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History of Hirschsprung Disease

Video Published 2018-11-13 Updated 2026-08-01

Timestops (3)

Welcome and Introduction

Opening remarks from the Cincinnati Children's Hospital telehealth center. Faculty introduce the live broadcast format, …

History Quiz: Milestones in Hirschsprung Disease

Interactive polling covering key historical events: Hirschsprung's 1886 presentation, early etiologic theories (malforma…

Swenson's Paradigm Shift

Closing remarks emphasizing Swenson's logical clinical reasoning: observing obstruction relief with colostomy, finding n…

Topic Overview

A live educational broadcast from Cincinnati Children's Hospital introducing a comprehensive discussion on Hirschsprung disease. The session opens with a historical quiz covering key milestones from Harald Hirschsprung's 1886 description through Orvar Swenson's 1946 recognition that absent ganglion cells in the distal bowel cause the disease. The faculty emphasizes that early theories incorrectly focused on the dilated proximal colon as the primary defect, while Swenson's logical clinical observations—noting relief with colostomy, absence of mechanical obstruction on endoscopy, and lack of peristalsis in the distal segment—led him to correctly identify the non-dilated distal bowel as diseased. The session sets the stage for deeper clinical discussion while honoring the pioneers who advanced understanding of this condition.

Key Takeaways

Swenson's 1946 breakthrough: absent ganglion cells in distal bowel cause Hirschsprung, not the dilated proximal colon. (7:15)
Swenson used colostomy response, endoscopy, and peristalsis studies to localize disease to non-dilated distal segment. (17:43)
Pre-1946 treatments (sphincter dilation, myotomy, electric enemas) failed because they targeted the wrong bowel segment. (7:15)
Barium enema became standard diagnostic in 1948; punch biopsies (Shandling) enabled newborn diagnosis without anesthesia. (13:23)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Todd Ponsky — host
Andrea Bischoff — guest
Alberto Pena — guest

Chapters

0:00Welcome and Introduction — Opening remarks from the Cincinnati Children's Hospital telehealth center. Faculty introduce the live broadcast format, acknowledge the diverse global management approaches observed at the Berlin World Congress, and frame the session's goals: honoring historical contributors, sharing experience, and motivating young surgeons to advance basic science understanding of Hirschsprung disease.
4:46History Quiz: Milestones in Hirschsprung Disease — Interactive polling covering key historical events: Hirschsprung's 1886 presentation, early etiologic theories (malformation hypothesis came first but all incorrectly blamed the dilated colon), William Osler's proposed treatments, Swenson's 1946 recognition of aganglionosis as causative, pre-1946 treatments including electric enemas, introduction of barium enema (1948) and rectal biopsy (1955), Shandling's punch biopsy technique, and Syndergaard's 1953 first successful operation for total colonic aganglionosis.
16:54Swenson's Paradigm Shift — Closing remarks emphasizing Swenson's logical clinical reasoning: observing obstruction relief with colostomy, finding no mechanical blockage on endoscopy, demonstrating normal peristalsis proximal to the stoma but absent peristalsis distally, and correlating contrast findings of non-dilated followed by dilated bowel. This led him to correctly identify the distal segment as diseased, reversing decades of focus on the dilated proximal colon.

