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ineffective. As STALLYBRASS 2 has remarked, immu-nity to smallpox, whether produced by artificial ornatural means, is not a mathematically preciseprocess, and there are considerable individual * varia-tions in the solidity and permanence of the resultantincrease in resistance. Moreover, immunity to small-pox cannot yet be measured or even roughly assessedby skin or serological tests as can that to diphtheria.In discussing difficulties in the diagnosis of atypicalcases CONYBEARE 3 has drawn attention to the helpnow obtainable from the laboratory tests recentlydescribed in detail by DowNiE.4 4 It is not surprisingthat some atypical cases with a minimal focal eruptiongo completely undetected, since these people maynever be sufficiently ill to call a doctor. After two orthree days of malaise with headache and fever, at thistime of year easily regarded as influenza, they suddenlyfeel better and may not pay any attention to the fewspots-often not more than a dozen-which haveappeared usually on the forehead and about the wristsor backs of the hands. In this infectious stage theygo unhindered about their work and social occupations.So unless and until a more florid form of the diseaseappears in some person with a weaker immunity thepresence of smallpox in a fairly well vaccinated

community may remain unsuspected and all chance oftracing its origin may be lost. Even when smallpoxis already in mind the clinical diagnosis of cases witha minimal focal eruption may be extremely difficult.Significant points are the prostration associated withthe pre-eruptive illness, even when the rash itself isalmost negligible, and the sudden cessation of theconstitutional disturbance when the eruption appears.The centrifugal distribution of the eruption remainsthe sheet anchor of smallpox diagnosis ; but the fewerthe lesions the less evident is this characteristic pattern.The lesions of a minimal eruption lack the uniformshape and orderly development which are useful guidesin a more pronounced rash ; thev also tend to berelatively superficial in the skin and to mature rapidlyor sometimes to abort without pustule formation.

Atypical smallpox should be seriously considered whenpapular lesions, however few, some of which haverapidly acquired vesicular or pustular heads, suddenlyappear about the face, wrists, hands, or feet of anyvaccinated person who has just recovered fromso-called influenza. In most cases of this sort theclinical diagnosis, even when made by an expert,should be checked by laboratory tests.The focal eruption of smallpox may be more or less

profuse and yet remain in some respects atypical.Such cases nearly always come under medical observa-tion and are not often completely overlooked thoughthey may be misdiagnosed, usually as chickenpox.In these, careful attention to the distribution patternof the mature rash and to the nature and developmentof the lesions, plus the history of the pre-eruptiveillness, will usually be sufficient for a confident clinicaldiagnosis ; but here again the help of the laboratoryis not to be despised. It is worth noting that in someof the Grimsby cases the distribution pattern of themature eruption has been typical but the order of theoutcrop has been unusual in that the initial lesionswere on the body.2. Stallybrass, C. O. Publ. Hlth, Lond. 1947, 60, 77.3. Conybeare, E. T. Practitioner, 1946, 157, 191.4. Downie, A. W. Publ. Hlth, Lond. 1947, 60, 82 ; see Lancet, 1946,

ii, 205.

Another form of smallpox which may not be

promptly recognised is the severe toxic hsemorrhagictype which is sometimes fatal before the delayed focaleruption appears. Such patients are critically illwith extreme prostration. They usually have a diffuseerythema, sometimes with petechiae or purpuricspots over the bathing-drawers area, and conjunctivalhaemorrhage is common. These cases may be admittedto hospital as scarlet fever, measles, or septicaemia.Although usually unvaccinated, the patients sometimesgive a history of a successful vaccination in childhoodwithout revaccination, for infant vaccination does notnecessarily provide lifelong protection against thissevere and almost invariably fatal form of smallpox.At times like the present, when smallpox is prevalent,the medical staffs of hospitals should be specially ontheir guard against the inadvertent admission of suchcases to open wards.

Annotations

BEFORE OR AFTER?

