THE DGUADIUATE MEDICAL OUINC J · Less commondefects of this orderare those of tle pituitary, suprarenal, and genital glands. Theinfluence ofsyphilis in theproduction of dull and

THE

9OT DGUADIUATEMEDICAL JOUINC

VOL. III. SEPTEMBER, 1928. No. 36.

CONTENTSPAGE

DULL AND BACKWARD CHILDREN ...... ...... ... ... 209By PROFESSOR F. S. LANGMEAD, M.D., F.R.C.P.

HYPERTROPHIC STENOSIS OF THE PYLORUS .............. 217By NORMAN C. LAKE, M.D., M.S., D.SC., F.R.C.S.

HICCUP ... ... ... ... ... ... ... ... ... ... ... 222

By ROBERT HUTCHISON, M.D., F.R.C.P.

EDITORIAL NOTES ... ...... ......... ... .. ... 225POST-GRADUATE NEWS ... ... ... ... .. ... ... ... ... 226

INDEX .. ... ..... ... . ... .....227FELLOWSHIP OF MEDICINE AND POST-GRADUATE MEDICAL ASSOCIATION.--

SPECIAL COURSES ... ... ... ... .. ..... ... iv

DULL AND BACKWARDCHILDREN.

._y PROFESSOR F. S. LANGMEAD,M.D., F.R.C.P.,

Director of Medical Clinic, St. Mary's Hospital.

THE terms "backward" and "dull" arepurely arbitrary and signify merely, whenapplied to a child, that the individual ulsingthem regards the child as below the normalstandard in mental attainments. They havea different meaning when used by differentobservers. Thus, the school teacher willgive an educational value and will often duba child as dull and backward if his educa-tional standard is low in certain aspects, forinstance, if he fails to make progress in

reading or spelling, or fails to appreciate thevalue of figures. The same child, as judgedby his capabilities other than those inscholastic subjects, may be an average oreven exceptionally useful citizen. In thislecture I propose to use the words "back-wardness " and " dullness"' in their broadestmeaning, and not merely in a scholasticsense. In the great majority of cases back-wardness in school attainments and thegeneral mental outfit are correspondinglyweak, but in some the failure to progress atschool is due to a lack of certain mentalattributes distinct from-men tal backwardnessconsidered as a whole.

Regarding backwardness in this bioad'sense, we may next consider how its exam-ples can be classified, for by some classifica-tion we can, I think, approach the siibject

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210 DULL AND BACKWARD CHILDREN

with more precision, and so more clearlyand usefully.We may divide mental backwardness first

into two varieties, which I will call "essential"and " nont-essential" backwardness.The essentially backward children are

those who are born with brains incapable ofmental development up to the standardregarded as average. The backwardness isinnatc, the children being potentially back-ward from birth.By "non-essential ' backwardness I mean

backwardness which is clue, not to someinherent defect, but to environmental orother causes to which the child is subjected.These children are born with a potentialmental capacity equal to the average,but circumstances prevent or delay itsdevelopment.

I will now consider these two groups inmore detail.

(I) ESSENTIAL BACKWARDNESS.

With this group I am not to-day veryclosely concerned in this lecture. It iscomposed largely of examples of childrenwho, if somewhat more lacking in men-tality, would be called mentally deficientor aments. Amongst these essentially back-ward children must beincludedthose affectedby microcephaly and mongolism to a slightdegree. The microcephalic, with charac-teristic narrow forehead, roof-shaped vaultand very small circumferential cranialmeasurement, who, if capable of standing,takes up an animal-like pose, which has evenled to the subdivision of microcephalicsaccording to the animals they suggest, isusually an idiot or imbecile. The " mongol,"with characteristic features of brachycephaly,almond eyes, projecting granular or fissuredtongue, frequent grimacing and hypotonia,is usually an imbecile in the category ofchildren regarded according to their talents.But both these disorders in mild degreesmay be accompanied by mental povertywhich could be calleld merely dullness or

backwardness, a few physical features in eachcase indicating the group to which it belongs.The child with hydrocephalis is often no morethan slightly defective mentally, and is aptto be more hampered by his physical defectsthan by those of his mind. The large groupwhich has been headed paralytic amsentia isa very composite one. It comprises childrenwho have spastic paralysis due to want ofcortical development, and also those whosebrains have suffered damage in early life,perhaps at birth by trauma, or later frominfective, toxic or vascular processes. Ofthis mixed group, the children whose defectis in development are lowest in the mentalscale and least capable of improvement.They are generally below the level of meredullness. The miacrocephalic and a maui otic

Jfamily i(diots are never outside the pale ofsevere mental deficiency.

