Trauma in Early Infancy and Later Personality Development by kellena93

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									     Trauma in Early Infancy and Later
         Personality Development
                              RALPH M. GIBSON, PH.D.



    The psychodynamic patterns of personality of children born with congenital ob-
    structions in the alimentary tract were compared with those of normal children
    in later childhood. The congenital anomalies had required surgery within the first
    4 months of life. The psychodynamic patterns were elicited by 4 projective tech-
    niques. Information regarding the mothers' emotional stability and attitudes was
    gathered by means of 3 paper-and-pencil inventories. The results suggested that
    there is no unilateral relationship between trauma in early infancy and signs of
    emotional disturbance in later childhood.


 A HE AIM of the investigation was to            hospitalization and surgery,2-4 have sug-
study the relationship between trauma            gested that younger children are more
in early infancy and the psychodynamic           easily traumatized because of their weak-
pattern of personality in childhood as in-       er capacity for mastery and consequent
dicated by projective techniques. Trau-          need for support from the mother. Oth-
ma in this study is defined as a disrup-         ers5"7 have stated that the constitutional-
tion of the basic normal pattern of gas-         physiological influence is at least of
trointestinal activity (hunger, feeding,         equal importance in the breakdown of
defecation, and sleeping) due to con-            personality development. Gerard7 states
genital obstructions in the alimentary           that pyloric stenosis or other obstructive
tract, requiring surgical repair within the      conditions which initially elicit physi-
first 4 months of life. The congenital           ological reactions such as vomiting, chok-
anomalies studied were atresia of the            ing, etc., can establish psychological re-
esophagus, imperforate anus, and pyloric         actions to food intake, such as reduction
stenosis.                                        of food intake or refusal to eat. When
   Theoretical formulations and empirical        the organic condition is corrected, an
studies have emphasized the importance           anxious expectation of the physiological
of either the constitutional-physiological       reaction may remain, and sensitive care
or the environmental-experiential influ-         in feeding by the mother is needed to
ence on the breakdown of personality             prevent later difficulties concerning food
development in infancy and early child-          or feeding.
hood. Studies dealing with maternal                 In the present study, the oral period
deprivation1 and with illness requiring          of development was complicated by the
   From the Department of Pediatrics, Univer-
                                                 anomalies interfering with normal physi-
sity of Michigan, Ann Arbor, Mich.               ological functioning. Compounding these
   Received for publication Sept. 17, 1964.      difficulties were parental anxiety, sepa-
                                           229
230                                                                TRAUMA AND PERSONALITY