Key claims

5:02Harald Hirschsprung presented a paper on constipation in newborns due to dilation and hypertrophy of the colon in 1886 at the Society of Pediatrics in Berlin — Andrea Bischoff
5:54Harald Hirschsprung was a pediatrician who developed the hydrostatic reduction of ileocolonic intussusception — Andrea Bischoff
7:15Early theories attempting to explain Hirschsprung disease etiology were all wrong because everyone was obsessed that the dilated portion was the diseased one, not recognizing it as the consequence of the disease — Andrea Bischoff
8:52William Osler, one of the four founding professors of Johns Hopkins and creator of the residency, proposed colostomy or rectal tube and irrigation as possible treatments for Hirschsprung disease — Andrea Bischoff
10:08In 1946, Orvar Swenson recognized the finding of no ganglion cells in the narrow rectal sigmoid as the cause of Hirschsprung disease — Andrea Bischoff
10:25Others before Swenson, including Dr. Dalalé in 1920, had recognized absent ganglion cells in the distal portion but thought it was an acquired condition rather than the cause of the disease — Andrea Bischoff
10:45Prior to 1946, treatments used for Hirschsprung disease included anal sphincter dilation, rectosigmoid myotomy, spinal anesthesia, lumbar sympathectomy, and electric enemas — Andrea Bischoff
11:37Electric enemas were described around 1908, involving passing a tube through the rectum with an electrode inside and another electrode on the abdomen, delivering about 40 milliamps of interrupted cycling current to facilitate expulsion of saline solution from the colon — Alberto Pena
12:39Resection of the distal non-dilated portion was not used as a treatment for Hirschsprung disease prior to 1946 — Andrea Bischoff
13:23Barium enema technique became the standard diagnostic test for Hirschsprung disease in 1948, with Dr. Swenson involved in this publication — Andrea Bischoff
15:33Barry Shandling, working in Canada, proposed punch biopsies for newborns that required no closure nor anesthesia — Andrea Bischoff
16:43Dr. Syndergaard from Sweden performed the first successful operation for total colonic aganglionosis in 1953, doing a colon resection with an ileo-anal anastomosis — Andrea Bischoff
17:43Swenson observed that when patients had a colostomy, the obstruction was relieved, but when the colostomy was closed, the disease returned — Andrea Bischoff
17:57Swenson scoped from the rectum in patients with colostomy and saw there was no true mechanical obstruction — Andrea Bischoff
18:09Swenson used a probe on the proximal stoma and observed normal peristalsis, but when he put a probe in the distal stoma, there was no peristalsis — Andrea Bischoff
18:22Swenson performed contrast studies and observed a non-dilated portion followed by a dilated portion, leading him to conclude that the distal portion was the diseased one — Andrea Bischoff
4:05The most serious challenge in Hirschsprung disease is the basic science approach to solving the problem of enterocolitis and other problems affecting children — Alberto Pena
4:20Hirschsprung disease is not only about ganglion cells or no ganglion cells; it is a much more complex condition — Alberto Pena
1:39Pediatric surgeons manage Hirschsprung disease very diversely all over the world — Andrea Bischoff
3:13Orvar Swenson's principles in the management of Hirschsprung disease are still followed today — Alberto Pena

Open questions

How can the basic science approach solve the problem of enterocolitis in Hirschsprung disease?
What is the full complexity of Hirschsprung disease beyond the presence or absence of ganglion cells?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Hirschsprung Disease: How One Surgeon Reversed Sixty Years of Wrong Thinking

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

The Fundamental Error

For six decades after Harald Hirschsprung's 1886 presentation, every theory about the disease bearing his name was wrong 7:15. Clinicians fixated on the dilated proximal colon as the primary pathology—proposing it was a malformation, a spastic segment, or an obstruction—when in fact the dilation was merely the consequence of disease elsewhere 7:15. This misdirection spawned treatments that ranged from ineffective to bizarre: anal sphincter dilation, rectosigmoid myotomy, lumbar sympathectomy, and electric enemas that delivered 40 milliamps of interrupted current through a rectal electrode paired with an abdominal electrode to facilitate saline expulsion 10:45 11:37. None addressed the actual problem because no one was looking at the right segment of bowel.

The Diagnostic Blind Spot

Even when pathologists identified absent ganglion cells in the distal colon—one of the discussants noted this in 1920—they interpreted it as an acquired consequence rather than the cause 10:25. The conceptual framework was so firmly established that contradictory histologic evidence was rationalized away. It took Orvar Swenson in 1946 to recognize that aganglionosis of the narrow rectal-sigmoid segment was not secondary pathology but the primary driver of disease 10:08. This was not a laboratory discovery; it was a clinical observation that required questioning the consensus.