Children whose mental weakness is conse-

quent upon ductless gland defect are a classto themselves, for although the error is

usually developmental it is not one primarilyof the brain. The best known example, thecretin, if frankly so physically, is equallyfrankly a low-grade ament, and hence outsidethe scope of this lecture, but mild examplesof hypothyroidism, or treated cretins, providemuch slighter deviation from the average.Less common defects of this order are thoseof tle pituitary, suprarenal, and genitalglands.The influence of syphilis in the production

of dull and backward children is difficult to

compute. If only those be regarded as

syphilitic who have the physical stigmata ofthat disease, its incidence is small andamounts to not more than 2 or 3 per cent.of mentally defective children. But in thesecases the infection is acquired within tileuterus, the foetus being infected from tliemother's blood. The frequency with whicllsyphilis in the parents affects the germinalbioplasm, and leads to the birth of a

mentally defective or merely dull child, is

probably greater, for a positive Wassermanlreactionl is obtained amiongst many in insti-

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DULL AND BACKWARD CHILDREN 211

tutions who have no physical signs of thedisease.There remains the large mass of mentally

weak children who are unclassifiable on aetio-logical grounds, or on grounds of physicaldevelopment, to whom the term " simple "or " genetous " mental deficiency has beenapplied. Within this group are all gradesof defect from idiocyto slight dullness. Theycan be subdivided only according to theirtalents into idiots, imbeciles, feeble-mindedand dull, or according to some specialcharacteristics as excitable, fatuous, destruc-tive or apathetic, &c. While some of theseshow the physical stigmata accompanyingmental degeneration, such as misshapenheads, large, distorted and projecting ears,highly-arched and narrow palates, and certainpeculiarities of pose, combined with obviouslack of attention and inability to concentrate,others may appear quite normal to ordinaryexamination, and are only recognizable byquestioning themselves, their parents andtheir teachers, or by the application ofpsychological or educational tests, such asthose devised by Binet. The apparentalertness and brightness of mien and attitudeof some of these children is very deceptive,and it comes as a surprise to find that theirquick and ready answers are invariablywrong and reveal a serious lack in associationof ideas.

(2) NON-ESSENTIAL DULLNESS ANDBACKWARDNESS.

Let us now turn to the cases of what Ihave called non-essential backwardness, orbackwardness not due to any defect in thebrain itself. It is to these I wish particularlyto draw your attention, for they are thosewhich are most important for us, as practis-ing physicians, to recognize. Due recogni-tion and treatment may lead to such im-provement that a special school or systemof education recedes from the offing. Everychild who is reported upon as being back-ward, either by parents or teachers, should-be examined and considered from both

points of view, physical and environmental,to see whether the backwardness cannot beexplained on grounds other than primarymental defect, for it is a serious error toplace a child whose backwardness is tem-porary or capable of correction amongothers worse mentally equipped than them-selves, and from whom no- progress can beexpected other than that which age itselfbrings. Once a child such as this is labelledmentally defective or even a dullard, themantle of inferiority is apt to be assumedfor good and the incentive to improvementto be lost. Should he be an attendant atone of the public elementary schools, I amdistinctly opposed to sending him to aspecial school for a probationary period, inthe hope that he may improve and be trans-ferred back, for the labelling as defective andthe association with those who are essentiallyso is almost a guarantee against improve-ment. The same is true of children ofhigher social grades if sent to many of theprivate schools for backward children. Thiscriticism is, of course, no longer valid ifthey are sent to schools whose scholars arein the same category as themselves.

