diastole against the chest wall and S2 to impulse impelling the base of the heart against the chest. Pigeaux regarded the S1 as diastolic and Corrigan attributed S1 to atrial systole and S2 to ventricular systole. Despite the big names making huge wrong sounds, Bouillaud stuck to his decision and won at the end. Further experiments in this regard in AD 1832 by Rouanet, 1839 by Hope, in AD 1840 by C. J. B. Williams, in AD 1860 by Halford and many others gradually established the view held up by Bouillaud. Scores of textbooks were written on auscultation. In AD 1858, Hamernik, a physician of regard in University of Prague assigned himself as the professor of auscultation! Many signs were brought up via auscultation later. Duroziez gave the signs of mitral stenosis, its presystolic murmur and snapping first sound, second sound, opening snap, and diastolic rumble. Potain described splitting of sounds and gallop rhythm. The development of phonocardiography further refined this science.

(Ref: Halford, G. B. (186o). The Action and Sounds of the Heart; A Physiological Essay. Churchill, London.

Hamernik, J. (1858). Das Herz und seine Bewegung. Dominicus, Prague.

Hope, J. (1839). A Treatise on the Diseases of the Heart and Great Vessels, 3rd ed. Churchill, London)

Leannec’s contribution to Cardiology is unparalleled in history, in league with that of William Harvey. It looks daringly evident in the everyday life of any physician!

Next time, we shall see further progress of clinical cardiology.

On a personal note, this week saw few heartbreaks. I had seen an infant with Ebsteins anomaly with ASD and communication between LV and atrialised RV. (What should we call such defects?) This baby had a turbulent post-operative course after complete correction and succumbed. I had not seen this variant of Ebsteins earlier. Any inputs?

We saw a couple of adolescent girls with infective endocarditis. It is very painful experience when we see the multiple vegetations hanging on to the valves and are set to get into the circulation any time. One among them already had a probable systemic embolization, as right radial pulses were feeble. The other had developed severe regurgitation and was in multiorgan failure. Can we see a time when such a happening be prevented in India?

Not everything was bad. Our surgeons operated on sever MR in an infant very successfully. Also, a symptomatic newborn with TAPVC and restrictive PFO was taken for emergency surgery and saved. The numbers of device closures are increasing gradually. It is very heartening to see the success in front of our eyes.

Thanks to Mr Praveen Kumar, our beloved Echo technician for following the blog. Believe me, he knows a lot of computer stuff. I look forward to his inputs.

I think the field of Pediatric Cardiology and Surgery is going through a major polarization in India. The arrival of Five-star hospitals in metros is drawing the best brains from charitable institutions into them. Whether it is the indifferent behaviour of such institutions that prompt the hard working souls to move away or the perceived need of a decent life for a doctor and his family which mandate such a step is a matter of debate. I have seen world-class doctors working for peanuts at many institutions. After a while, the institute takes them for granted and neglects their services. This happens when the hospital management shifts from Doctors to MBAs. For a non-medical administrator, every doctor is a file on his table. He would not have worked with the doctor skin-to-skin to appreciate their subtle value and prodigal skills. Consequently, they fail to see the reason from the point-of-view of the doctor. The loss of a brilliant medical brain to another institute bleeds the colleagues from within, but the administrator does not even feel the loss in short term. They would put in their efforts to rope in another name to get the work done, without analyzing the causes that prompted the previous person to leave. How much can it serve the team spirit, how much would it affect the overall efficiency, how much would it translate to losses on a long run is probably never thought, as the administrator himself is not considering a long-term prospect in the said hospital. For them, any place is as good as the other. However, a hospital is much more than a financial institute. A non-medical person can possibly never understand it.

All this was written in the context of a major Pediatric Cardiology center at Kerala losing out both its fantastic surgeons to Five-star hospitals at Mumbai. What was carefully built over a decade with lot of care, love and passion collapsed in short time due to myopic vision of non-medical administrators. I bet neither of the surgeons would have left if somebody more empathic had run the show. It is probably the beginning of the downfall of such “charitable” institutes. The overall effect is really bad for the country. But, who would tell the “practical” administrators who cannot see beyond balance sheets? How would you put the entire picture to a person who has his eyes fixed to a narrow tube?
It pains to write such stuff, but it is time to ponder over such issues. Time is the most crucial factor; hope the best prevails at right time. Please let me know your views on this issue of “braindrain” from places where it is badly required.

Regards

Kiran

Lets continue with our fascinating journey into Historical aspects of Pediatric cardiology. Its time to remember the father of auscultation and stethoscope. Prior to that, lets have a few words on Senec again.