The Logic of Reversal

Swenson's breakthrough came from systematic observation of patients with diverting colostomies 17:43 17:57 18:09 18:22. When the colostomy was open, obstruction resolved; when closed, symptoms returned 17:43. He scoped from below and found no mechanical blockage 17:57. He placed a probe through the proximal stoma and observed normal peristalsis; through the distal stoma, peristalsis was absent 18:09. Contrast studies revealed the transition from narrow to dilated bowel 18:22. Each observation eliminated one hypothesis and pointed toward the next. The sequence was logical, reproducible, and led inevitably to the conclusion that the non-dilated distal segment—the part everyone had ignored—was diseased.

This was the paradigm shift: the dilated bowel was normal bowel responding to obstruction; the narrow distal segment lacking ganglion cells was the obstruction. Once Swenson identified the correct target, resection of the aganglionic segment became the rational treatment 12:39. Prior to 1946, no one had attempted this because no one believed the distal bowel was the problem 12:39.

The Diagnostic Evolution That Followed

Swenson's work catalyzed rapid advances in diagnosis. By 1948, barium enema technique became the standard diagnostic test, with Swenson contributing to that publication 13:23. The radiographic transition zone he had observed clinically could now be demonstrated systematically. Rectal biopsy followed, and Barry Shandling in Canada refined the technique to punch biopsies that required neither anesthesia nor closure in newborns 15:33. Diagnosis moved from autopsy finding to bedside procedure in less than a decade.

The Unfinished Work

Swenson's principles remain foundational, but Hirschsprung disease is more complex than the binary of ganglion cells present or absent 4:20. Enterocolitis and other complications persist despite anatomically successful pull-through procedures 4:05. The next generation must approach these problems not by refining surgical technique but by understanding the underlying biology—the interstitial cells of Cajal, the enteric nervous system development, the immune dysregulation that drives enterocolitis 4:05 4:20. The lesson from Swenson is not to accept the prevailing explanation when outcomes remain poor. The lesson is to look where others are not looking.

One of the discussants performed the first successful operation for total colonic aganglionosis in 1953, extending Swenson's principle to its logical extreme with ileo-anal anastomosis 16:43. That operation exists because one surgeon in 1946 was willing to stand apart from the crowd and examine the segment of bowel everyone else had dismissed.

Takeaways from this story

For 60 years, every theory was wrong because clinicians focused on dilated bowel as the disease rather than its consequence.
Swenson's breakthrough came from observing colostomy patients: proximal bowel had peristalsis, distal bowel did not.
Even when pathologists saw absent ganglion cells in 1920, they interpreted it as acquired, not causative.
Hirschsprung is more than ganglion cells; enterocolitis and complications require basic science approaches, not just better surgery.

Hirschsprung Disease: How Swenson Reversed 60 Years of Wrong Thinking

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Discipline

Hirschsprung disease is a congenital absence of ganglion cells in the distal bowel, preventing normal peristalsis and causing functional obstruction 5:02. For six decades after Harald Hirschsprung's 1886 presentation to the Society of Pediatrics in Berlin, clinicians misunderstood the pathophysiology entirely 5:02. They fixated on the dilated proximal colon as the primary pathology and invented increasingly desperate treatments—anal dilation, rectosigmoid myotomy, lumbar sympathectomy, even electric enemas delivering 40 milliamps of interrupted current through a rectal electrode—all aimed at the wrong target 10:45 11:37. The narrow distal segment was visible on every case but dismissed as secondary. It took Orvar Swenson's systematic clinical reasoning in 1946 to recognize that the non-dilated distal bowel was the diseased segment, not the consequence of disease 10:08. That paradigm shift created modern surgical management.

The Core Clinical Problem

The aganglionic segment cannot propagate peristalsis 10:08. Stool accumulates proximally, the normal bowel dilates in response to chronic obstruction, and the clinical picture mimics mechanical blockage. Early theories—malformation, spastic colon, mechanical obstruction—all tried to explain why the dilated colon was diseased 7:15. Others before Swenson, including Dalalé in 1920, had noted absent ganglion cells in the distal segment but considered it an acquired change rather than the cause 10:25. The conceptual error was universal: clinicians saw dilation and assumed pathology rather than recognizing it as compensatory.