I will now consider these examples ofsymptomatic or non-essential backwardnessunder two main heads:-

(A) Those related to environment.(B) Those ascribable to physical

defects.(A) Under environment I include in-

sufficient food and sleep, overwork and poorhygiene. They are, in the main, theattributes of poverty and therefore applyespecially to the children of the publicelementary schools. I need not emphasizethe ill-effect upon mental growth of lack ofsufficient and suitable food, and the treat-ment is obvious in the provision of schoolmeals. The only danger is that the causemay go unrecognized, for these children are

apt to be very adverse to admitting poverty,and give an account of meals which existonly in their imagination. The number of

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hours of sleep and recreation are alwaysworthy of inquiry, even in the case of thosewho are not poor. In the greater freedomwhich it is now the fashion to give tochildren seems to be included a compliancewith the old-established disinclination to goto bed. In other instances bed-time is re-garded as a chairce to continue an excitingstory to the bitter end, to solve a puzzle orpursue a hobby. Among the poor it may bethat bed-time coincides with the return offather or mother late from work. Concern-ing overwork in the child, I do not meanoverwork at school but overwork when thatdone at home is added. " All work and noplay makes Jack a dull boy " is, in these dayswhen paid work out of school hours isillegal, a maxim fairly well complied with,but it is often not applied to Jill. The girlis often kept busy every hour of the cday,while the boy out of school hours joinsothers in their gaimes. If continued, suchpersistent work leads surely to delay inmental progress.Among similar causes, I will only mention

one other, viz., lack of fresh air and sunlight.The pale, dull and listless dweller in thebasement is often recognizable at sight, andin such cases I have frequently heard state-menlts of backwardness at school or ofteacher's complaints of actual deteriorationof work during the winter months. A

special report to the local housing authoritythat the need for new quarters is pressinghas, I am glad to say, usually met with a

sympathetic response, and the improvementin mental as well as physical health ispatient.

(B) BACKWARDNESS DUE TO PHYSICALDEFECT.-It is clear that bodily maladiesmay delay mental-development in severalways. They may, by their chronicity or

frequent repetition, so interfere with schoolattendance or hours of study that the child isalways behind. Such a child is backward, butwhen his health is again restored or during a

period of intermission is not dull. He will,however, appiear dull if forced into school

work when he should be convalescing. Twooutstanding examples of diseases whichseriously reduce the time for education arechorea and asthma. Both frequently recur,and in both the period of unavoidableabstention from school work is apt to beprotracted. Yet these children are brightrather than dull, set back though they maybe. In fact, it is rather surprising how well,in many cases, their naturally active mindsmanage to acquire knowledge up to theaverage standard, or even beyond. Again,bodily disorders may obstruct understandingby blocking the avenues by which knowledgeis received (sense deprivation), or may be ofsuch a kind that it interferes with develop-ment as a whole (infantilism). Anotherinterference with education which may becaused by even such minor ailments astoothache is loss of sleep. Let us considersome of these effects of bodily disorders onmental growth in greater detail.

(i) Sense Deprivation.There is no better example of the need

for detailed medical examination than sensedeprivation. If undetected, it may lead to agross error in judgment as to the potentialmental ability, and may even cause the childto be labelled definitely mentally defective.Here, if the sense deprivation be unmixedwith other defects, there is no essentialmental weakness, the brain is ready for im-pressions which it fails to receive, and mentalgrowth is stagnant or delayed. Perhaps thebest known case of this kind to be found inthe literature is that of Helen Keller. Theable mind of this talented authoress, whowas both blind and deaf, and being deaf wasdumb, was awakened into activity and grewby being approached and trained throughother senses by a persevering and devotedteacher. Such extreme cases are, of course,exceptional and not likely to go undetected.The child, totally blind or totally deaf, isearly separated out for special education.Minor degrees of defective hearing and sightmore easily escape detection and may do so,

