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MENTAL ACTIVITY IN INFANCY
747 the cause. This is the reason for the failures of surgical treatment-not bad surgery, not bad luck, but failure to remove the cause. The straightened toe is immediately deformed again when the patient wears shoes. With the patient standing upright with the feet close together, the normal, or restored to normal, feet make contact with each other throughout their length. There is no angle or gap between the big toes. Only shoes thathave a straight inner border and no gap between the inner side of the toes can therefore accommodate the feet in this shape (fig. 2). Which is the most effective operation for advanced I suggest, hallux valgus I am not competent to say. however, that the best method will only be effective if the patient wears correctly designed footwear after the
operation. Preventio,n, by Correet Footwear I do not myself wear correctly designed shoes, for I do not know where I can buy them, an d I cannot afford to have them specially made. Some children’s shoes are correctly designed but most are not. Through my Member of Parliament, I have asked the Minister of Health to create a Seal of Approval which manufacturers under licence could emboss on their footwear to show that it is correctly designed-the first requirement of design being that the footwear must accommodate the straight hallux. The Minister seems to favour the idea of a seal but he is unwilling or unable to do anything about it himself. In my iew it is the duty of a Minister of Health to take immediate action to reduce the crippling prevalence of hallux valgus. The first requirement is official medical approval of a correct design ; and this would form the basis of whatever further action is necessary. Surely the medical profession is prepared to tell the shoe manufacturers what are the medical requirements for satisfactory footwear! .Only when this has been clearly stated can we expect manufacturers to comply with these standards ; and upon their action successful treatment and prevention depend. Neither apathy nor opposition should delay action, for only when we have revolutionised the design of footwear can we confidently recommend an operation for advanced hallux valgus and look forward to the day when hallux valgus will be of interest only to the historian. CHARLES A. PRATT. London, S.E.22. MENTAL ACTIVITY IN INFANCY
SIR,—Mrs. Collis (March 28) misses the point of
our
argument. We agree that " mental and motor defects both affect physical activity, though in differing ways." We cannot, however, agree that the tests recommended by Mrs. Collis can be relied upon to separate mental deficiency in cerebral palsy from mental retardation due to the motor defect. We argued that all the tests for mental development were motor tests only. The term " release phenomena " as applied to tonic neck and tonic labyrinthine reflexes is, we believe, common neurological usage. We used this term as it seemed to us relevant to the problem for at least two reasons. First, the degree of release is a direct indicator of the severity of the motor handicap. Secondly, the released motor phenomena,,by their persistence and strength, are responsible for the non-appearance of a higher integrated motor behaviour that may well be, and often is, potentially present. London,
W.I.
KAKEL BOBATH KAREL BERTA BOBATH. agrees, in his letter last
SIR,—Professor Illingworth week, that it is through its physical expressions that we judge mental development. As he himself admits, however, assessment of this through alertness, interest (or awareness), social responsiveness, response to sound, grasping reactions, and vocalisations (all mentioned in
my original text) relies upon the infant’s neuromuscular coordination. At the time when this " is not quite ready " for mature expression, and in cases where it is impaired, assessment by these means is impracticable. It was for these reasons that I ventured to select some other neuromuscular reactions of infants and to suggest that their modification may also be linked with mental advance. Cerebral Palsy Unit, Queen Mary’s Hospital for Children, Carshalton, Surrey.
EIRENE COLLIS.