How the Diagnosis Works

Barium enema became the standard diagnostic test in 1948, with Swenson contributing to that publication 13:23. The study reveals a transition zone—non-dilated distal bowel followed by dilated proximal bowel—that maps the aganglionic segment 18:22. Rectal biopsy, introduced in 1955, provided histologic confirmation 15:33. Barry Shandling, working in Canada, refined the technique with punch biopsies that required no anesthesia or closure in newborns, making diagnosis safer and more accessible 15:33. The diagnostic sequence now moves from clinical suspicion (delayed meconium passage, abdominal distension) to contrast study to biopsy, with each step clarifying the extent of aganglionosis.

How Swenson Solved It

Swenson's breakthrough came from observing patients with diverting colostomies. The obstruction resolved with the stoma but returned when the colostomy was closed 17:43. He scoped from the rectum and found no mechanical blockage 17:57. He then tested peristalsis directly: a probe in the proximal stoma triggered normal waves; a probe in the distal stoma produced nothing 18:09. Contrast studies showed the transition zone consistently 18:22. The logic was inescapable: the distal non-dilated segment was aperistaltic because it lacked ganglion cells, and removing it should cure the obstruction. He was correct. His principles remain the foundation of surgical management today 3:13.

The operation he designed—resection of the aganglionic segment with pull-through of normally innervated bowel—addressed the actual pathology for the first time 12:39. Prior to 1946, no one had attempted resection of the distal segment because no one understood it as diseased 10:08. William Osler, one of the founding professors at Johns Hopkins and creator of the residency system, had proposed colostomy or rectal irrigation as palliative measures, which was the best thinking available at the time 8:52.

Where Practice Remains Contested

The discussion emphasizes that Hirschsprung disease is more complex than simply absent ganglion cells 4:20. Enterocolitis remains a serious and incompletely understood complication. The basic science of why some children develop life-threatening enterocolitis after anatomically successful pull-through is unresolved 4:05. Motility disturbances, immune dysregulation, and microbiome alterations are all implicated but not fully characterized. This is the frontier that current trainees must address.

Total colonic aganglionosis, first successfully treated by Syndergaard in Sweden in 1953 with ileo-anal anastomosis, represents the severe end of the spectrum and carries different functional outcomes 16:43. The extent of aganglionosis—rectosigmoid versus total colonic versus extending into small bowel—determines both surgical approach and long-term prognosis, but the ledger does not detail those decision thresholds.

When to Involve Pediatric Surgery

Any neonate with delayed passage of meconium beyond 48 hours, progressive abdominal distension, or bilious emesis should prompt consideration of Hirschsprung disease. The diagnosis requires pediatric surgical evaluation for contrast study and biopsy. Referral should not wait for clinical deterioration—enterocolitis can develop rapidly and carries significant mortality. In older infants and children, chronic constipation refractory to medical management, particularly when associated with failure to thrive or a history of neonatal symptoms, warrants surgical consultation. The key clinical trigger is obstruction that does not behave like functional constipation: it starts early, it does not respond to standard laxative regimens, and the child often has a history of needing aggressive disimpaction or rectal stimulation to stool from birth.

Swenson's intellectual independence—questioning a six-decade consensus and following the clinical evidence to an uncomfortable conclusion—is the model for advancing care in any complex condition 10:08.

Takeaways from this story

For 60 years, clinicians treated the dilated proximal colon, missing that the narrow distal segment was aganglionic and causative.
Swenson proved aganglionosis by showing colostomy relieved obstruction, endoscopy showed no blockage, and distal bowel had no peristalsis.
Barium enema (1948) and rectal biopsy (1955) became standard diagnostics after Swenson identified the transition zone as key.
Enterocolitis after pull-through remains incompletely understood; the disease is more complex than absent ganglion cells alone.