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even at the present time, 'when systematicexaminations of them are practised in mostschools. This is particularly true of minordegrees of hypermetropia and astigmatism.The extent to which hypermetropia can becompensated for by muscular effort is soconsiderable that the child passes the some-what rough and ready and infrequent schooltests. Yet the effort necessary to follow theschool work brings exhaustion, and lack ofattention and concentration follow close.An imperfect appreciation of what is beingwritten or read, headache from eye-strain,and the consequent exhaustion so hamperand isolate the child that it loses ground andis grouped among the backward.Some degree of sense deprivation is ex-

perienced by the child paralysed from birthor in early life, for it loses the mind-develop-ing influence of muscular movement and therecognition of the size, shape, weight andcharacter of objects by 'touch. Only insevere cases of paralysis is it likely that thisplays a decided part in backwardness. In

spastic paralysis in children, for this is theform of paralysis with which mental defectand backwardness are associated, there ismore than simply sense deprivation to beconsidered. In some, as is mentioned above,there is congenital lack of cerebral develop-ment; in these the degree of defect is con-

siderable, and the prospect of improvementslight. In others there is a traumatic, in-fective, toxic or vascular lesion of a previoushealthy brain-here there is considerablymore hope of improvement and more scopefor education, but the normal level of mentaldevelopment is not to be confidentlyexpected.

(2) Tonsils and Adenoids.The slow, listless, dull stupidity associated

with serious degrees of mouth-breathing, theresult of naso-pharyngeal obstruction, iswell known and has been called "aprosexia."Sleep does not refresh them, for during itthey show evidence of considerable oxygendeprivation in blueness and turgidity of the

lips and face. They are restless and theirnights are full of dreams. In the morningthey are tired, refuse their breakfasts, and goreluctantly and wearily to school, with mindsfar from receptive. Perhaps there is alsodefective hearing. The treatment for such Ineed not emphasize, for it is obvious.

(3) Ductless Gland Defects.These have already been referred to. I

only mention them here again to point outthe need for bearing tliem in mind, especi-ally wlien backwardness is accompaniedby unusual retardation of growth or byspecial peculiarity in development. For thesmall, square, fat child, with broad shortfingers and dry skin, or the undersized childwith alopecia, it is worth while to try theeffect of thyroid medication, even thoughneitlier in bodily features nor in mentalqualities can he be called a cretin. Theobese children generally regarded as suffer-ing from dyspituitarism are not backward asa rule in my experience, but on the contrarymore often precocious, the full picture ofFr6hlich's disease, with its retarded physicaland mental growth, being comparativelyuncommon. There are, however, slim"childish " boys, small for their age, takingno interest in games, whose mental outlookand school attainments are retarded liketheir growth, who appear to benefit byprotracted treatment by extract of wholepituitary gland.

(4) Infantilism.As commonly used to-day, the term in-

fantilism has come to have a somewhatbroad and, as many consider, erroneousimplication. I am using it here in referenceonly to children who in body and mind areretarded in growth, but mentally would passas normal for an earlier age. Even from thisstandpoint the scope for the term is large,for serious disorder of any important organreacts upon the organism as a whole, stuntingboth body and mind to various degrees.Omitting primary disorders of the brain

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which fall within the pale of "essential"backwardness, and also ductless glanddiseases of which I have just spoken verybriefly, I will now consider some of the bestknown examples of infantilism due to visceraldisease.

(i) Renal Infantilismn.-Here the child islikely to be indeed miniature, with mind notequal to its age, but somewhat more de-veloped than its body. It may even passfor precocious if the intellect be taken incomparison with stature instead of with age.A history of polyuria and polydipsia may beprocurable, and examination may reveal thecardiac and vascular changes consequentupon chronic renal disease. The urine isabundant, clear, of low specific gravity andcontains usually some albumin, though thismay be absent at a single examination.There is frequently some deformity of thelegs. Renal efficiency tests show usually astriking defect of renal function. Postmortem, the kidneys are very small,granular, and grey in colour, and showexcess of fibrous tissue and arterioscleroticchanges. In the accounts written by clini-cians, they are spoken of as characteristic ofchronic interstitial nephritis, but to thepathologist they are examples of a late stageof parenchymatous nephritis, for there isabundant evidence of previous inflammatorychange. The disorder is not long compatiblewith life, a consideration which helps us todecide what advice should be given withregard to education.