THE PROBLEM OF PEPTIC ULCERATION
SIR,—I must agree with most of Mr. Downie’s criticisms last week of my annual lecture." I can only plead that it was the best I could do under the circumstances-an hour in which to cover a large topic before a mixed audience, few of whom were surgeons. I have, however, a few comments on each of his paragraphs. Mr. Downie seems to have found some political or social implications in my views on the aetiology of ulcer. I can assure him none were intended. Certainly most of my ulcer patients are both intelligent and ambitious, but they are all just ordinary chaps," and quite a few of I find out if a bus driver is them are bus drivers. ambitious by talking to him as a man rather than a patient, by discussing with him his job, his home, his family, and his pals as well as his pain. I am not sure that the word " stress " is really a " meaningless phrase "; I prefer it to the " adaptation syndrome " which has the semblance of meaning without the reality. The struggle for existence is not new, but the constant awareness of the struggle is a phenomenon of the present century, as is duodenal ulcer. With the views on the indications for operation that Mr. Downie expresses in his second paragraph I feel less happy. He says : "I hope Sir Heneage will agree that in the treatment of peptic ulcer there must be one law for the rich and another for the poor." I could not agree less. I feel very sorry for the German who lost his motorcycle because he had a month of medical treatment for his duodenal ulcer, but the implication that he might have kept it had he been admitted to the surgical wards seems to err on the side of optimism. The figure " 40 " has no more magic than 400 or 04 ; but merely represents my opinion which, on this occasion, I had been asked to give. We must all operate earlier sometimes. I have recently been forced to do a gastrectomy on a boy of 14. But, in my view, we should remember that gastrectomy, successful as it is, is a gross mutilation, a wholesale sacrifice of normal tissues and of one of the most important phases of normal digestion. The man who has lost the major part of his stomach has lost most of his reservoir, most of his mechanical kneading apparatus, most of his mechanism for dealing with meat-fibres, and most of his protection against swallowed bacteria. How sure are we that a man so deprived will not eventually suffer some hormonal or nutritional disturbance ? We know already that he appears to suffer no ill effect in twenty years. Have we any right to assume that this immunity will hold good for forty or sixty years ? I did not discuss the treatment of high gastric ulcers, because I was not speaking to those who were interested in technical details. In any case my experience is nothing to that of Norman Tanner. I agree, however, that the high gastric ulcers, particularly that group that Mr. Downie has recently discussed so ably,1 the high lesser-curve ulcers that cannot be demonstrated by X rays or the gastroscope but that bleed torrentially, present a problem of real difficulty. I personally have only found one in which it was not possible to do a high Billroth-i gastrectomy of the Pauchet type, cutting round the ulcer with scissors. In one the ulcer involved "
"
1.
Downie, V. J.
Brit. med. J. 1952, ii, 24.
operation. Preventio,n, by Correet Footwear I do not myself wear correctly designed shoes, for I do not know where I can buy them, an d I cannot afford to have them specially made. Some children’s shoes are correctly designed but most are not. Through my Member of Parliament, I have asked the Minister of Health to create a Seal of Approval which manufacturers under licence could emboss on their footwear to show that it is correctly designed-the first requirement of design being that the footwear must accommodate the straight hallux. The Minister seems to favour the idea of a seal but he is unwilling or unable to do anything about it himself. In my iew it is the duty of a Minister of Health to take immediate action to reduce the crippling prevalence of hallux valgus. The first requirement is official medical approval of a correct design ; and this would form the basis of whatever further action is necessary. Surely the medical profession is prepared to tell the shoe manufacturers what are the medical requirements for satisfactory footwear! .Only when this has been clearly stated can we expect manufacturers to comply with these standards ; and upon their action successful treatment and prevention depend. Neither apathy nor opposition should delay action, for only when we have revolutionised the design of footwear can we confidently recommend an operation for advanced hallux valgus and look forward to the day when hallux valgus will be of interest only to the historian. CHARLES A. PRATT. London, S.E.22. MENTAL ACTIVITY IN INFANCY
SIR,—Mrs. Collis (March 28) misses the point of
our
argument. We agree that " mental and motor defects both affect physical activity, though in differing ways." We cannot, however, agree that the tests recommended by Mrs. Collis can be relied upon to separate mental deficiency in cerebral palsy from mental retardation due to the motor defect. We argued that all the tests for mental development were motor tests only. The term " release phenomena " as applied to tonic neck and tonic labyrinthine reflexes is, we believe, common neurological usage. We used this term as it seemed to us relevant to the problem for at least two reasons. First, the degree of release is a direct indicator of the severity of the motor handicap. Secondly, the released motor phenomena,,by their persistence and strength, are responsible for the non-appearance of a higher integrated motor behaviour that may well be, and often is, potentially present. London,
W.I.