THE essence of the National Service Bill now beforeParliament is that all men between 18 and 26 years of

age shall be liable to 18 months’ full-time militaryservice, to be followed by 51/2 years’ part-time serviceduring which they may have to undergo a total of 60 days’further training. Postponement of service is mentioned,though the grounds for postponement are not defined ;and for doctors and dentists who are working for addi-tional qualifications the age-limit for call-up is extendedto 30. The 8-year span of liability may perhaps benecessary to include any who through illness or for someother reason cannot be recruited in their teens ; but itleaves the young man uncertain as to when he will haveto serve, and all would welcome a specific assurancethat this latitude will not be used to gratify the admini-strative whims of Service departments. The wide sweepof the age clause enables the Minister of Labour, if hewishes, to defer the call-up of medical students untilthey are qualified ; but we are not told whether this willin fact be done ; and he might hold that by keeping suchstudents in line with others he would avoid the perils ofestablishing a privileged group.

Before qualifying, the medical student has six yearsof arduous, expensive, and unpaid work ; and, by anunhappy tradition, the young doctor often receives onlyan apprentice’s salary for the first few years., Hencethe price paid by nearly all who elect to study medicineis the deferment of marriage and a settled home ; and ifmilitary service is to be interposed before medical trainingthe possibility of marriage may be yet further postponed.Some medical educationists 1 approve of an interlude ofmilitary service, between school and medical school,because it broadens the student’s outlook and improveshis judgment ; but it amounts to an addition of nearlytwo years to the curriculum, which could only betolerable if the methods of paying young doctors werechanged so that they could support a family soon afterqualifying.That is of course mainly a professional matter. But

there are also strong national reasons for postponing themilitary service of medical students until they havequalified. Presuming that in time of war they are goingto be used as doctors, can we doubt that a period of

training in Service medical work, with responsibilityfor the care of troops, will stand them in better stead thana corresponding period of general training at 18 years ofage I Is it economical to teach young men to drive tanks,or look after aircraft, or keep naval stores, when theyare going to be employed as medical officers ? Few will

1. See Lancet, 1946, ii, 305.

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deny that the future doctor, like anyone else, will gain muchby serving in the ranks ; and if it were administrativelypossible there is something to be said for the suggestion 2that his military service should be done in two spells-one after leaving school and the other after qualifying.But if the choice is between service entirely before medicaltraining or entirely after it, the latter appears moreadvantageous to the Armed Forces themselves.

It is also less wasteful to the community as a whole.The latent shortage of doctors will become manifestwhen the National Health Service comes into operation,and this shortage cannot be overcome for many yearsbecause of the insufficient capacity of our medical schools.Until (if ever) there -is a surplus of doctors, every man orwoman who has passed successfully through a medicalschool must be regarded as a national asset. The effectof calling up men before military training is to subtractat least 18 months from their professional working lives,and such wastage of medical educational resources shouldbe avoided if possible. The Services may say that in

peace-time they could not find work for all the men whoqualify in medicine each year ; and the emphasis mighthave to be on training and observation of Service medicalmethods rather than on active employment for all. Butis there any reason why a considerable proportion ofthese young men should not be seconded for part of theirtime to the Colonial Medical Service or indeed to anyother national service which has need of them ’?The medical schools can turn out only a limited

number of doctors each year, and the greatest advantagewill be gained if these qualify at the earliest age that theyare competent for their work. Even with this principleconceded, they must still undertake " national service,"but we hope that in course of time the present narrowconnotation of that term will be extended (as it alreadyhas been with miners) and that it will come to includework in civilian hospitals abroad or even at home. Ifthe different Government departments begin to competefor the services of young doctors, the Medical PriorityCommittee would be the right body to judge betweenthem, and it will gain wide support if it tries to arrangea. realistic distribution.

THE STEVENS-JOHNSON SYNDROME

TiiE rare syndrome of which two examples weredescribed in these columns last week by Dr. Murrayand Dr. Nellen is one of the conditions which may leadthe doctor to suspect smallpox and the smallpox expertto say : " It isn’t smallpox, but I don’t know what itis." First noted in France in 1822 by Alibert and Bazin,it was not until a century later that Stevens andalohnson 3 in the U.S.A. clrew attention to its charac-teristic features-swinging fever, skin rash, stomatitis,and ophthalmia-though Hebra had included it in hisDiseases of the S’-kin, of 1866 under the name of erythemaexudativum multiforme.