Senec continued to be a major influence to the generations of Cardiac anatomists and physicians. His systematic approach starting from anatomy and going on to post-mortem studies found him devoted followers. His text Traite remained an influential work throughout the eighteenth century, finding many reprints and revisions. The section on heart diseases itself appeared in 2 editions under the title Traite' des maladies du coeur in AD 1778 and AD 1783. An Italian translation in AD1773 and a German translation in AD 1781 have also been recorded. As a rare achivement for the period, even Senac's contemporaries and rivals regarded the Traite as an authoritative work in cardiology. Authorities on subject of Cardiology in the likes of von Haller and Giovanni Morgagni spoke highly of Senac's treatise.

(Ref: Renouard PV. History of Medicine, from its Origin to the Nineteenth Century. Philadelphia, Lindsay & Blakiston, 1867, p 387)

Cardiac physical diagnosis altogether changed with the idea of stethoscope. Prior to this era, in one of the Royal Society meetings, celebrated physician Robert Hooke had wondered, “I have been able to hear very plainly the beating of a man's heart.... Who knows I say that it may be possible to discover the motions of the internal organs."

Within few years of this comment, a French physician by name Rene Theophile Hyacinthe Laennec revolutionized the diagnosis of cardiopulmonary diseases and opened new horizons to a hitherto undiscovered world. Before that time, physicians listened to the mysterious sounds of the heart by placing their ears directly on a patient’s chest, with interpretations that were ambiguous and highly subjective, not to forget the embarrassment both to patient and listener. Laennec was a student of Covisart, a celebrated physician who had refined the technique of percussion proposed by Leopold Auenbrugger. His association paved Laennec to think beyond percussion. Incidentally, Auenbrugger was a son of innkeeper and had devised the system of percussion to note the level of wine in barrels. Auenbrugger did not see much difference in diseased human chest filled with secretions and wine barrel. The resonation mattered. He was musically gifted enough to make a physical diagnosis with this invaluable technique.

Laennec’s era was also that of tuberculosis, with large number of deaths in Europe. He had not only lost many members of his family to this dreaded disease, he himself suffered from it. His knowledge of medical history had told him the Hippocratean way of direct auscultation over the chest. His knowledge of physics was sound enough to recognize acoustic principles: “The augmented impression of sound when conveyed through certain solid bodies, as when we hear the scratch of a pin at one end of a piece of wood, on applying our ear to the other”. In AD 1816, when confronted with an aristocratic woman of exceptional obesity who proved nearly impossible for “direct auscultation”, he rolled some sheets of paper into a cylindrical shape and applied one end of it to the region of the heart, and the other end to his ear. He noted his experiment in one of his landmark articles as “I was not a little surprised and pleased, to find that I could thereby perceive the action of the heart in a manner much more clear and distinct than I had ever been able to do by the immediate application of the ear”.

His experiment encouraged him to try tubes of various materials for clarity and he finally decided to go with a wooden instrument, which served as the prototype of present stethoscope. It was a foot long and 2 inches wide, perforated in the center and fitted with a plug for listening to heart. It was made portable by making it in parts, which were assembled as per need. The name “stethoscope” was derived from two Greek words, which meant, “examining at the chest”, the name derived by Laennec himself. Wooden stethoscopes were in use until second half of the 19th century, when rubber tubing came along.

Although his idea of stethoscope was primarily for the evaluation of lungs, Laennec’s curious mind did not stop at that. He distinguished two heart sounds and correctly attributed the first heart sound to ventricular systole. However, his idea of second sound to atrial systole made him unable to make accurate correlations between murmurs and pathological findings. Nevertheless, it was valiant attempt to classify the heart sounds in a way that was hitherto unheard of.

In AD1818, Laennec presented his saga on the stethoscope to the Academy of Sciences in Paris. In the subsequent year, he published his masterpiece, “De l’auscultation me´diate ou Traite´ du Diagnostic des Maladies des Poumon et du Coeur,” in two volumes. Already hit by tuberculosis and frial, Laennec still brought out a revised edition of his epochal work in the subsequent year with a masterly correlation of stethoscopic sounds and diseases of the chest documented by postmortem findings. He made an innovative marketing strategy by presenting one of his stethoscopes to each buyer of copy of his revised book! The pinnacle of his glory came with the English translation of his work by John Forbes in AD 1821. A number of Physicians from Europe came to Paris to understand and gain “first-hand” experience with this new diagnostic tool. He was perhaps the most honored and talked about man in Europe at the time of his death in AD 1826, at the age of 45 years. He succumbed to the same disease that he tried to make the world understand better. 13th of August happens to be the day Laennec died and is an opportunity for us to commemorate a man who gave us the symbol by which doctors are recognized worldwide.

