HERNIA AND INTESTINAL INJURY

957 The study thus showed that a diet based on Opaque-2 strain of maize, which is low in leucine, was relatively ineffective in inducing canine black-tongue. On the other hand, black-tongue could be induced regularly with maize of the Deccan- hybrid variety, which has a relatively high leucine concentration. The nicotinic-acid and tryptophan contents of the Deccan hybrid maize and the Opaque-2 maize diets were the same and therefore could not have accounted for the differences in pellagra-inducing properties. When the levels of leucine in Opaque-2 maize diet were raised to those obtaining in the Deccan hybrid variety, by leucine supplementation, canine black-tongue could easily be induced. These observations indicate that when pellagra occurs in association with maize diets, relative excess of leucine may have an important role. We thank Miss E.

Rangavalli Tayaru for her help.

Nutrition Research Laboratories, Indian Council of Medical Research,

Hyderabad 7,

India.

C. GOPALAN BHAVANI BELAVADY D. KRISHNAMURTHI.

HERNIA AND INTESTINAL INJURY SIR,-I was glad to see your annotation (Oct. 18, p. 833) on our article,! since it gives me the opportunity to add a name to our list of references. Mr. J. A. Shepherd2 described a case of great interest since it was only the second one recorded in which rupture of the intestine was associated with a femoral hernia. University Department of Surgery, W. A. F. MCADAM. Leeds.

A BASIS FOR SEX EDUCATION SiR,—The decision of the Health Education Council to set up a sex-education panel is welcome. The panel’s aim is to reduce the number of therapeutic abortions by encouraging a comprehensive contraception service, and Lady Birk, the panel’s chairman, has broadly indicated that the problem can only be properly understood in the context of sex education in general. Since the approach to sex education must be consistent, may I suggest that it should be founded on a detailed knowledge of personality development ? The disagreement between medical and educational authorities on sex education hinges on two factors: firstly, the facts of personality development are not all known, and advances in knowledge take some time to be assimilated; and secondly, the roles which the family and the school should play in sex education are still not clear. It would be interesting to discover what percentage of the 40,000 women legally aborted during the first year of the Act were familiar with contraceptive techniques. I suspect that the figures would bear out the observation in clinical practice that many of these pregnancies are the result, not of ignorance, but of psychological forces which can only be understood if the underlying unconscious motivation is taken into account. Ignorance of contraceptive techniques may result not only from lack of information, but also from the persistence of childhood prohibitions against sexual curiosity and knowledge. Sex education should take account of the unity and frailty of human personality. Moral and sexual development should go hand in hand. Sex education based on personality development, should reap rewards not only in terms of better personality and improved loving and sexual life. Knowledge of personality and sexual development should also permit treatment of those whose life experiences have interfered with the development of personal responsibility and the quality and direction of emotional needs. These are the real problems 1. 2.

McAdam, W. A. F., Macgregor, A. M. C. Br. J. Surg. 1969, 56, 657. Shepherd, J. A. Surgery of the Acute Abdomen; p. 266. Edinburgh, 1960.

for society in an age suddenly aware of technological power. Technology in the shape of pills and preventives is invaluable, but, in itself, it can never compensate for the hardships of personality development. ISMOND ROSEN.

CARE OF THE MENTALLY SUBNORMAL SIR,-It is a great pity that in your concern for the mentally handicapped (Oct. 4, p. 727) you turn to illinformed prejudice for guidance. Discussions on the provision of care, both in hospitals and in the community, has been bedevilled by emotion and woolly thinking, not a little due to the fact that the self-appointed authorities on whose opinion you set so much store, have little experience and less understanding of the problems involved. There is constant confusion between those mentally handicapped people who can achieve integration in the community if given adequate support, and those who are so severely handicapped as to need residential care throughout their lives. Unquestionably the former should be returned to the community: the psychiatric hospitals for the mentally subnormal have always directed their energies and therapeutic endeavours to that end. The chief point under discussion is the best way of providing care for the latter group, who need a considerable amount of care throughout their lives. It is a vain hope that community care will prove to be cheaper than the care of patients in the hospital. Judging by the experience in the London boroughs, both the provision and the cost of running hostel accommodation is over twice that of the hospitals. Attempts to provide it on the cheap by the transfer of patients into decrepit old houses, as suggested by Dr. Freeman, will very soon replace the overcrowding of wards by unbearable slum conditions in the community. The feasibility of replacing the hospital system by community care is equally doubtful. It is one thing to set up odd small units; it is quite another to recruit enough personnel to provide a service on a national scale. The experience of existing hostels is that hostel staff are hard to recruit and harder to keep. It is a sobering thought that objections to the proposals of replacing hospitals by community care come equally from the hospital and local-authority workers. The more removed people are from the responsibility of providing care-whether sheltered by the ivory towers of university, voluntary societies, or Alexander Fleming buildings-the more enthusiastic they appear to be for the scheme. There is very little, if any, hard scientific evidence that community care is of greater advantage to the handicapped than care in hospitals. Evidence from the little work that has been done is invalidated by the fact that small wellendowed and amply staffed projects on community care are compared with neglected, overcrowded, and under-financed hospitals deprived of every facility. The deficiencies of the hospitals, to which Dr. Morris draws attention in her book, are in great part due to lack of finance and facilities, and complete lack of interest in the service by all the authorities from the Ministry of Health downwards (until, very recently, Mr. Crossman decided to tackle the problem). Is it to be wondered at that this neglect has resulted in a profound loss of morale which has been

responsible for the deplorable conditions which the Ely report has highlighted, but which are by no means typical ? The wonder, in fact, is that so much has been achieved under such difficult conditions. You, yourself, draw attention to the vast improvements that have taken place in the past 10 years in the hospitals, and the clinicians who have brought these improvements about are still at work there. The " deplorable isolation of subnormality hospitals " is a cliche which is repeated ad nauseum without any basis of fact. The relative isolation of clinicians working in specialist