(2) Intestinal Infantilismn.-Here the small-ness of body and infantilism of mind areaccompanied by prominence of the abdomenand evidence of dilatation of the colon orthe intestines generally. The child is prob-ably a survivor from coeliac disease of morethan slight severity in infancy, the history ofwhich may be obtainable, and there may bea story of recurrent attacks of colitis sincesuch an illness in the first few years of life.Some cases are probably due to congenital di-latation of the colon, or true Hirschsprung'sdisease.

As in the case of renal infantilism, thesechildren are quite out of place in a schoolfor mental defectives.

(3) Cardiac Infantilism.-Although verysevere grades of mitral stenosis beginningin early life undoubtedly lead to a degree ofinfantilism, children with acquired heartdisease seldom come up for considerationfrom the point of view of their mentalcapacity. In congenital heart disease, onthe other hand, some degree of backwardnessis often present. There are, of course, manycases of congenital heart malformation inwhich the function of the heart is perfectlygood, and in which there are no symptomswhatever. Excluding these and consideringonly children with definite symptoms andsecondary results, such as clubbing, cyanosisand dyspncea, it is found that their mentalacquirements are equal to those of averagenormal children of about two years junior.

Before leaving the varieties of backward-ness considered from the aetiological stand-point, there are two others to which I willrefer.

(C) LACK OF SELF-ESTEEM.-One of theseis due to lack of self-esteem, in which thechild suffers from what has come to be calledthe inferiority complex. The ways by whichthis mental state comes into being are toonumerous and various to consider, but givena child with a suitable temperament, it isremarkable how small a matter may cause itto "take a back seat" as its self-appointedplace. An understanding instructor, a littleencouragement, or some source of self-gratulation, be it only so trivial a matter as anew suit of clothes, will sometimes awakenin such children a new interest and removethem from the ranks of the dull andbackward.(D) LATE MENTAL DEVELOPMENT.-The

other is due to late mental development pureand simple. The child whose mind developslate, since he is not up to the usual standardfor his size, we must perforce call "back-ward," but there is no defect, either mentalor physical. He is merely late in beginning

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to take his first mental steps, but once startedis found perhaps to be an apt learner, andsoon equals or surpasses his fellows.

We have now considered very brieflysome of the causes and clinical associationsof dullness and backwardness in children.You will appreciate that much has beenomitted, and that a large part of that whichcomes within our view has received butscant, even meagre, attention. I propose,however, in the concluding part of thelecture, to speak of certain children whomay be brought to you because, in commonparlance, they are thought by their parentsor others to have something "wrong withtheir heads," but who are neither backwardnor dull in the ordinary sense of the terms.They have certain peculiarities in theirbehaviour or in their attitude towards learn-ing which draw attention to them andcause their mental qualities to be wronglyassessed. They should be recognized ariddistinguished from the dull. I will select afew of these unusual, but not dull, childrenfor special discussion.

(i) Nervousness.-There are some childrenwho are so nervous that they easily pass asignorant or dull. If questioned, they standtransfixed with fear or make involuntaryconvulsive clutching movements with theirhands, they go pale, they flush and sweatby turns, their mouths go dry and theirtongues "cleave to the roofs of theirmouths." All they know runs away, indeedthey may never hear the question. Suddenlyrealizing that an answer is required of them,they blurt out something altogether wrongor apart from the question. As they growolder they learn more confidence and con-trol, but they fail to do themselves credit inoral examinations. In pose they are oftenawkward, in gait ungainly. Even an under-standing and sympathetic examiner mayfail to get en rapport with them, while thehasty may misjudge them grossly, and bemuch surprised at their prowess when thewritten term examinations come to be done.