ration from the mother, surgical insult,         or more times for the removal of food or
and postsurgical care. Therefore, in view        foreign bodies from the esophagus. While
of the acuteness and severity of the con-        attempts were made to feed these children
stitutional-physiological and environ-           orally after surgery, in every case it was
mental-experiential influences, one would        necessary to utilize gastrostomy feedings
expect significantly different psychody-         at various times, usually to the age of 1
namic personality patterns to be ex-             year. It seems obvious that the total trauma
                                                 for after-care, as well as initially, was very
hibited by the children later in child-
                                                 great compared with the group with pyloric
hood—namely, between 5 and 8 years of            stenosis.
age.                                                All the children in the experimental
                                                 groups were matched individually in sex,
                  Subjects                       age, and intelligence with children in a
                                                 control group. The latter were selected by
   A]] the medical records of children be-       reviewing the school records of the total
tween the ages of 5 and 8 years, hospitalized    kindergarten, first-, second-, and third-grade
at the University of Michigan Medical Cen-       population of a small school system draw-
ter for surgical correction of congenital        ing its pupils from a fairly representative
hypertrophic pyloric stenosis, congenital        socioeconomic population. The teachers of
atresia of the esophagus, and congenital         these children were asked to rate each for
imperforate anus, were reviewed. It was          the presence or absence of disturbing be-
necessary to eliminate some of the children      havior in the schoolroom. The parents of
because of other congenital anomalies. Of        those children who exhibited no such be-
the possible 26 children with pyloric ste-       havior were contacted about participating
nosis, 15 were included in the study, 2          in the study, but if conversation with the
were eliminated because of broken homes,         parents revealed broken homes, enuresis, a
5 were unable to participate, and the pa-        history of hospitalization, chronic illness,
rents of 4 did not reply to "follow-up"          or physical handicap, the child was ex-
letters. Of the possible 11 children who         cluded. Thus, it should be noted that the
had imperforate anus, 5 were included, 1         control group was not an average group of
had died, 2 were unable to participate, and      children but, insofar as could be determined,
the parents of 3 did not reply to the letters.   an entirely "normal" group by selection. It
Of the possible 29 children with atresia of      would be expected that any randomly se-
the esophagus, 9 were included, 20 were          lected group, with or without early phys-
not. Over 50% of those unable to partici-        ical trauma, would have more emotional
pate had moved to far distances. Thus, of        problems than our "control" group.
66 possible subjects, only 29 or 43% were           The Revised Stanford-Binet Intelligence
included in the study. Table 1 presents the      Scale, form L s was administered to the re-
relevant data regarding sex, age, IQ, age        maining children in order to find those
when operated, and length of initial hos-        whose genera] intelligence classification
pitalization.                                    matched those of the experimental groups.
   In the group with imperforate anus, both      In order to exclude further all those with
boys and one of the girls required subse-        physical defects and/or chronic disease, a
quent hospitalization and additional sur-        physical examination was carried out.
gical repair. In the group with atresia of
the esophagus, all but one had a primary
anastomosis. The exception was a girl who                          Method
had the multiple surgical approach because
the two ends of the esophagus were too              Four projective techniques were admini-
far apart. She had been fed by gastrostomy       stered to all the children in order to obtain
up to the time of the study when she was         the psychodynamic patterns of their per-
6 years old. All of the other children had       sonalities. These techniques consisted of
experienced difficulty with solid foods, and     the Draw-a-Person Test, Wishes and Fears
 returns to the hospital were necessitated one   Inventory, 9 Children's Apperception Test, 10
                                                                   PSYCHOSOMATIC MEDICINE
GIBSON                                                                                          231
                                TABLE 1. DATA ON PATIENTS STUDIED
                                                                         A ye at     Length of initial
                                        A ye                            operation     hoxpitalization
                      No.             (yr-, mo.)         Mean 1Q          (days)         (days)
    Group         M         F        M         F        M      F        M.     F        M       F
Atresia of the
  esophagus       3         6       5,2      6,1                        6      4       67    102
                                    5,8      7,10
                                    7,10     7,10
                                             8,0
                                             8,0
                                             8,0
                 MEAN               6,2      7,7        108    98

Imperforate
  anus            2         3        5,8      6,6                       4.5 20         12      24
                                     6,6      6,9
                                              7,8
                 MEAN                6,1      7,0       102    103

Pyloric
  stenosis       11         4        5,11     5,5                      54     47.5     12.5 20.5
                                     6,6      6,7
                                     6,7      7,8
                                     6,7      8,0
                                     6,8
                                     6,8
                                     7,3
                                     7,4
                                     7,10
                                     8,0
                                     8,2
                  MEAN               7,0      6, 11      99    110

and the Blacky Pictures.11 The projective             cepted psychological interpretation, these
records of the children were coded and                were any response containing a specific oral
evaluated by means of a check list espe-              reference such as "meal," "food," "eating,"
cially devised for this study. The general            "hungry," "breast milk," etc.; or implying
form of the check list was suggested by the           the stealing of food, the act of chewing,
methods developed by Bellak10 and Blum11              being eaten up, or using profane language);
for grouping and tabulating responses on               (7) anal-related comments (any response
the Children's Apperception Test and the              specifically referring to defecation or to the
Blacky Pictures. The list consisted of 10             anal region, with the expulsive and/or re-
variables which were considered likely to             tentive quality emphasized; (8) references
give the most adequate picture of the per-            to hospitalization; (9) references to surgery;
sonality dynamics of the subjects. The                and (10) perceptions of the self, parents,
variables were: (1) content of anxiety; (2)           siblings, and contemporaries. Within each
content of guilt feelings; (3) defense mech-          variable, specific contents were listed for
anisms; (4) other reactions to frustration;           each of the child's responses on the projec-
 (5) direction of identification; (6) oral-re-        tive techniques. Twelve cases, 6 boys and
lated comments (according to common ac-               6 girls, were then selected by the method
VOL XXVII, NO. 3, 1965
232                                                                    TRAUMA AND PERSONALITY

