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RECTAL BIOPSY IN HIRSCHSPRUNG'S DISEASE
1236
Drug and Therapeutic Information Incorporated.1I With the aid of a panel of distinguished medical advisers the evidence for and against a drug is stated and evaluated. Where the evidence is deemed to be clear, the reader is not left wondering whether the advisory panel believes the drug to be an advance or not. Where the evidence is
insufficient, then
this is stated and
a
further report is
promised. The Medical Letter has so far expressed opinions on the newer steroids (nothing to choose between them); buffered tetracycline (not a useful advance); meprobamate (little reason to prescribe it in preference to phenobarbitone); chlorpropamide, a new oral antidiabetic agent (the published reports and advertisements do not fully reflect the toxic properties, and a fuller review is being completed); erythromycin propionate (a valuable introduction); and many other preparations. When considering claims of efficacy which are superficially convincing but which yet leave a doubt in his mind, the doctor can now turn to the opinion of experienced people who are not influenced by commercial considerations and who have had time to weigh the evidence. The value of the Medical Letter will depend on its providing up-to-date and reliable opinions, and so far it seems to be succeeding. Good drug firms should welcome this development, for in the long run dissemination of reliable information on their products can only benefit them. Unfortunately the Medical Letter costs$12.50 a year, and probably not many British doctors will feel inclined to pay individually for a service which, it can be argued, should be supplied free by the State-for it is the State which has the prime interest in inducing them to prescribe economically, though such prescribing is in the patients’ be real need for a similar first hand in this country, financed publication prepared by the Ministry but (as the Hinchliffe Committee insisted) run " by the medical profession for the profession". The American example should encourage the Ministry to seek early action.
interest
too.
There
seems to
at
RECTAL BIOPSY IN HIRSCHSPRUNG’S DISEASE
IN cases of Hirschsprung’s disease routine methods of diagnosis often fail to establish the diagnosis; but Swenson et al.3 have shown that rectal biopsy (which has already proved of value in other disorders 4) may be a useful aid and may even be the sole means of establishing the diagnosis in infants and in some older children with atypical histories and non-specific X-ray findings. The patient is prepared for the biopsy by irrigation of the rectum to remove all fsecal material. A general anxsthetic is given to prevent pain and allow the anal sphincter to be widely
dilated. A site for the biopsy is chosen on the lateral wall 2-3 cm. above the mucocutaneous junction; the mucosa is incised for 2 cm. and by blunt dissection separated from the muscular layer. A triangular piece of muscular wall, 5 x 10 mm., is removed, care being taken that both circular and longitudinal layers are included in the biopsy material. The defect in the rectal wall is closed by interrupted sutures.
The pathologist may have to examine several sections in order to decide whether ganglion cells are present. Swenson et al. say that in 100 consecutive biopsies in patients considered possibly to have Hirschsprung’s disease a positive diagnosis was made in 38. All 38 were operated on, and all the operation specimens showed the typical lesion of Hirschsprung’s disease. 2. 136, East 57th Street, New York, N.Y. $12.50 a year ($6 for residents, internes, and students). 3. Swenson, O., Fisher, J. H., Gherardi, G. J. Surgery, 1959, 45, 690. 4. See Lancet, 1957, i, 774.
