490

clinical circumstances. The patients are therefore monitoredby serial analysis of Pa O2 and arterial oxygen saturation.

In the support of severe reversible respiratory failure, con-sideration of the balance between oxygen supply and utilisa-tion is the fundamental concept. We think that reducingoxygen consumption by nioderate hypothermia may preventthe need for E.c.M.o.

Departments of Anæstheticsand Intensive Care,

University of Sydney,and Royal Prince Alfred Hospital,

Sidney, Australia

JOHN FLACHSMICHAEL BOOKALLILBRIAN CLARKE

HOW DOCTORS DEAL WITH EPILEPSY

SIR,—Dr Hopkins and Mr Scrambler (Jan. 22, p. 183) sug-gest that general practitioners could diagnose and manage epi-lepsy adequately, but show that, at least in the area sampled,they do not. Nor does the hospital service seem to do much bet-ter. This was broadly the raison d’être for the Reid report andits suggestions. Dr Hopkins may not wish to encourage theiradoption but his findings will provide many a cogent argumentin favour of some service aimed specifically at the needs ofthose with epilepsy.

His dismissal of the E.E.G. as an aid to diagnosis is sweeping.Its value depends, as in most laboratory procedures, on theskill of those who perform and interpret the test. Almost alltests have to be viewed as one part of the evidence. If the E.E.G.is never unequivocally diagnostic, it can at times be crucial evi-dence-as in a record with classical three per second wave andspike, for example.

This sample inquiry seems to illustrate misuse of a test andmismanagement of disability. Improving, rather than aban-doning, the use of procedures might be a better way of remedy-ing the situation.

Department of Neurology,Radcliffe Infirmary,Oxford C. W. M. WHITTY

ÆTIOLOGY OF DIARRHŒA IN CHILDREN AGEDLESS THAN TWO YEARS IN CENTRAL JAVA

SIR,—Recent studies of the aetiology of acute diarrhoea inchildren have focused attention on enterotoxin-producingstrains of Escherichia coli (E.T.E.C.) and a reovirus-like agentlocated by electron microscopy ("duovirus" or "rotavirus").Duovirus is a major cause of acute diarrhoea in children under5 yr both in the developed world1-5 and in developing coun-tries.b E.T.E.C. infection appears to be a rare cause of sporadicdiarrhœa in children in developed countries3 8 but is thoughtto be of major importance as an enteric pathogen in developingcountries.y E.T.E.C. infection in Bangladeshb seems to occuralmost exclusively in children over 10. The relative importanceof these two enteric pathogens in the aetiology of acutediarrhoea in children in South-East Asia is not yet known.

1. Davidson, G. P., Bishop, R. F., Townley, R. R. W., Holmes, I. H., Ruck,B. J. Lancet, 1975, i, 242.

2. Bryden, A. S., Davies, H. A., Hadley, R. E., Flewett, T. H., Morris, C. A.,Oliver, P. ibid. 1975, ii, 241.

3 Kapikian, A. Z., Kim, H. W., Wyatt, R. G., Cline, W. L., Arrobio, J. O.,Brandt, C. D., Rodriguez, W. J., Sack, D. A., Chanock, R. M., Parrott,R. H. New Engl. J. Med. 1976, 294, 965.

4. Middleton, P. J., Szymanski, M. T., Abbott, G. D., Bortolussi, R., Hamilton,J. R. Lancet, 1974, i, 1241.

5. Tufvesson, B., Johnson, T. Acta path. microbiol. scand. sect. B, 1976, 84,22.

6. Ryder, R. W., Sack, D. A., Kapikian, A. Z., McLaughlin, J. C., Chakra-borty, J., Rahman, A. S. M. M., Merson, M. H., Wells, J. G. Lancet,1976, i, 659.

7. Lancet, 1975, i, 257.8 Echeverria, P., Blacklow, N. R., Smith, D. H. Lancet, 1975, ii, 1113.9. Nalin, D. R, McLaughlin, J. C., Rahaman, M., Yunus, M., Curlin, G. ibid.

p. 1116.

CHILDREN UNDER 2 YR HARBOURING POSSIBLE PATHOGENS-

I

*6 colonies from every child tested for E.P.E.c.

1-4 colonies from 12/16 controls and 25/41 patients patients testedfor E.T.E.C.

We have examined stool specimens obtained during Januaryand February, 1976, from Central Javanese children under 2.41 of these children had been admitted to hospital with acutediarrhoea. Stool specimens were obtained no later than 4 daysafter onset of symptoms from 37 of the 41 children. Stool

specimens were also obtained from 16 control children with nodiarrhoea at the time of sampling.

Specimens were examined by techniques used routinely toculture bacterial pathogens, and by electron microscopy todetect non-cultivable viruses.1U Serotypes of E. coli were iden-tified by slide agglutination of six colonies from each fxcalspecimen with polyvalent and monovalent E. coli OB antisera(Baltimore Biological Laboratories). The capacity of thesestrains to produce heat-labile toxin (L.T.) was assayed in mono-layers of Y, adrenal cells. Ability to produce heat-stable toxin(S.T.) was measured using infant mice 12 and was indicated bya ratio of intestinal weight/remaining body-weight of 0.083 orgreater.

Candida spp. apart, stool electron microscopy and rou-

tine bacterial culture demonstrated astiological agents in 16 of41 patients (see table). Duovirus, described in other studies asthe major enteric pathogen in this age-group, was associatedwith only 15% of cases ofdiarrhoeal illness. No duovirus parti-cles were seen in the control group. Enterotoxin (L.T. and/ors.T.) was produced by E. coli strains isolated from 6 of 25children with diarrhoea and 7 of 12 control children. 4 of these

enterotoxigenic strains belonged to OB serotypes regarded asbeing enteropathogenic (E.P.E.C.). Of the 12 specimens ofE.P.E.C. isolated from 8 children, 4 were L.T. and/or S.T. pro-ducers.

Two conclusions can be drawn from these results. Firstly,duovirus is a cause of diarrhoea in Central Javanese childrenaged less than 2 yr. Seasonal variation in incidence mightexplain our low recovery of virus compared with an earlierstudy in Jakarta that located duovirus particles in 9 of 19children (47%) with acute diarrhoea." The possibility that

storage conditions during transport of specimens from Jogjak-arta to Melbourne affected virus recovery is also being exam-ined.

Secondly, neither E.P.E.c. nor E.T.E.c. is uncommon in stoolsof children with or without symptoms of acute diarrhoea. Tox-

in-producing strains were found among both typed and un-typed E. coli (6 and 8 strains respectively). Enterotoxigenic E.coli may be found to be a major enteric pathogen in this age-group in Central Java when more detailed longitudinal studiesare undertaken.

10. Bishop, R. F., Davidson, G. P., Holmes, I. H., Ruck, B. J. ibid. 1974, i, 149.11. Donta, S. T., Moon, H. W., Whipp, S. C. Science, 1974, 183, 334.12. Dean, A. G., Ching, Y. C., Williams, R. G., Harden, L. B. J. infect. Dis

1972, 125, 407.13. Gracey, M, Stone, P E, Papdimitriou, J., Suharjono, Sunoto, Pœdiat. In-

donesiana. 1975, 15, 229.