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CORRESPONDENCE

SANITY IN A MENTAL WARD

To the Editor of THE LANCET

SiR,-Unavoidable circumstances have preventedme from reading till now the annotation with theabove heading in your issue of April 28th (p. 909).May I extract the following passage from it in orderto point what I believe to be the obvious moral ? YA " delirious " patient is consigned to the

" mentalward of a public hospital." (Incidentally, is not sucha place well-nigh legendary ) Your annotatorcomments :-

" Ideally it would be possible to have two wards ina general hospital in each large centre reserved for deliriousand confused patients whose mental symptoms followedupon physical disease." This arrangement " might lead togeneral physicians and psychiatrists working in closer asso-ciation ; some general trained nurses would acquire greateracquaintance with some forms of mental disorder; andthe medical students would have occasional opportunitiesof seeing acute psychoses without being wholly dependentupon journeys to distant hospitals.... So far as thestudent is concerned the divorce of ordinary clinicalexperience from his acquaintance with acute psychoticand psychoneurotic disorders leaves him unpreparedfor the exigencies of practice when at any time he mayneed to deal with them."

The moral is that there should be in every citywith a medical school a complete indoor and outdoorpsychiatric clinic in association with and a recognisedpart of the general hospital centre. Large towns,without a school, can follow suit. Here such patientsas the above-and many other cases of psychosis-could be dealt with, and the skilled cooperation,teaching, and experience referred to could be provided,and research in its highest forms carried out.

This provision, regarded as elementary, and longsince made on the continent, has been urged for thiscountry to my personal knowledge for 40 years-and probably longer. But apart from the MaudsleyHospital (a special case), nothing has been done.I read that Their Majesties are to honour with a visita new mental hospital. The latest of the kind it maybe, nevertheless of a familiar kind ; not a funda-

mentally new conception. This is as far as we have

got. The occasion is doubtless auspicious. It wouldbe far more so were it concerned with the inaugurationof the psychiatric clinic we have so long been pleadingfor. I am, Sir, yours faithfully,

Hove, May 9th. EDWIN GOODALL.EDWIN GOODALL.

ORAL IMMUNISATION AGAINST TYPHOID

To the Editor of THE LANCET

SlB,—In your issue of April 7th (p. 764) yourParis correspondent gave an account of the annualmeeting of the Marseilles Medical Society at whichthe endemicity of typhoid fever in that city wasconsidered. It was decided at this meeting to recom-mend preventive vaccination, but exclusively bysubcutaneous injection, vaccination by the mouth,according to the Marseilles practitioners, givinguncertain results, an immunity of a few weeks only,and a false sense of security. But in my opinionimmunisation by the mouth is to be considered, bothin the light of statistics and of experience, as certainas parenteral vaccination, the mechanism of theestablishment of immunity being precisely the samein the two cases. The only difference between theresults lies in the fact that the oral route seems toestablish immunity more rapidly than the hypo-

dermic route. We have seen for instance, during anepidemic of typhoid at the Prytanée Militaire de laFleche, where the pupils were vaccinated fifty-fiftyby the two methods, that among those vaccinated bythe mouth the epidemic was stayed much morerapidly than among those immunised by T.A.B.More than four million persons have been vac-

cinated against typhoid, cholera, and bacillarydysentery by the mouth, of these some 250,000 underthe control of public sanitary authorities. All withoutexception have declared that the two modes ofvaccination had equal value. I do not wish to insisthere on the Japanese experience that the oral resultsare superior to the hypodermic ; but comparativevaccinations carried out in India under the controlof the Health Commission of the League of Nations,and based on a large number (31,700) of subjectsled Dr. Russell to conclude : "The bilivaccine (fulldosage) and anti-cholera vaccine (double dose) givemuch the same degree of protection from attack."Dr. Cluver, who undertook the same vaccinationsunder the segis of the Government of South Africa,estimates that the results obtained by oral vaccinationare more favourable than those given by injection.

There remains’ the question of the duration of

immunity, said to be " only for a few weeks." Thisstatement seems to me gratuitous. None of thesanitary institutions quoted, nor any government,has reported that oral immunity lasted a shorter timethan hypodermic. It is possible that among vaccinatedpersons there could be found a small minority whocannot be protected, at all events completely ; butthis minority is found equally among

"

parenterals."During the war the only method of vaccination wasby injection and that did not prevent, among 2334typhoid cases nursed at Bar-le-duc hospital, the

discovery of 469 cases who had been vaccinated byinjection one or more times and had contractedtyphoid one to eight months after vaccination.

I have only attempted to bring to your knowledgerectifications based entirely on controlled facts,leaving your readers to draw their own conclusionsin favour of this or that method of vaccination.

I am, Sir, yours faithfully,Paris, May 3rd. L. F. DESTOUCHES.L. F. DESTOUCHES.

DIAPHRAGMATIC HERNIA

To the Editor of THE LANCET

SIR,-With reference to the case of congenitaldiaphragmatic hernia reported by Dr. G. H. Greenwayin your issue of March 24th (p. 628), and his requestfor information of other recorded cases, may I drawhis attention to the case of G. H. Dodds and J. D. S.Flew (Univ. Coll. Hosp. Mag., 1928, xiii., 43) and tothe letter of Dr. Herbert R. Spencer in the subsequentissue (p. 123) where he draws attention to four

specimens in the University College Hospital Museum,and to the value of the Obstetrical Transactions,particularly the last (index) volume of 1907 as a recordof obstetrical and gynaecological publications from1860 to 1907. In Dodds and Flew’s case, the infantlived eleven days. The hernia was through a per-sistent pleuro-peritoneal sinus on the left side andwas therefore without a hernial sac, and the left sideof the thorax contained the stomach, jejunum, ileum,cacum, ascending colon, transverse colon, spleen,pancreas, and left lung.

I am, Sir, yours faithfully,STEPHEN K. MONTGOMERY, M.D., D.R.

Johannesburg, April 25th.STEPHEN K. MONTGOMERY, M.D., D.R.