A second type of nervous child, to whichLeonard Guthrie applied the term "therestrained emotional type," I cannot describebetter than in his own polished and lucidstyle. " Emotions are strongly felt, but thepowers of control are equally strong. Suchchildren are observant, intelligent, but soreticent that they often pass for being dull,sullen and obstinate. Their expression islowering, their attitude statuesque or stoop-ing, their gait slouching, slow and clumsy.They are often extremely sensitive, shy andproud. They appear wanting in affection,but really yearn for it, and brood overslights, imaginary or otherwise, until theybecome morose, gloomy and revengeful.Being slow to take or give offence, they areoften shamefully bullied at home and school,but suffer all with apparent stolid indiffer-ence, except for occasional outbreaks offury. They are solitary in habits, intro-spective, prone to self-analysis, imaginative,superstitious, with morbid love of horrors,and equally morbid dread of them. Theytake all things seriously a~nd have little or nosense of humour. This disposition is aptto lead to dreamy mental states and in-tellectual torpor, or to hysterical melan-cholia."

(2) Educational Overstrain. - There arechildren who are wrongly called "back-ward" because they do not fulfil someeducationists' conceptions of progress.They cannot assimilate and retain a rapidlyaccumulating mass of facts, and the attemptleads to weariness and boredom. Facts areuseful pegs on which ideas may be hungand are inseparable from education, but thebest education is that which teaches howto think. Sometimes children with goodintellects, capable of close and constructivethinking, have this power weighted downand smothered by being fed with masses offacts which they are expected to retain andserve up at a moment's notice. Lists of allsorts-the kings and queens, and theirdates, battles, capitals and counties, &c.,ad infinitum, may be borne by some children

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with comfort, and if without advantage atleast without harm, but this fact-crammingprovides in others mental exhaustion andchaos, and effectually chokes such intellectand powers of thought as they possess. Tosome children a part of the school curri-culum may be so unpalatable and burden-some that it permeates their whole schoollife. Some people can never spell, and willalways remember the intolerable burden ofattempting to learn by heart whole stringsof words, many of which to them werealmost or quite meaningless. Many, saidGuthrie, " will sympathize with little MajorieFleming when she wrote: ' I am now goingto tell you the trouble and wretched plaguethat my multiplication gives me. You can'tconceive it. The most Devilish Thing is8 times 8 and 7 times 7, what Nature itselfcan't endure.'" Some children can concen-trate on a subject for much longer thanothers, but must not be called either lazy ordullard-remember that eveln Darwin gaveup the attempt to pursue his special subjectfor more than an hour or so at a time.

(3) Night and Day Terrors.-The childwho is subject to night or day terrors isusually the reverse of stupid or dull. He isbright, alert, excitable, imaginative, quickin learning and ready in response. But ifthe terrors recur nightly or, as they some-times do, two or three times during thenight, he may go tired to school. Luckilythey are not usually remembered and causeno haunting fears during waking hours, butwhen this happens they may colour for thetime the child's whole outlook and seriouslyinterfere with his attention to school work.Day terrors are yet more disturbing.

(4) Epilepsy.-The relationship betweenepilepsy and mental disorders in children isill-defined and variable. Epileptic fits area common symptom of all kinds of amentia.In very few do repeated epileptic fits seemto be in themselves the cause of the mentaldeficiency. Excluding these cases withgrave mental defect, the epileptic child isusually bright, receptive and excitable. His

mother will complain that his hrain is tooactive, that he is always reading, acquisitiveof knowledge, and thinks and talks too muchof school and what he learns there. He isnot one, therefore, who would be likely tobe considered dull. Should, however, heget repeated attacks of petit mal, his work atschool may come under disapprobation andtheir cause be overlooked. There may becomplaint that he goes into a brown studyand pays no attention. Though quitecapable of writing and spelling well, thereare times when both are badly done, and noone has detected that before each period of"delinquency" there occurred an attack,perhaps marked only by fixity of expressionand change in the pupils. One such childI saw recently used to appear to go intodeep thought in the middle of the street, tothe discomfiture of the drivers and the alarmof its mother. Others get attacks of beingdazed, others unexpectedly go to sleep; yetothers have "day somnambulism" fromtime to time. Behaviour such as this, theminor fit being so short and so little inevidence that it is overlooked, is almostcertain to lead parents and masters alike toquestion the child's mental capacity.