of random numbers to be similarly assessed           atresia of the esophagus. No significant
by another experienced psychologist in or-           differences in age at the time of initial
der to check the reliability of the method.          operation were demonstrated between
An item was retained for the final analysis           the babies who had pyloric stenosis and
of the data when there was at least 80%               those with imperforate anus or between
agreement between the 2 psychologists.               the latter and those with atresia of the
   In the 3 experimental groups, a minimum
                                                     esophagus. The babies with atresia of
of 4 years had elapsed between the initial
hospitalization for surgery and the time of
                                                     the esophagus were hospitalized signifi-
the study. While many experiences during              cantly longer than the babies in the oth-
the intervening years contributed to the             er 2 groups. No significant differences
psychodynamic patterns of the children, it           in the length of initial hospitalization
was felt that information about the mother's         were evident between the babies having
emotional stability and attitudes in each            pyloric stenosis and those with imper-
case would afford knowledge about one of             forate anus.
the most consistent and meaningful experi-              The analysis of the checklist-data is
ences contributing to the patterns. Ac-              summarized in Table 2. If the total num-
cordingly, the mothers were given a form of
the Semantic Differential,12 the Saslow
                                                     ber of 102 items on the check list, which
Screening Inventory, 13 and the Guilford-
                                                     could have differentiated the experimen-
Zimmerman Temperament Scale.14 The                   tal and control groups, were assumed
Semantic Differential is a method of elicit-         to be independent, any combination of
ing the connotative meaning of words and             10 differences could be expected by
is a variant of the word association method."        chance at the 10% level. Table 2 indicates
The Saslow Screening Inventory has been              that the boys in the group with pyloric
described as eliciting anxiety proneness.            stenosis and the girls in the group with
The Guilford-Zimmerman           Temperament         imperforate anus exhibited a total num-
Scale assesses 10 traits: general activity,          ber of differences from their respective
restraint, ascendance, sociability, emotional        controls just beyond chance expectancy
stability, objectivity, friendliness, thought-       at the 10$ level. Furthermore, an inspec-
fulness, personal relations, and masculinity-        tion of the check-list items revealing sig-
femininity.                                          nificant differences suggests that the di-
   The Mann-Whitney U Test, 19 a nonpara-            rection of the signs of disturbance is to-
metric statistical method, was employed to           ward the boys in the one experimental
evaluate and interpret the differences be-           group and the girls in the other as com-
tween the experimental and control groups.           pared to their respective normal controls
Because of the exploratory nature of the             (Table 3). The boys in the group with
present study, values at the 10% level or            pyloric stenosis exhibited 10 indicators
better were utilized in interpreting the sig-
nificance of the differences.
                                                     of disturbance. These were: (1) anxiety
                                                     over nocturnal fears; (2) denial as a de-