(Ref: 1. Laennec RTH. De l'Auscultation Mediate ou Traite du Diagnostic des Malades des Polmons et du Coeur fonde` principalement sur ce nouveau moyen d'exploration. Paris; JA Brosson & JS Chaude, 1819.
2. McKusick VA. Cardiovascular sound. London: Bailliere Tindall and Cox, 1958)

Next time, lets dwell upon the refinement in auscultation and further developments.

On a personal note, the week saw kids of team members getting ill. The work schedule became a bit of haywire with unexpected leaves and absences. Hope things will get better soon.

This problem may be seen exclusively in developing countries; how do you manage a 35-year-old single ventricle man, who is found to be fit for Fontan surgery in Cath? Are we really offering him any benefit? Is the natural history better than surgical outcome? Our senior cardiac surgeon, Dr Shekar Rao, is of the opinion that if a patient has earned his surgery, it should be given to him. Others did not approve of this. Any experiences in this regard?

What should be done for an adolescent patient with single ventricle with complete heart block? The cath study showed an increased ventricular EDP, a clear contraindication for Fontan repair. But bradycardia is known to increase the EDP; it may be more augmented with AV dissociation. How to put a correction factor for this? Our surgeons informed us that single ventricle patients with complete heart block have undergone Fontan surgeries in the past. But, if high EDP is the only contraindication, is there any way of dissociating the bradycardic component from innate problem? Any takers for temporary transvenous pacing for few hours prior to cath procedure? Can it nullify the high EDP secondary to bradycardia, leaving only the other factor? Any suggestions or experiences?

Send in your inputs. It seems as if I am the only person reading this blog! If no one posts comments, I cannot make out if the blog is read or not. If you find it difficult to post the comments, send it to my email. Let me hear suggestions and comments.

Regards

Kiran

Lets continue the fascinating journey into pediatric cardiology. Last time we saw the origin of first description of the future Tetralogy of Fallot.

William Harvey was probably the first to suggest the possibility of coronary circulation, which he mentioned in a letter to his friend, Jean Riolan, who was an acclaimed physician of his times. This led to dissection studies of coronaries by Riolan and he confirmed the same findings as his predecessor, Gabrielle Fallopius.

(Ref: Bing RJ. Coronary circulation and cardiac metabolism. In Fishman AP, Richards DW (eds): Circulation of the Blood: Men and Ideas. Bethesda: American Physiological Society, 1982, p214.)

In AD 1698, another Frenchman, Pierre Chirac, ligated the coronary vessel of a dog to produce cardiac standstill. This revived the interest in coronary anatomy. In AD 1704, Frederik Ruysch elucidated the anatomy of coronary vessels by using a special injection technique.

(Ref: Willius FA, Dry TJ. A History of the Heart and the Circulation. Philadelphia, W.B. Saunders Company, 1948, p 66)

In AD 1715, Raymond Vieussens gave his landmark description of mitral stenosis. In his book, Traite' nouveau de la structure et des causes du mouvement natural du coeur, he reported the clinical course of many patients suffering from heart disease, along with the postmortem findings. The same book contains his famous description of the internal surface of the left ventricle and the malfunctioning mitral valve. His views were seconded by Giovanni Lancisi, another noted physician of his times, who authored “De motu cordis et aneurysmatibus” in AD 1728.

(Ref: Kellett CE. Raymond de Vieussens on mitral stenosis. Br Heart J 1959; 21:440-444)

The year AD 1749 is considered as a memorable one for medical historians, more so from cardiac point of view. A book titled “Traite de la structure du coeur, de son action, et de ses maladies” was published, which systematically dealt with anatomy, physiology and pathology of the heart. It offered the results of anatomical investigations and postmortem examinations, which hitherto was unheard of. The treatise was authored by a Frenchman named Jean-Baptiste Senac. His work reveals the state of the art in cardiology before the development of percussion of the chest and auscultation.

(Ref: Smeaton WA. Senac, Jean Baptiste. In Gillispie CC (ed): Dictionary of Scientific Biography, vol. 12. NewYork, Charles Scribner's Sons, 1975)

In AD 1761, one of the greatest books on medical literature was published. It was titled “De sedibus et causis morborum per anatomen indagatis” and was authored by Giovanni Morgagni (remember Morgagnian Hernia?) who vividly described a ventricular septal defect and Single ventricle in his treatise. Historically, it was the first time these lesions were described authentically.

(Ref: Morgagni GB. De Sedibus ei Causis Morborum per Anatomen Indagates, Venetia:Remondiniana, vol 1 and 2, 1761)

In the same year, clinical cardiology saw a major turn of event, which is practical even for today. Physicians prior to this era relied on their sense of touch, sight or smell to diagnose diseases. Leopold Auenbrugger suggested the use of percussion of internal organs to further aid the clinical diagnosis. He called his system “Inventum Novum” (Novel invention). The skill of percussion was further refined by Corvisart and applied firmly to clinical evaluation. Laennac’s invention of stethoscope in AD 1819 completed the basic tools of clinical diagnosis.