It is found almost exclusively in boys or young men.The rash is usually but not always preceded by severaldays of gradually increasing cough, malaise, headache,and vomiting. The distribution of the rash is mainlyperipheral, the dorsum of the hands and feet, the forearmsand legs, and the face being the sites of election. It startsas macules or papules about 1.5 cm. across, each sur-rounded by a ring of erythema ; later, vesicles appear,followed by crusts which leave little or no mark. As arule the rash does not itch. For about the first week the

temperature swings between 102° and 105° F, after whichit falls to around 99° F. The most unpleasant and dan-gerous part of the illness is the swelling and infectionof mucous membranes, particularly of the conjunctiva,mouth, and urethra. The tongue and lips may swell to

2. Hoffstaedt, E. G. W. Ibid, p. 506.3. Stevens, A. M., Johnson, F. C. Amer. J. Dis. Child. 1922,

24, 526.

twice their normal size, and the eyes may be gummedup with pus ; the Rosenbergs draw attention to theair of dejection which these swellings give to the patient.Partial or complete blindness is a common sequel,resulting from corneal ulceration and scarring, bilateralsuppurative keratitis, and other causes.

So far, attempts at incriminating an organism havefailed-Vincent’s organisms have not been found

regularly in the mouth, fluid taken from a vesicle of oneof Dr. Murray’s cases proved negative when examined forvariola-vaccinia antigen, and no predominant organismwas grown from a purulent urethral discharge. The

aetiology must be regarded as unknown, though allergicsensitisation seems to be a factor. As regards treatment,there is not much evidence that the sulphonamides haveany specific effect ; whether the fall in temperature hadany association with the penicillin given in Dr. Murray’scase is uncertain. The most urgent measure seems to beprotection of the eyes.

THYROIDECTOMY OR THIOURACIL ?

DiscussiON of toxic goitre nowadays centres roundthe place of thiouracil in treatment. At the MedicalSociety of London meeting on March 10 the balanceof opinion was against thiouracil ; its drawbacks, saidDr. Horace Evans, are the risk of idiosyncrasy, the

persistence of the tumour, and the need for protractedtreatment. There is, he suggested, little to choose betweenthe results with thiouracil and those after subtotal thyroid-ectomy by an expert surgeon ; surely the short treatmentby surgery is preferable. In his view thiouracil has itsvalue in the preoperative preparation of iodine-sensitivepatients, and in the treatment of those who refuse

operation or are poor operative risks ; it is a substitutefor operation where expert surgery is unobtainable.

Mr. Geoffrey Keynes also preferred surgical treatment.He argued that the sustained use of thiouracil, which isa dangerous drug, must mean psychic trauma to bothpatient and doctor. Means, of Boston, found that thecondition after withdrawal of the drug was satisfactoryin only 10% of over 1000 cases ; and when the drugwas resumed toxic reactions became more frequent.Mr. Keynes mentioned cases in which thiouracil hasproved ineffective or actually dangerous. Some patientswith toxic goitre-particularly the nodular variety-get worse despite this treatment ; some are intolerant.of thiouracil; a pregnant woman treated with it maygive birth to a baby with a large thyroid ; and thereis a possible, though unproved, risk of carcinomatous

change. He preferred a carefully planned operation ; inover 2000 cases operated on at St. Bartholomew’sHospital, London, the death-rate was under 1%. Thetrouble with thiouracil is that it does not act on thegland ; by depriving the gland of iodine it stimulatesit to further activity. Preoperative treatment withthiouracil may prejudice surgical chances, for after thistreatment there is often torrential haemorrhage at opera-tion. Thiouracil may be of value in the preoperativetreatment of patients whose condition is really acute;otherwise its use means loss of time and effort, sincebefore operation its effect has to be damped down againwith iodine. To the question " Have we gained fromthiouracil " Mr. Keynes’s answer was : " While thedrug is being given with enthusiasm we have lost heavily.So far, on balance, there is a heavy loss."

This view was largely supported by the meeting ; forthe young woman with thyrotoxicosis, it was suggested," there is much to be said for leaving the invisible scarrather than the larger goitre." Dr. Evan Bedford’sfaith in surgery was unimpaired : " I cannot conceiveof the heart patient," he said, " who cannot be preparedfor surgery with iodine ; I go on with it,-if necessary, fora month." The aim, when there are cardiac c6mplica-tions, is not only to end the thyrotoxicosis but to produce