56

clusions were reached in another investigation 9 of 79infants and children, of whom 38 had been partlytreated before diagnosis, again mostly with penicillin.5 of them died, of whom 4 had been partly treated.The spinal-fluid findings were analysed in the hopethat a guideline would emerge for differentiatingbetween bacterial and viral meningitis. Bacterial

meningitis was usually associated with an excess of1200 leucocytes per c.mm. (of which more than 60%were neutrophils), with protein in excess of 80 mg. per100 ml., and with glucose less than 45 mg. per 100 ml.The opposite was true in most cases of viral meningitis.In only two pretreated children who had positivecultures were the cell-counts misleading, suggestingthat part-treatment may occasionally modify the spinalfluid so that the changes resemble those in asepticmeningitis.

These investigations show that the fears surroundingpartial treatment are probably exaggerated. Menin-

gitis due to Hcemophilus influenzæ, the offendingorganism in as many as 70% of the children, is unlikelyto be masked by the low doses of oral penicillincommonly used in the treatment of minor respiratoryinfections. This organism is highly resistant to

penicillin. Moreover, the penetrance of all the

penicillins into spinal fluid is low, and even ampicillin,to be effective, must be given parenterally and in highdoses. Provided the laboratory is alerted to their

previous use, the low levels likely to have been attainedbefore hospital admission can be overcome by theinclusion of penicillinase in the culture medium.Failure to isolate the causative organism is not

confined to partly treated patients. The decision tocontinue treatment for unproven bacterial meningitisremains, like the decision to perform a lumbar punc-ture, a matter for fine clinical judgment.

PSYCHIATRY AND COMMUNITY MEDICINEIN LONDON

REVIEWING the pattern of examinations in psychiatryin the United Kingdom in 1973, Crisp 10 concludesthat " comprehensive examination in psychiatry occursin the final professional examination in most schoolsof medicine in the United Kingdom outside of LondonUniversity ". The isolation of London in this respecthas been noted before 11—and the twelve Londonmedical schools produce about half the country’smedical graduates. The Todd Commission stated" we have been dismayed to find how inadequate isthe present provision for the teaching of psychiatryin most undergraduate medical schools, and we thinkevery effort should be made to remedy this " 12 ; andthe Commission made equally pointed comments aboutcommunity medicine. The importance of psychiatryand community medicine in modern medicine is nowaccepted. The load of psychiatric illness is increasing;

9. Converse, G. M., Gwaltney, J. M., Strassburg, D. A., Hendley,J. O. J. Pediat. 1973, 83, 220.

10. Crisp, A. H. Br. J. med. Educ. 1973, 7, 254.11. Carstairs, G. M., et al. Br. J. Psychiat. 1968, 114, 1411.12. Royal Commission on Medical Education 1965-1968. H.M.

Stationery Office, 1968.

and community medicine is crucial to provision ofappropriate health services and to understanding ofthe causes and prevention of disease.

’

Since the Todd Commission published its report,the Royal College of Psychiatrists and the Facultyof Community Medicine of the Royal College of

Physicians, responsible for vocational training and themaintenance of standards in psychiatry and communitymedicine, respectively, have been established. These °

two specialties span the whole of medicine and accountfor more than 2500 consultants or their equivalents iin the National Health Service. The medical schoolsshould be preparing people of high calibre now to fillsuch positions in the future. Yet, in the twelve under- !graduate schools in London, there are only three

professors of community medicine. Some schools haverudimentary departments which struggle againstoverwhelming odds; others are beginning to expressinterest in the subject and are willing to appoint asenior lecturer. The situation in psychiatry is slightlybrighter. Each teaching hospital does have a clinical jdepartment of psychiatry. But there are still six I,London medical schools without academic units of

psychiatry.To attract good entrants, a specialty must be able

to convince the medical student of its importance andrelevance. Unfortunately, in the existing system,examination or at least assessment in a subject is oneof the- main ways in which students measure its

standing. London University is unique in Britainin having no proper examination in psychiatry or

community medicine. Proposals for a separateexamination have evoked determined opposition fromsome members of longer-established specialties.But if a proper climate for the development of thesetwo subjects is to be created, these attitudes must giveway to a more constructive approach; it is to be hopedthat the University will accept these proposals.Of course, there are strong arguments against

separate examinations in individual subjects. Probablythe undergraduate curriculum should aim not only tointroduce the student to the various aspects of medical

practice and to provide him with a sound basis forspecialised training, but also to give him a well-

integrated understanding of medical problems; sep-arate examinations in individual specialties tend to

divide rather than integrate. Many schools outsideLondon, and some inside, now provide integratedcourses and examinations, with subjects like com-

munity medicine and psychiatry being introducedat appropriate times throughout the course. Wherethis is not happening, a separate examination in thesetwo neglected but fundamental areas is an essentialinterim measure. Perhaps in 1974 London Universitywill at last come up to the standards of its provincial (counterparts in this vital aspect of medical education.

PRINTING OF THE LANCET

PRINTING of this issue was again hampered by the iGovernment’s fuel restrictions. On the editorial sidethe scene is brighter: a paraffin lamp has been vacquired. :

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