                    Results                          TABLE 2. ANALYSIS OF CHECK-LIST DATA

   The analysis of ages at the time of                                             Total, No. of
initial surgery revealed that the babies                                           differ enr,es*
in the group with pyloric stenosis were              Gravy                        M                 F
first operated upon at significantly older
age than the babies in the group with                Pyloric stenosis            11              5
                                                     Atresia of esophagus         1              3
   *The following words were used: mother,           Imperforate anus             0             11
stomach, girl, surgery, love, husband, food, wife,
sick, hate, care, marriage, boy, death, mouth,       •Between experimental and control subjects at
child, bowel, father.                                P < .10 on content of check list.
                                                                      PSYCHOSOMATIC MEDICINE
GIBSON                                                                              233
TABLE 3. DIRECTIONAL TREND OF SIGNS            tors of disturbance: (1) anxiety over loss
              OF DISTURBANCE                   of love; (2) denial as a defense mecha-
                                               nism; (3) the self perceived as depend-
                               No. of srigna
                            of disturbance     ent; (4) the mother perceived as puni-
                                               tive; and (5) the father perceived as
Group                       M             F    competitive. No indicators of disturb-
                                               ance were seen in the girls of the
Pyloric stenosis            10                 matched control group.
Control                      1                    The total number of significant differ-
Atresia of the esophagus       0               ences between the boys and the girls of
Control                        1               the group with atresia of the esophagus
                                               and their respective controls did not
Imperforate anus                               exceed chance expectation (Table 2)
Control                                        The directional trends within the psy-
                                               chodynamic patterns were not suggestive
fense mechanism; (3) acquisition of ob-        of disturbance (Table 3), the boys in the
jects; (4) flight into fantasy as a re-        experimental group showing no indica-
sponse to frustration; (5) oral sadistic       tors of disturbance while the boys in the
comments; (6) references to surgery;           control group showed one—the mother
perception of the self as (7) acquisitive,     perceived as passive. The girls in this
 (8) fearful, and (9) passive; and (10)        experimental group revealed 2 indicators
perception of father as aggressive-hos-        of disturbance, anxiety over loss of love
tile. Only one indicator—the self per-         and projection as a defense mechanism.
ceived as dependent—was characteristic         The girls in the control group exhibited
of the normal boys with whom they were         1 indicator, the self perceived as re-
compared.                                      sistant.
   The girls in the group with imper-             Since there were only 2 boys in the
forate anus demonstrated 8 directional         group with imperforate anus, the Mann-
trends of disturbance. These were: (1)         Whitney U Test could not be applied to
anxiety over phallic injury; (2) guilt         evaluate the significance of the differ-
over aggressive thoughts; (3) extra-           ences. However, an inspection of the
punitiveness in response to frustration;       directional tendencies of the total num-
 (4) the self perceived as aggressive-hos-     ber of significant differences suggested
tile; (5) the mother perceived as de-          chance findings.
pressed, and (6) rejecting; and (7) the           There were 63 items to be compared
brother, and (8) father pereceived as          on the Semantic Differential, and 6 dif-
depressed. The girls in the control group      ferences would be expected by chance
demonstrated 3 indicators—the self,            at the 0.10 level. Table 4 shows the
mother, and father perceived as com-           analysis of these data. Only the mothers
petitive.                                      of the boys in the group with pyloric
   Although the total number of signifi-       stenosis and their respective controls ex-
cant differences between the girls of the      hibited a total number of differences
group with pyloric stenosis and their          beyond chance expectancy. The words
controls did not exceed chance expecta-        that differentiated the experimental and
tion (Table 2), the directional trend was      control mothers, together with their as-
suggestive of more signs of disturbance        sociational and connotative meanings are
within the psychodynamic pattern of the        listed in Table 5. On the Guilford-Zim-
experimental group than the control            merman scale, the one difference would
group (Table 3). The girls comprising          be expected by chance at the 0.10 level.
this experimental group showed indica-         The mothers of the girls with pyloric
VOL XXVII, NO. 3, 1965
234                                                                TRAUMA AND PERSONALITY


TABLE 4. SEMANTIC DIFFERENTIAL DATA                               Discussion
                              Total No. of     Two very important considerations
                              differenct',S* should be pointed up. First, as it turned
Group                       M           F    out, the sample of patients studied in
                                             each of the 3 groups was a highly se-
Pyloric stenosis            12           5   lected one, and caution must be exerted
Atresia of esophagus         3           2   in making generalizations to all such
Imperforate anus             0           6   patients on the basis of those studied.
                                             Second, in any study of this type, the
•Between mothers of experimental and control
subjects, at P < .10 on words of Semantic question must be raised as to whether
Differential.                                the samples of behavior tapped, i.e., re-
                                             sponses to pictures or questions, are
stenosis were significantly different from particularly relevant to the dimension of
their respective controls in that they behavior, attitudes, or feelings being in-
were more submissive, and the mothers vestigated. The present author readily
of the girls with atresia of the esophagus admits the reality of possible irrelevancy.
were significantly different from their re- However, it is felt that the scoring of the
spective controls in that they were more responses along the dimensions outlined
seclusive. Both of these were chance re- in the study resulted in clinical judg-
sults. However, the mothers of the girls ments and inferences which, as always,
with imperforate anus were significantly must be considered tentative but provide
 more impulsive and thoughtless than hypotheses for further confirmation.
 their respective controls, a result which      The lack of both significantly different
was beyond chance expectancies. No psychodynamic personality patterns and
 significant differences were demon- emotional disturbances in the group with
 strated on the Saslow Screening Inven- atresia of the esophagus was unexpected.
 tory.                                        This is particularly surprising in light of