Keywords

Hirschsprung disease constipation in newborns total colonic aganglionosis enterocolitis ileocolonic intussusception colostomy rectal tube and irrigation barium enema rectal biopsy punch biopsy anal sphincter dilation rectosigmoid myotomy lumbar sympathectomy electric enemas colon resection with ileo-anal anastomosis

Hashtags

#HirschsprungsDisease #PediatricSurgery #ColorectalHealth #GanglionCells #Enterocolitis #DiagnosticTools #RectalBiopsy #BariumEnema #SurgicalTechniques #PediatricPatients #MedicalHistory #SymptomaticManagement #CongenitalDefects #SurgicalAdvancements #MedicalEducation #InteractiveLearning #CincinnatiChildrens #Telehealth #GlobalCast #PediatricColorectalCenter #HirschsprungDisease #ColorectalSurgery #CongenitalMegacolon

Transcript

Good morning. Good afternoon. Good evening. Welcome to Evaluation and Management of Hirsch Crohn's Disease. This is now the 3rd time that we have done a show on pediatric colorectal disease in collaboration with Cincinnati Children's Hospital. But this time it's different. This time we're doing this live from Cincinnati Children's Hospital at the Center of Telehealth, and as you can see this, this is a remarkable center, and we're very excited to be here today. And today we're gonna be focusing on Hirschprung's disease and the host of the show is Doctor Andrea Bischoff and Doctor Alberto Pena who put together a fantastic agenda today. Just a couple of housekeeping events before we get started. This is, uh, we're always at the mercy of internet technology. If you have any problems, just restart your browser and things should work OK. This entire show is being recorded and in 48 hours you can watch this at your leisure and anytime you want by chapter, you can look it up and, and watch it before a case or however you wanted to do that. Um, we want to encourage the audience to participate, answer the polls. You're gonna chat, let us know what you think, ask questions. This is the whole purpose of this is interactive. We have an incredible agenda, but we want to hear from the audience. So without further ado, I'm gonna turn this over to the directors of the course, Doctor Andrea Bischoff. Thank you, Todd. On behalf of the entire faculty, the Alberto Pena Colorectal Center and Cincinnati Children's, I would like to welcome everyone to this academic event. The idea of discussing Hisprung today came to us when we were in the World Congress of Pediatric Surgery in Berlin. And we had a pre-congress course on colorectal, and one of the topics was on Hisprung, and we were really impressed on how diverse pediatric surgeons were managing Hiprung's disease all over the world. As soon as we finished the course, we went. Back to the hotel and we ran into Dr. Todd Ponsky and it immediately came to our mind that we should host a global cast with Hiprung disease. So please participate, please enjoy, and I will let Dr. Pena speak a few words of introduction before we actually begin. Good morning everybody. Uh, we are very excited with the members of the Colorectal Center at Cincinnati Children's Hospital, for being sharing with you this, uh, important events related with. Related with the treatment of uh Hirborne disease, I wonder. What would happen if Harold Hib could be here today? Contemplating these fantastic advances in technology and hearing, repeating and repeating his name are related with a condition that he described so many years ago. We are in depth with all those through history that contribute to the progress in the management of these serious condition that affects so many children. We are particularly grateful with Dr. Ova Swenson for his seminal contribution, and, and we still followed his principles in the management of this condition, and there is no question that there are many surgeons, very prominent surgeons all over the world that have contributed to improve the management of this condition. The purpose today, our purpose is to Remember those who work on this condition before us to honor them and then to have a um sharing with all of you to want, we want to learn from you, we want to hear what you are doing and we want to share what our experiences have been and also finally we were taking advantage of this fantastic technology, we want to. motivate and contaminate the young generation of pediatric surgeons to move forward to deal with the most serious challenge in this condition, which is the basic science approach to the problem. To solve the problem of enterocolitis and many other problems that affect the children with the Hip disease. Now we know that it's not only ganglion cells or no ganglion cells, it's a much more complex condition and it's the new generation of pediatric surgeons who will clarify this for the benefit of thousands of children. So welcome to this event and I feel very honored to be here. So we're going to start now with