618

for some time been considering another of the CranbrookCommittee’s recommendations-the provision of beds forgeneral-practitioner obstetricians. A deputation fromManchester, consisting of members of the regional hos-pital board, the corporation, the board of governors, andthe executive council, have asked if they may meet theMinister of Health to discuss the idea of opening maternityhomes in some congested districts. Dr. C. Metcalfe

Brown, the medical officer of health, has suggested thatthe homes should have 20-25 beds and be staffed bygeneral practitioners and municipal midwives (though notnecessarily exclusively so). It has not yet been decidedwhether the homes should be set up by the regional hos-pital board or by the local health authority. Therewould apparently be no legal hindrance to the board’sproviding homes of this kind; but, if the board did not feelable to accept this new responsibility, the local authoritywould consider doing so. As the homes would in fact beoffering the equivalent of domiciliary care, near, insteadof inside the patients’ own homes, Dr. Metcalfe Brownbelieves that the general practitioner could call on con-sultant advice exactly as he does now, asking, should needarise, for the transfer of his patient to hospital or for adomiciliary visit (to the nursing-home) from a consultant.

TORULOSIS OF THE NERVOUS SYSTEM

FUNGUS infections of the central nervous system are

rare; but Rose et al.l have described three such cases,all of which were fatal. Similar cases have been reported

. only occasionally in the United Kingdom; but we haveheard of two in a general hospital in four years, and pos-sibly the diagnosis is sometimes overlooked. The firstverified case was described by Busse 2 in 1894, and thefirst cases in this country in 1930 3 and 1938 4; but con-siderably more cases have been reported in the UnitedStates and Australia. The organism, variously known asTorula histolytica or Cryptococcus neoformans, is widelydistributed and is found in the mouths of healthy people,only rarely causing disease. The common sites of infec-tion are the lungs and the central nervous system.

Neurological involvement is of two main types: sub-acute meningoenceplialitis with lymphocytic response inthe cerebrospinal fluid, which is the commoner form; andintracranial toruloma, giving the clinical picture of anintracranial tumour. In the meningeal form the diseaseusually develops over the course of several weeks; especi-ally if there is also a pulmonary lesion, it may superficiallyresemble tuberculous meningitis, but there are often onlyslight pyrexia and very slight changes in the erythrocyte-sedimentation rate and white blood-cell count. Intra-cranial toruloma may be accompanied by torula menin-gitis or may arise without signs of meningeal irritationand with a normal cerebrospinal fluid. In the cases ofmeningitis the diagnosis is made by finding the organismsin the cerebrospinal fluid, and these are most readilydetected in wet films of the centrifuged deposit stainedwith nigrosin or indian-ink. If this examination is notcarried out, the organisms may be confused with lymph-ocytes. Cultures should be made on Sabouraud’s medium,but growth may develop only after several days. Unfor-tunately in some cases the organism cannot be found, andin one of Rose’s patients it could be neither cultured norfound despite repeated attempts.

Until recently treatment has been ineffective. On a few1. Rose, F. C., Grant, H. C., Jeanes, A. L. Brain, 1958, 81, 542.2. Busse, O. Zbl. Bakt. 1894, 16, 175.3. Smith, F. B., Crawford, J. S. J. Path. Bact. 1930, 33, 291.4. Greenfield, J. G., Martin, J. P., Moore, M. T. Lancet, 1938, ii, 1154.

occasions an intracranial toruloma has been removed

surgically, but there has been a grave danger of fataltorula meningitis ensuing. Krainer et al. reported theremoval of a toruloma under the left frontal lobe, and thepatient remained well eleven months afterwards. In 1951 1Wilson and Duryea 6 reported the successful use of an anti-fungal antibiotic, ’ Actidione ’ (cycloheximide), in a patientwho subsequently was free of symptoms and had sterilecerebrospinal-fluid cultures twenty months after the

diagnosis had been made. But Boshes et al.7 treated three

patients with this substance without success, and in onecase there was an acute exacerbation a few days after treat-ment was started. More promising results have recentlybeen reported with the use of amphotericin B 1; of ten casesof torula meningitis treated in this way by Rubin andFurculow 9 eight were alive two to fourteen months later,and in seven of these the cerebrospinal fluid was

consistently sterile.

OVERSEAS VISITS BY STUDENTS

THE appeal by Mr. Moore and others for the BritishMedical Students’ Trust (p. 636) deserves to succeed.The Trust, which owes its origin to the British MedicalStudents’ Association, aims to provide travel grants forstudents proposing to study at universities and hospitalsabroad, and to defray the expenses of delegates of theB.M.S.A. attending meetings of the InternationalFederation of Medical Student Associations. The Trustis a development of the B.M.S.A.’s Student Travel Fund,founded in 1954, and its International Delegates’ Fund.From the two funds altogether E1893 has been distributed(S.T.F. S505, I.D.F. E1388), and a very large proportionof this total was subscribed by students themselves.Under the Trust the expenditure on delegations is

expected to remain about the same, but it is hoped toenhance greatly the amount spent on travel.The potential value of visits by medical students to

overseas centres is clear. For a student confined to the,often narrow, circle of his own medical school it is diincuitto picture other methods of teaching, other settings formedical practice, and different-perhaps better, perhapsworse-resources for practice. Hitherto it has been

unusual for men and women in medicine to gain grantsfor overseas visits until they have qualified and are

perhaps on the way to establishing themselves. And yetit is in undergraduate days, before habits of thought andplans for the future have solidified, that the impact of adifferent medical scene is likely to be greatest. Nor willthe value of travel grants be confined to those who goabroad; for on their return those who have been abroadwill fertilise the minds of contemporaries who have

stayed here. For this reason the new Trust should havethe support of medical educationists and others.

5. Krainer, L., Small, J. M., Hewlitt, A. B., Deness, T. J. Neurol. Nesurg. Psychiat. 1946, 9, 158.

6. Wilson, H. M., Duryea, A. W. Arch. Neurol. Psychiat. 1951, 66, 470.7. Boshes, L. D., Sherman, I. C., Hesser, C. J., Milzer, A., Maclem, H.

ibid. 1956, 75, 175.8. Appelbaum, E., Shrokalkos. Ann. intern. Med. 1957, 47, 346,9. Rubin, A., Furculow, M. L. Neurology, 1958, 8, 590.

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