                   TABLE 5. ASSOCIATIONAL AND CONNOTATIVE MEANINGS
                          OF SEMANTIC DIFFERENTIAL WORDS*

                     Sex of
Group                 child                    Word                         Meaning
Pylon'c stenosis       M       Stomach, girl, hate, death        Weak, shallow, small
                               Boy, child, mouth                 Fast, hot, active
                               Care, marriage                    Slow, cold, passive
                               Sick                              Strong, deep, large, beauti-
                                                                   ful, valuable, clean, fast,
                                                                    hot, active
                       F       Me, food, boy, mouth              Ugly, worthless, dirty
                               Sick                              Weak, shallow, small
 Atresia of the        M       Surgery                           Strong, deep, large
   esophagus                   Wife                              Slow, cold, passive
                               Bowel                             Beautiful, valuable, clean
                       F       Love                              Slow, cold, passive
                               Sick                              Beautiful, valuable, clean
 Imperforate anus      F       Mother, stomach, me, bowel        Slow, cold, passive
                               Girl                              Ugly, worthless, dirty
                               Hate                              Beautiful, valuable, clean
 'Showing significant differences between motliers of experimental and control groups.
                                                                    PSYCHOSOMATIC MEDICINE
GIBSON                                                                             235
their significantly longer period of hos-     period of partial starvation, 54 days be-
pitalization, the frequency of readmis-       ing the average for the boys and 47.5
sion for removal of food and foreign          for the girls, was experienced as such a
bodies from the esophagus, and the need       traumatic and unremitting event that it
for gastrostomy feedings. Adverse effects     affected the subsequent personality de-
upon the emerging personality, as sug-        velopment. One can certainly conceive
gested by studies of maternal depriva-        of this experience as being very upset-
tion and hospitalization, were expected.      ting for the mother and providing fertile
In speculating about the reasons for          ground for real anxiety. In addition, the
these negative findings, several possibili-   mothers tended to rate the words on the
ties are suggested. Probable influence of     Semantic Differential significantly differ-
 a selective factor should be pointed out—    ently from their respective controls.
namely, that in this experimental group       Their responses suggested that illness
 only those mothers participated whose        tends to be associated with the child and
 relationship to the hospital and staff was   its dependency needs, but gives rise to
 sufficiently good to make them willing to     hostility and possible death wishes.
 return after a long period of time. There     Problems centering around perceived in-
 is also the possibility that the children     adequacy were suggested. The mothers
 who were not seen might have already          of the girls in this group, as compared
 been considered by the parents them-          to their controls, tended to deny the
 selves to have so many problems that          potency of illness and the child of the
 they were unwilling to face an objective      opposite sex as their own, and to depre-
 evaluation of their adjustment. Another       ciate themselves and the child's depend-
 possibility may be that the physical con-     ency needs. Added evidence of de-
 dition may have been such that travel of      creased self-esteem is suggested by the
 any distance would have been inadvis-         marked submissiveness on the Guilford-
 able. A fourth possibility is suggested       Zimmerman scale. Thus, one can specu-
 by the lack of a significant number of        late that there was disturbance in the
 differences on the measures given to the      mother-child relationship which could
 mothers in this group and their respec-       also account for the presence of difficul-
 tive controls, together with the signifi-     ties in the children.
 cant differences that were exhibited.
 These mothers tended to be more pas-            Of the girls with imperforate anus, the
 sive and accepting of illness; hence one     significantly different psychodynamic
 might speculate that the severe trauma       patterns which pointed toward signs of
 in early infancy had been assuaged by a      emotional disturbance were not unex-
 fairly healthy mother-child relationship.    pected. The signs did not appear to be
                                              related to the age at surgery as in the
   The significantly different psychody-      case of pyloric stenosis. The length of
namic patterns and indications of emo-        hospitalization did not appear to be the
tional disturbance in the boys with py-       prime factor since these girls were hos-
loric stenosis and the indications of emo-    pitalized for significantly shorter periods
tional disturbance in the girls of this       of time than those in the group with
group was likewise unexpected. How-           atresia of the esophagus, who showed no
ever, it was noted that these children        disturbance, and for about the same
had undergone surgery at a significantly      amount of time as those with pyloric
older age than those in the group with        stenosis, who did exhibit disturbance.
atresia of the esophagus. Though not          At the time of this study 2 of the 3 girls
significant for those with imperforate        in this group had fecal leakage. This
anus, the tendency is in the same direc-      had been a persistent problem for these
tion. One wonders if the relatively long      girls, as well as being especially anxiety-
 VOL. XXVII, NO. 3, 1965
236                                                             TRAUMA AND PERSONALITY