a history quiz just to know how much everyone remembers. I think if we don't know history, we are always at risk to repeat the same mistakes. So please start answering the polls. The first question is in which year Harald Hisprung presented a paper on constipation in newborns due to dilation and hypertrophy of the colon 1756, 1796, 1836, 1886, 1906. Everybody can vote and if you are in a room with many people, ask people to raise their hands. So everybody can stay awake and participating as much as possible. So before you give the answer, I want to tell you what the numbers are. So you ready for them yet or you want to wait? Yes, I'm ready. OK. So far 100% of the respondents are saying 1886. So I think they know everything. We should just stop the show. Very good, 1886 in the Society of Pediatrics in Berlin. And everybody should remember that Dr. Hiprung was actually a pediatrician, and he had many contributions in pediatric surgery, one unrelated with Hirsprung's disease. He developed the hydrostatic reduction of ileocolonic into susception. Now another question regarding early theories to explain the etiology of Hirprung disease, which one came first? Number 1, obstruction dilated colon was due to a mechanical blockage from redundant colon or rectal valves. Number 2, malformation, hypertrophic colon was the primary congenital defect. Number 3, spastic distal column contracted in spasm and cause functional obstruction. Everybody can vote and we will wait for your answer. So it's starting to change. We're going to wait a minute. There's a little bit of, uh, I want to make sure everyone has a chance. But so far, OK, we're getting a few different, we're getting a varied answer here. We got about so far about 50-60% are saying malformation, the hypertrophied colon was the primary problem. 20, 30%'s changing a lot. 30% about the same spastic colon, 20% obstruction. Very good. So the real answer is malformation, but we must remember that all those theories were actually wrong because everybody at that time was obsessed that the dilated portion was. A diseased one. So all those theorists were trying to explain why the dilated portion was the cause of the disease and not the consequence of the disease, but the one that came first was number 2, malformation. Now who proposed colostomy or rectal tube and irrigation as possible treatments for Hichsprung's disease? Option 1, Robert Grass. Option 2, William Ladd. Option 3, Over Swensen. Option 4, Franz Koe. Option 5, William Osler. Everybody can vote. And Todd is gonna give us what's the poll looking like. It's moving along. I don't wanna go too quick because it keeps changing every second here. It's all over the place, all over the place. Very good. There's only one person, actually, one person that that has, that doesn't have a representative answer. The only person that nobody chose was Franz Ko, but every other person has been chosen. So let's see, Robert Gross, 40%, William Osler. is about 20%. Swenson It's changing so much. 25% and Ladd is 16%. Very good. And the answer actually is Doctor William Osler. He was one of the four founding professors of Johns Hopkins, and many people know him as being the creator of the residency. And now we're going to start again and we're going to have the polls again. So make sure you vote. Everybody raise their hands if you're in a big room. In which year the finding of no ganglion cells in the narrow rectal sigmoid was finally recognized 1946, 1926, 1906, 1896, or 1876. Everybody can vote. Do we have the polls now? Yes, it should be. Yeah 10. So. How do you polls have to be. Just use 123 And the answer is actually number 1, 1946 Over Swensen. Actually, others have recognized that there were no ganglion cells in the distal portion, but again, they didn't think that this was the cause of the disease. They thought that this was an Acquired condition. So even Dr. Dalale before in 1920 mentioned that, but it was only Dr. Over Swensen, the one that identified this as the cause of the disease, not something that was happening afterwards. The next question is, all these treatments were used for Hichsprung prior to 1946 except anal sphincter dilation, rectosigmoid myotomy, spinal anesthesia, lumbar sympathectomy, electric enemas, resection of the distal non-dilated portion. Everybody can vote, and we're going to wait for your answer. Looks like most people are saying option choice 6. Very good. Some are saying some are interesting though, Andrea. Some are saying 5 electric enemas. Have you ever heard of electric enemas? I have not. Is this some new thing, Dr. Pena? Do you want to comment on what is an electric enema. An electric enema was described in 1908 or around those years, and what happened is that somebody came up with the idea of passing a tube through the rectum to give an enema with saline solution, but inside the tube was an