(Ref: Osler W. The evolution of modern medicine. Yale; Yale University Press:1921)

We shall see the further developments next time.

On the personal note, it was a matter of pain to relieve Dr Pankaj and Dr Ritesh from their services to the team. They have successfully completed their fellowship training and are leaving for next stage of career in Pediatric Cardiology. We all wish them best of good luck for their future.

The week went quite busy, with many falling sick! Changes of season with a fresh leash of viral attacks have troubled us a bit. Academics were usual. I happened to see a {S,L,S} with single ventricle physiology! Is it reported? Can anyone come with some more data on this?

I need more followers and replies. Hope I get them!

Regards

Kiran

In our voyage on History of Pediatric Cardiology, it is time to dwell upon the contributions of 16th century Europeans.

In AD 1578 was born a man who changed the way Cardiology should be understood. He had the gift of seeing fallacies of traditional Galenic teachings as a medical student. His concepts were so powerful that he used simplest of the equipments to prove his point. A mere tourniquet was all he required. His name was William Harvey.
He demonstrated the centripetal flow of blood in the veins aided by venous valves. His concept of circulation was as we know it today, except that he could not establish what connected arterial and venous systems, which he tried till his death in AD 1657. His idea of blood being propelled by heart into arteries and returning back via veins was completed by Marcello Malpighi, who discovered capillaries in his frog experiments in AD 1660. Malpighi also found the reason for red colour of blood by demonstrating the red blood cells. Together, Harvey and Malpighi laid the foundation for modern physiology. It was further strengthened by the invention of microscope by Antoni van Leeuwenhoek in AD 1774. Leeuwenhoek also gave the first accurate description of red blood cells and their circulation in the capillary networks of frog’s web spaces and ears of rabbits.

(Ref: Harvey W. Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus. Frankfurt:W. Fitzeri, 1628)

There was a simultaneous interest in the anatomic defects of heart in Europe. Niels Stenson, who described the Stenson’s duct of salivry gland, was an accomplished anatomist of Europe. Also called Steno at his country, he reported an interesting case in 1673. In this stillborn infant, he described the combination of bifid sternum, omphalocele, in addition to the modern description of Fallot’s tetralogy. This combination is now termed pentalogy of Cantrell. He described the infant also having syndactyly and cleft palate with harelip on the right side. As an anatomist, his interest was primarily non-cardiac. About the cardiac abnormality he wrote, "As to the cause of this phenomenon, I have nothing to say.” This appears to be the first description of Tetralogy of Fallot in the history of Pediatric Cardiology.

(Ref: Warburg E. Niels Stensen’s description of first published case of Tetralogy of Fallot. Nord Med 1942;16:3550-3551)

We shall see the further descriptions of congenital heart diseases next time.

On a personal note, untimely death of MJ showed how heterogeneous our team is! There were few who mourned the day badly; few were blissfully ignorant of who he actually was! When we saw the news popping up everyday in the dailies even after a week, Dr Anamika Metha exclaimed that we, as doctors, are losing out lots of happenings in the world. She suggested that, once in a fortnight, gathering of the team should be for non-academic discussions, wherein anybody can discuss something that inspired them. It can be a movie, music album, book, news snippet, real life incident or anything of interest. It is indeed a nice concept and we should work on it. May be, alternate Saturdays are good time.

Dr Pankaj and Dr Ritesh had a good session of RGUHS fellowship theory examination on 1st July. The questions were as expected, with no real bouncers! Their practical exams are scheduled for 7th July at Sri Jayadeva Institute of Cardiology, Bangalore. Good luck to both of them.

Dr Amol Moray left the team back to Australia. He is due for his certification examination in Pediatric Cardiology. Good luck to him from all of us in the team.

We came across an intermediate AV Canal defect with supramitral membrane in an infant. The interatrial communication was distal to the membrane and the LA appendage was connected to proximal chamber. A rare combination indeed! Our surgeons are dealing with the child now.

I saw another infant with AV discordance, DORV, l-malposed great vessels, VSD with subpulmonic extension with severe PAH. VSD is routable to MPA but not to aorta. If we decide on 2-pump repair, we will have to route LV to MPA, do an arterial switch and an atrial switch. But MPA and ascending aorta had wide discrepancy in their diameters. I don’t know if such extensive surgery is good or bad for the baby. The other palliation may be a PA band.

Please send in your inputs. How about the non-academic sessions every fortnight that is planned? Send me your suggestions on it

Regards

Kiran