provoking in social situations. The words     signs of disturbance. The mothers of
on the Semantic Differential that signifi-    these children were found to be rela-
cantly differentiated the mothers of          tively emotionally healthy. The children
these girls from their controls suggested     who had experienced the most pro-
that they tended to depreciate the fe-        longed severe physiological reaction to
male child and to perceive themselves         food intake, required no tube feedings,
and the organs affected by the anomaly        experienced partial starvation for at least
as inadequate. On the other hand, they        the first 6 weeks of life, but who had
tended to perceive hostile feelings as        minimum separation from their mothers,
very important. On the Guilford-Zim-          exhibited many signs of emotional dis-
merman scale they were shown to be            turbance. The mothers of these children
significantly more immature. It would         were found to exhibit deviant attitudes
seem that this anomaly was a very diffi-      which were not entirely related to illness
cult one for the mothers to accept. When      and the child's anomaly. The children
one considers the necessity for the moth-     whose physiological obstruction led to
ers to perform postsurgical dilatation of     problems relating to elimination and the
the anus, which is painful to the child,      need for intensive postsurgical manipu-
it would seem that the mother-child re-       lation of the anus by the mother, like-
lationship is disrupted by the feelings of    wise exhibited many signs of disturb-
both the mother and child.                    ance. The mothers exhibited deviant at-
                                              titudes toward the child, themselves, and
                                              the zone of the anomaly and its related
                Summary                       functions. More generally, the results
                                              suggest that trauma in early infancy as
   The psychodynamic patterns of per-          an event in itself does not necessarily
sonality in children who had experienced      predispose the child to personality dys-
trauma in early infancy were compared         functioning in childhood. The reactions
with those of normal children by means         and interpretation of the event by the
of projective techniques. The trauma          parents and the personalities of the par-
consisted of a disruption of the normal        ents must tentatively be seen as the
pattern of gastrointestinal activity due       etiological factors.
to congenital obstructions in the alimen-
tary tract which required surgical repair                         Department of Pediatrics
within the first 4 months of life. The                              University of Michigan
anomalies studied were atresia of the                                    Ann Arbor, Mich.
esophagus, imperforate anus, and pyloric
stenosis.                                                      References
   The results must be considered in the
light of the particular tests that were        1. BOWLSY, J. Maternal Care and Mental
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unilateral relationship between trauma         2. LEVY, D. M. Psychic trauma of opera-
                                                  tions in children and a note on combat
in early infancy and personality dysfunc-
                                                  neurosis. Ainer. J. Dis. Child. 69:7,
tioning in childhood. The children who            1945.
had experienced the most severe disrup-        3.   JESSEH, L., BLOM, G., and WALDFOGEL,
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testinal activity, who were separated               lectomy and Adenoidectomy in Chil-
from their mothers the longest after birth,         dren." In The Psychoanalytic Study of
and who required gastrostomy feedings               the Child, Vol. 7. Internat. Univ. Press,
up to 1 year of age, exhibited the fewest           New York, 1952.
                                                                 PSYCHOSOMATIC     MEDICINE
GIBSON                                                                                 237
 4. ECKENHOFF, J. E. Relationship of                Apperception Test. C. P. S. C o , New
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 6. ERIKSON, E. H. Childhood and So-                  analysis of a case of multiple person-
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    atry, Ed. by Alexander, F., and Ross,             Bois, P, H. Evaluation of a new psy-
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10.   BELLAK, L., and BELLAK, S.   Children's       Hill, New York, 1956.




                  1965 Rorer Awards Contest of the
                 American College of Gastroenterology
         The American College of Gastroenterology, in cooperation with William
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         First prize in this category is $500 and a 3-year subscription to the
      Journal; second prize is $300 and a 2-year subscription, and third prize,
      $200 and a 1-year subscription.
         These prizes are to be awarded for the best papers published in the
      Journal during the 12 months ending June 30, 1965, for which no previous
      prize has been awarded.




VOL. XXVII, NO. 3, 1965

								
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