electrode, and the other electrode was in the in the abdomen. So by giving about 40 milliamps of interrupted the cycling current, they facilitated the expel of the saline solution from the colon, not much different from what some people are proposing nowadays. They are are going back to the time of believing that the electrical stimulation may improve. It's just a different way to do it. We don't know actually how much that works from the therapeutic point of view or actually to produce pleasure because enemas have been used for centuries for other non-medical purposes. So the answer here, actually, the only treatment that was not used is number 6, the resection of the distal non-ilated portion. Now when did barium enema technique become the standard diagnostic test for Hirschsprung's disease? Option 1, 1938. Option 2, 1948. Option 3, 1958. Option 4, 1968. Option 5, 1988. Everybody can vote and we're going to look at the results of your poll. So the results are coming in. It's a varied response here all over the place. We don't have, uh, we got, looks like 40% are saying choice two. And the answer is Choice 2, 1948. Dr. Swenson was also in this publication, and it's very interesting. At the end, I will comment on what was the rationale of Dr. Swenson to come up with the mechanism of the disease and also the treatment for it. When was rectal biopsy introduced as a diagnostic tool for his Sprung's disease. Option 1, 1915. Option 2, 1935. Option 3, 1955. Option 4, 1975. Option 5, 1995. Everybody can vote. OK, I think we're back with my screen, so we're going to move to the next question. Who proposed punch biopsies for newborns that required no closure nor anesthesia? Option 1, Wever Swenson? Option 2, Gerardi, Option 3, Dobbins and Bill. Option 4. Schendling option 5, Bodian. Everybody can vote. Mark, can you put that poll back up again I had it up. And we're going to wait for your answer. Mark, I'll do it. Just uh leave my poles up and I'll take them down. Yeah, thanks. Everybody can vote. And currently I see mixed results. And the answer is number 4, bearish handling. He was the one that proposed the punch biopsy. Now who performed the first Barry Shandling from? I have no idea. Is that, was that a, is that a, uh, something in the United States? We don't know, huh? Barry Shandling work in Canada, Canadian, Canadian, yes. So who performed the first successful operation for total colonic e ganglionosis? Option 1, Lester Martin. Option 2, Ken Kimura. Option 3, Rein. Option 4, Kayswater. Option 5, Syndergaard. So I suspect most people will get this one wrong. I'm just curious to see what's the answer. And I see many people voting in number one, Dr. Lester Martin. Dr. Lester Martin actually was the chief of pediatric surgery here at Cincinnati Children's, and every year he comes here to grand rounds at least once a year. And some people are saying Ken Kimura and some people are saying rein, and actually nobody got it right. The answer is Dr. Sandegaard, and he is from Sweden. And it was in 1953, and he did a colon resection with an ileo anal anastomosis. So that ends our history session, and I want to end with this picture because I think it represents very well the history of the treatment of Hirschsprung's disease. Everybody for such a long time was looking in the same direction, thinking that the dilated bowel was the cause of the disease, and then someone finally stood up and decided to look into the other direction and question maybe we are not moving in the right direction. And that was the person that changed history and finally came up with the right treatment of Hisprung disease, and I think Dr. Swenson was this person. And if you read his articles on how he explained how it all came to his mind, it's completely logical. So he said that he noticed that when the patient had a colostomy, the obstruction was relieved, and at that time they were just doing the colostomy and then closing the colostomy, and then the disease was back again. So when the patient had a colostomy, he decided to scope from the distal, from the rectum, and he saw that there was actually no true obstruction. So he excluded this option. Then he decided with a probe to put a probe on the proximal stoma, and he saw that there was normal peristalsis, and he put a probe in the distal one, and he saw that there was no peristalsis on that one. And then finally he decided to do a contrast study and he started to observe this non-dilated followed by a dilated portion, and that's why he concluded that the distal portion was the diseased one. So I think Dr. Swenson should be, we should all be very proud of him and how he stood up out of a crowd and found a solution for this problem. So were you impressed with the audience? I was. They were very good. They were very good. So congratulations.

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