KAKEL BOBATH KAREL BERTA BOBATH. agrees, in his letter last
SIR,—Professor Illingworth week, that it is through its physical expressions that we judge mental development. As he himself admits, however, assessment of this through alertness, interest (or awareness), social responsiveness, response to sound, grasping reactions, and vocalisations (all mentioned in
my original text) relies upon the infant’s neuromuscular coordination. At the time when this " is not quite ready " for mature expression, and in cases where it is impaired, assessment by these means is impracticable. It was for these reasons that I ventured to select some other neuromuscular reactions of infants and to suggest that their modification may also be linked with mental advance. Cerebral Palsy Unit, Queen Mary’s Hospital for Children, Carshalton, Surrey.
EIRENE COLLIS.
THE PROBLEM OF PEPTIC ULCERATION
SIR,—I must agree with most of Mr. Downie’s criticisms last week of my annual lecture." I can only plead that it was the best I could do under the circumstances-an hour in which to cover a large topic before a mixed audience, few of whom were surgeons. I have, however, a few comments on each of his paragraphs. Mr. Downie seems to have found some political or social implications in my views on the aetiology of ulcer. I can assure him none were intended. Certainly most of my ulcer patients are both intelligent and ambitious, but they are all just ordinary chaps," and quite a few of I find out if a bus driver is them are bus drivers. ambitious by talking to him as a man rather than a patient, by discussing with him his job, his home, his family, and his pals as well as his pain. I am not sure that the word " stress " is really a " meaningless phrase "; I prefer it to the " adaptation syndrome " which has the semblance of meaning without the reality. The struggle for existence is not new, but the constant awareness of the struggle is a phenomenon of the present century, as is duodenal ulcer. With the views on the indications for operation that Mr. Downie expresses in his second paragraph I feel less happy. He says : "I hope Sir Heneage will agree that in the treatment of peptic ulcer there must be one law for the rich and another for the poor." I could not agree less. I feel very sorry for the German who lost his motorcycle because he had a month of medical treatment for his duodenal ulcer, but the implication that he might have kept it had he been admitted to the surgical wards seems to err on the side of optimism. The figure " 40 " has no more magic than 400 or 04 ; but merely represents my opinion which, on this occasion, I had been asked to give. We must all operate earlier sometimes. I have recently been forced to do a gastrectomy on a boy of 14. But, in my view, we should remember that gastrectomy, successful as it is, is a gross mutilation, a wholesale sacrifice of normal tissues and of one of the most important phases of normal digestion. The man who has lost the major part of his stomach has lost most of his reservoir, most of his mechanical kneading apparatus, most of his mechanism for dealing with meat-fibres, and most of his protection against swallowed bacteria. How sure are we that a man so deprived will not eventually suffer some hormonal or nutritional disturbance ? We know already that he appears to suffer no ill effect in twenty years. Have we any right to assume that this immunity will hold good for forty or sixty years ? I did not discuss the treatment of high gastric ulcers, because I was not speaking to those who were interested in technical details. In any case my experience is nothing to that of Norman Tanner. I agree, however, that the high gastric ulcers, particularly that group that Mr. Downie has recently discussed so ably,1 the high lesser-curve ulcers that cannot be demonstrated by X rays or the gastroscope but that bleed torrentially, present a problem of real difficulty. I personally have only found one in which it was not possible to do a high Billroth-i gastrectomy of the Pauchet type, cutting round the ulcer with scissors. In one the ulcer involved "
"
1.
Downie, V. J.
Brit. med. J. 1952, ii, 24.