(5) Speech defects may cause a child to beconsidered slow or backward. Stammering,stuttering, and lisping are too well knownto be likely to be wrongly judged, but thetreatment they receive from masters andmistresses is often calculated to make themworse. They are incidental to nervousness,and made worse by over-anxiety to avoidthem. Should they be regarded as due tolack of understanding or laziness and be metby remonstrance and reproof, they willcertainly become worse. Idioglossia, how-ever, is more often attributed to backward-ness, for this peculiarity in speech is lessknown and appears so strange to the un-initiated that the educational capacity isgravely doubted. But children with idio-glossia are bright and capable, usually showno other abnormality, and almost alwaysacquire ordinary language.

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HYPERTROPHIC STENOSIS OF THE PYLORUS 217

SUMMARY.In this lecture I have approached dull-

ness and backwardness from the clinicalpoint of view rather than from that of thepsychologist.

Backwardness may be divided into essen-tial (that due to primary mental defect), andnon-essential (that in which the potentialcapacity of the mind is unimpaired).

Non-essential backwardness has been con-sidered under four headings :

A. That due to environment.B. That due to physical disorders.C. Lack of self-esteem.D. Late mental development.

Under backwardness due to physicaldisorders has been mentioned that due tothe following conditions:-

Sense deprivation.Tonsils and adenoids.Ductless gland defects.Infantilism.

Finally, the following states have beenmentioned which should be distinguishedfrom backwardness :

Nervousness.Educational overstrain.Night and day terrors.Epilepsy.Speech defects.

HYPERTROPHIC STENOSISOF THE PYLORUS.By NORMAN C. LAKE,

M.D., M.S., D.SC., F.R.C.S.,

Surgeon, Charing Cross Hospital; Consulting Surgeon,Queen's Hospital for Children.

(Summary of Lecture to South-WestLondon Post-GraduateAssociation.)

MODERN surgical literature appears to berarely free of some reference to the treatmentof that peculiar and interesting condition towhich the above title is applied. The reason

for this is perhlaps not far to seek, for withinthe last ten years a profound change hasoccurred both in the prognosis of the diseaseand in the attitude which both physiciansand surgeons adopt towards treatment. Sorapid has been this change that many havefound it difficult to accommodate themselvesto the new viewpoint, and the attempt togain a proper perspective has produced anabundant literature. Despite this fact, how-ever, we are little further on as far as theetiology of the condition is concerned.The two theories of origin still remain,neither being proven, the one that the con-dition is a congenital abnormality strictlycomparable with other deformities, whilethe second theory assumes that'the hyper-trophy is secondary to spasm, brought aboutby irritation either in the stomach itself, orreflexly from more remote situations. Whenthese two theories are critically examined, itis found that while some of the main factssupport, others disprove each in turn. Forinstance, if the condition is congenital, onewould expect the symptoms to start at birth,whereas there is usually a latent period oftwo or three weeks, which may even beextended to as many months, before theonset. Again, congenital abnormalities areapt to be multiple, but it is rarely that otherabnormalities are found in association withthe hypertrophied pylorus. In some thirty-five cases only two showed any other abnor-mality; one a gluteal hernia, and the other aminor degree of hypospadias which couldbe ignored. On the other hand, if the con-dition is secondary to spasm, then the causeof the irritation should be demonstrable.Clinical examination, however, never revealssuch, and in such cases as have come to

post-mortem examination no irritative lesionhas been discovered. It should here bementioned that at one time it was held thatphimosis might be the origin of a reflexirritation. It is true that the condition iscommoner in boys than in girls; in theauthor's cases the proportion was nearlythree to one, nevertheless, it is not extra-

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THE DGUADIUATE MEDICAL OUINC J · Less commondefects of this orderare those of tle pituitary, suprarenal, and genital glands. Theinfluence ofsyphilis in theproduction of dull and

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