THE EPIDEMIC IN AUSTRALIA
THE epidemic of influenza-like diseases now affecting Australia has many confusing and contradictory features, both clinical and virological. A number of epidemic illnesses have appeared since March of this year, and while many of them are clearly attributable to Asian type-A virus, many more may well be unassociated with it. In Western Australia three clinical syndromes have been noted, often affecting the same patient successively, and virus studies have shown three infective agentsAsian type A, influenza B, and an adenovirus-but their relative incidence among the affected population has not yet been determined. 18 deaths due to secondary staphylococcal pneumonia have been recorded. Among nurses suffering from influenza, Haemophilus influenza has been repeatedly isolated from throat swabs and sputum. In South Australia,the epidemic has been widespread with an equally confusing clinical picture. Apart from an illness with typical symptoms of influenza, there have been two other syndromes. In one, symptoms have involved the gastrointestinal tract, with central abdominal colic, diarrhoea, fever, and malaise (the so-called " gastric flu "). This condition has spread in epidemic fashion and been highly infective within families. It has been suggested that an Echo virus may be responsible, but evidence of this has not yet been produced. The second illness usually begins with conjunctivitis, often unilateral, and the palpebral conjunctivx are often affected to the exclusion of the globe. Though rapidly becoming purulent, the discharge contains no specific organisms. The condition is unaffected by topical antibiotics and is often accompanied by preauricular adenitis and the symptoms of an upperrespiratory infection. There is some evidence to support the view that this illness is caused by an adenovirus, but the type has not yet been identified. So far, there have been 14 deaths in South Australia associated with the epidemic, but not all were clearly related to infection with influenza virus. Rather more deaths have been recorded in the sixth and seventh decades than in the 1957 outbreak. Material examined from 3 fatal cases of staphylococcal pneumonia has contained two strains belonging to phage-type 80/81 and one to group III (7/47D+). All have been resistant to penicillin but sensitive to other antibiotics. Victoria and New South Wales have suffered severely, and it is estimated that in the first two months of the outbreak in Sydney 23 deaths were attributable to influenza and its complications. Isolations both in Melbourne and in Sydney have shown Asian type-A virus. In one children’s hospital in Victoria, however, admissions did not increase and there was no rise in the incidence of laryngotracheitis, as there was in the 1957 epidemic. Many of the staff of this hospital suffered an influenza-like disease, and virus studies have revealed two types of Echo virus, as yet ’
unidentified.
Throughout Australia, native populations
have been severely attacked. Millingimbi Mission, near Darwin, reports that almost the entire colony of 400 has been affected. Thousands of natives in Arnhem Land and on Croker, Bathurst, and Elcho Islands have also had influenza, and a recent outbreak amongst aborigines at the Coober Peedy opal mining area has brought 3 deaths. Influenza vaccine has been made available by the Commonwealth Serum Laboratories, and the National Health and Medical Research Council has been consider-
Drug and Therapeutic Information Incorporated.1I With the aid of a panel of distinguished medical advisers the evidence for and against a drug is stated and evaluated. Where the evidence is deemed to be clear, the reader is not left wondering whether the advisory panel believes the drug to be an advance or not. Where the evidence is
insufficient, then
this is stated and
a
further report is
promised. The Medical Letter has so far expressed opinions on the newer steroids (nothing to choose between them); buffered tetracycline (not a useful advance); meprobamate (little reason to prescribe it in preference to phenobarbitone); chlorpropamide, a new oral antidiabetic agent (the published reports and advertisements do not fully reflect the toxic properties, and a fuller review is being completed); erythromycin propionate (a valuable introduction); and many other preparations. When considering claims of efficacy which are superficially convincing but which yet leave a doubt in his mind, the doctor can now turn to the opinion of experienced people who are not influenced by commercial considerations and who have had time to weigh the evidence. The value of the Medical Letter will depend on its providing up-to-date and reliable opinions, and so far it seems to be succeeding. Good drug firms should welcome this development, for in the long run dissemination of reliable information on their products can only benefit them. Unfortunately the Medical Letter costs$12.50 a year, and probably not many British doctors will feel inclined to pay individually for a service which, it can be argued, should be supplied free by the State-for it is the State which has the prime interest in inducing them to prescribe economically, though such prescribing is in the patients’ be real need for a similar first hand in this country, financed publication prepared by the Ministry but (as the Hinchliffe Committee insisted) run " by the medical profession for the profession". The American example should encourage the Ministry to seek early action.
interest
too.
