988 THE RECONSTITUTION OF THE ROYAL ARMY MEDICAL CORPS.

the diagnosis is made and the case notified the duties of thesanitary officers commence." Taken literally, and acted

upon, this statement of the position would in many cases

lead to disastrous consequences, and would probably bringthe medical officer of health into serious collision with thelocal authority employing him. The medical attendant of asick person must not shirk his responsibilities ; he mustnotify in the case of certain specified diseases, if in his

opinion his patient is suffering from one of them. Shouldhe fail to do so he is liable to prosecution, and for this veryreason, if he writes to the medical officer of health duringan epidemic of small-pox and gives information to thatofficial of a case with regard to which he declines to advance Ia definite opinion., he may almost be assumed to do so withthe knowledge of his position and of the danger of shirkingresponsibility should such responsibility really rest uponhim. It is, however, perfectly well known that errors of

diagnosis may be made, and, in fact, have been made, incases of small-pox, and that a wrong decision, resulting ina case of small-pox escaping notification and the measuresconsequent upon notification, may be a very serious matterfor the community at large. Mr. Wynter Blyth’s view, asexpressed in his own letter without qualification, is that thediagnosis of cases is no part of the duty of a medical officerof health. As we have suggested, he may depart from it inpractice, but, taken merely as an academic statement ofprinciple, it will hardly bear investigation. He is not, of

course, to be regarded as a consultant who may be called inwhen any practitioner is in doubt; but he, for example, wouldnot, either in theory or practice, be justified in sending to asmall-pox hospital and otherwise dealing with a case

notified as small-pox if he felt sure that the medical manwho had certified it had done so in error, while the course hewould thus take would be the result of his own diagnosis.Again, it is the duty of a medical officer of health, beyond allquestion, where he has an admitted case of small-pox to traceits origin and to ascertain, if prssible, whether other personsmay have been infected by it. If in the course of such an

investigation he finds that the patient has been in frequentcontact with a person who in the opinion of a medical practi-tioner is at the moment suffering from chicken-pox, can themedical officer of health in such a case say that diagnosisforms no part of his duties or that they only begin after thediagnosis is made by someone else and the disease notified?It is not easy to define where the duties of a medical officerof health either begin or end at any time, and during theoccurrence of small-pox in his district their limits maybe said to extend themselves. They include the searching 1out-and, if possible, the stamping out-of the disease inhis district, and they involve cooperation with everyone jwho will assist in the task in his district or else- <where. If a medical practitioner informs a medical officer <of health that a case under his treatment may be small-pox <and declines to certify it as such he may be evading a duty duty whieh the law imposes on him, and whether he be doing 1

so or not is a question of fact, though not perhaps (

an easy one, which a magistrate may be called upon <

to decide. He may, on the other hand, be giving I

the earliest possible information as to a case in which

’early information is of the utmost importance and of t

which early information should beyond all question be given, f

even if it does not take the form of a certificate. That Dr. f

Roxburgh could not be blamed for not giving a certificate a

when he made his first communication seems clear from the t

fact that after this Dr. Greenwood saw. the patient twice with e

.an interval of several hours between his visits before she 1was removed. We have commented on Mr. Wynter Blyth’s t

letter, not because we have any fault to find with his 1=conduct, but because the second passage which we quote c

from his letter seems to suggest the view that Dr. c

Roxburgh would have done better to have waited until he 1:

was prepared to enunciate a definite opinion embodied in acertificate, and that the St. Marylebone Borough Council, act-ing through their medical officer of health, would have beenmorally or legally justified in not acting until such a cer-tificate was given. Neither of these views could be upheldfor one moment, and the occasion is one for cooperationrather than for discussion.

THE RECONSTITUTION OF THE ROYAL ARMYMEDICAL CORPS.

I IT may be well to make it known to would-be candi-dates for admission to the Royal Army Medical Corps thatthe reconstitution scheme drawn up by Mr. Brodrick’s Com-mittee, the full text of which was published in our issue ofOct. 5th, p. 929, is only a sclwme. Before it can be acted

upon or taken advantage of it will have to appear as a

Royal Warrant. Before this happens the outline scheme aspublished may be modified or amended in various ways. It

is therefore quite useless for anyone to write or to call atthe office of the Army Medical Department for informationconcerning the date of the next examination or any otherpoints in the scheme, for nothing more is known than has

been already published, and any letters asking for furtherinformation are merely a waste of time on the part both ofthose who write and of those who receive them.

DIFFERENTIAL DIAGNOSIS BETWEEN SMALL-POXAND CHICKEN-POX.

IN another column we publish a letter from a correspon-dent drawing attention to the fact that the vesicles in

chicken-pox are unilocular, whilst in small-pox they are

multilocular, so affording a valuable differential test betweenthe two diseases. As has been shown in the present out-

break of small-pox the diagnosis between that disease andchicken-pox is of considerable difficulty and, needless to

say, an error may give rise to grave results, not onlyto the individual affected, but to the community at large.There are other differences between the two of which

we may remind our readers, more particularly as the

younger generations of practitioners have not had many

opportunities of observing cases of small-pox. The initial

symptoms are not so marked in chicken-pox-indeed, theymay be entirely absent, whilst in small-pox the constitutionalsymptoms appear early and there is high fever. It is, how-ever, to the eruption that most attention is naturally directed.In chicken-pox it is most abundant on the trunk and is less on

the face and extremities. It is discrete and may appear in one

crop or in successive crops, during a period of from one tofive or more days. In small-pox the eruption is most

abundant on the face, arms, and legs ; moreover, there is

a characteristic fall of temperature after the appearanceof the rash. In chicken-pox the eruption is at first

macular or papular, but becomes vesicular within a fewhours. The vesicles vary in shape according to the partof the body on which they are situated, being oval on thechest, abdomen, and back, circular on the scalp, and irregu-larly round on the face, whilst on the arms and thighs theyare mostly circular. The vesicles likewise vary in size onthe various regions. They are clear, bright, and shiny andfilled with a clear fluid. In small-pox the eruption is nofully vesicular within from six to 12 hours of its appearance,and the vesicles when formed are not oval. Previous vaccina-tion frequently changes the characteristics of the small-poxeruption. Dr. J. MacCombie, writing in Professor CliffordAllbutt’s "System of Medicine," also points out that onthe extremities the similarity of the vesicles of chicken-

pox to those of modified small-pox usually increases i.direct ratio to the distance from the trunk. In manycases of chicken-pox the vesicles on the forearms, legs,backs of the Hands, and back and dorsum of the foot