There
seems to
at
RECTAL BIOPSY IN HIRSCHSPRUNG’S DISEASE
IN cases of Hirschsprung’s disease routine methods of diagnosis often fail to establish the diagnosis; but Swenson et al.3 have shown that rectal biopsy (which has already proved of value in other disorders 4) may be a useful aid and may even be the sole means of establishing the diagnosis in infants and in some older children with atypical histories and non-specific X-ray findings. The patient is prepared for the biopsy by irrigation of the rectum to remove all fsecal material. A general anxsthetic is given to prevent pain and allow the anal sphincter to be widely
dilated. A site for the biopsy is chosen on the lateral wall 2-3 cm. above the mucocutaneous junction; the mucosa is incised for 2 cm. and by blunt dissection separated from the muscular layer. A triangular piece of muscular wall, 5 x 10 mm., is removed, care being taken that both circular and longitudinal layers are included in the biopsy material. The defect in the rectal wall is closed by interrupted sutures.
The pathologist may have to examine several sections in order to decide whether ganglion cells are present. Swenson et al. say that in 100 consecutive biopsies in patients considered possibly to have Hirschsprung’s disease a positive diagnosis was made in 38. All 38 were operated on, and all the operation specimens showed the typical lesion of Hirschsprung’s disease. 2. 136, East 57th Street, New York, N.Y. $12.50 a year ($6 for residents, internes, and students). 3. Swenson, O., Fisher, J. H., Gherardi, G. J. Surgery, 1959, 45, 690. 4. See Lancet, 1957, i, 774.
THE EPIDEMIC IN AUSTRALIA
THE epidemic of influenza-like diseases now affecting Australia has many confusing and contradictory features, both clinical and virological. A number of epidemic illnesses have appeared since March of this year, and while many of them are clearly attributable to Asian type-A virus, many more may well be unassociated with it. In Western Australia three clinical syndromes have been noted, often affecting the same patient successively, and virus studies have shown three infective agentsAsian type A, influenza B, and an adenovirus-but their relative incidence among the affected population has not yet been determined. 18 deaths due to secondary staphylococcal pneumonia have been recorded. Among nurses suffering from influenza, Haemophilus influenza has been repeatedly isolated from throat swabs and sputum. In South Australia,the epidemic has been widespread with an equally confusing clinical picture. Apart from an illness with typical symptoms of influenza, there have been two other syndromes. In one, symptoms have involved the gastrointestinal tract, with central abdominal colic, diarrhoea, fever, and malaise (the so-called " gastric flu "). This condition has spread in epidemic fashion and been highly infective within families. It has been suggested that an Echo virus may be responsible, but evidence of this has not yet been produced. The second illness usually begins with conjunctivitis, often unilateral, and the palpebral conjunctivx are often affected to the exclusion of the globe. Though rapidly becoming purulent, the discharge contains no specific organisms. The condition is unaffected by topical antibiotics and is often accompanied by preauricular adenitis and the symptoms of an upperrespiratory infection. There is some evidence to support the view that this illness is caused by an adenovirus, but the type has not yet been identified. So far, there have been 14 deaths in South Australia associated with the epidemic, but not all were clearly related to infection with influenza virus. Rather more deaths have been recorded in the sixth and seventh decades than in the 1957 outbreak. Material examined from 3 fatal cases of staphylococcal pneumonia has contained two strains belonging to phage-type 80/81 and one to group III (7/47D+). All have been resistant to penicillin but sensitive to other antibiotics. Victoria and New South Wales have suffered severely, and it is estimated that in the first two months of the outbreak in Sydney 23 deaths were attributable to influenza and its complications. Isolations both in Melbourne and in Sydney have shown Asian type-A virus. In one children’s hospital in Victoria, however, admissions did not increase and there was no rise in the incidence of laryngotracheitis, as there was in the 1957 epidemic. Many of the staff of this hospital suffered an influenza-like disease, and virus studies have revealed two types of Echo virus, as yet ’
unidentified.
Throughout Australia, native populations
have been severely attacked. Millingimbi Mission, near Darwin, reports that almost the entire colony of 400 has been affected. Thousands of natives in Arnhem Land and on Croker, Bathurst, and Elcho Islands have also had influenza, and a recent outbreak amongst aborigines at the Coober Peedy opal mining area has brought 3 deaths. Influenza vaccine has been made available by the Commonwealth Serum Laboratories, and the National Health and Medical Research Council has been consider-