105.A CENTRAL OPHTHALMIC SCHOOL FOR LONDON.

3465 ; pleuritis, 2947; simple quinsy, 2745; and rheumatoidarthritis, 2517. ’

The aggregate number of deaths among the troops in 1891 was 1978, or 9 per 1000 of the mean force ; the officers of the Istanding army who died were 124. Deaths by infective dis-ease underwent some increase ; on the other hand there wasa diminution in tuberculous cases and suicides. The propor-tion of these was 0-33 per 1000.The garrisons on the Red Sea littoral gave an average of

11 ’75 sick per 1000 of the force, which, excluding the indige-nous soldiery, had a mean of 2603 men, with a maximum of36 48 in March and 17 -96 in number during October.To the admissions into infirmaries and hospitals during

1891, adding 157 remaining over from December, 1890, thereis, for the garrisons of the Red Sea littoral, a total of 3215under treatment, of whom 1439 were hospital and 1776infirmary patients.The losses by death during 1891 were, on that littoral, 36

in all-that is, one officer and 35 men.The average of the mortality of the troops was hence in the

aggregate 19-4 per 1000 of the force, while with restrictedreference to the sick under treatment in hospital and infir-mary the mortality itself is reduced to 9’7 per 1000-that is,9’5 in hospital and 9 9 in infirmary.Comparing the figures above given with the correspond-

ing ones of the year before, it is seen that in 1891 the sanitarycondition of the troops on the Red Sea littoral was some-what improved, if not on the side of disease, at least on thatof death.To aggravate the death-rate in 1891 the cholera made its

special contribution. From this epidemic, though muchrestricted and of very brief duration, there died six. De-

ducting these, the mortality of the troops remains 11 ’1 per1000 of the force.The greatest amount of disease was in November, a fact

attributable to the exceptional development of malaria insome garrisons and of rheumatic fever in others, due to theinclemency of the season.

Dr. Santanera’s report contains other matter of much

sanitary interest, civil as well as military. But the statisticsabove given exhaust the details bearing particularly on the health of the Italian army. I

A CENTRAL OPHTHALMIC SCHOOL FORLONDON.

BY SYDNEY STEPHENSON, M.B., F. R. C. S. EDIN.,SURGEON TO THE HANWELL OPHTHALMIC SCHOOL.

THE proposal to isolate cases of ophthalmia, in an institu-tion where treatment might be carried out together withschooling, was advanced twenty-four years ago by the lateMr. Critchett. It has been urged since then by Dr. Bridgesand by Mr. Nettleship and also by Mr. H. J. Searle, chair-man of the Central London School District. A practicalattempt at dealing with epidemic ophthalmia was madein 1886 at the Norwood Schools, which belong to the

parish of Lambeth. The guardians engaged my servicesand placed at my disposal a modern building and a

good staff of nurses. After two years I was able to saythat the attendance of an ophthalmologist was no longerrequired. As regards other parochial schools it is not

going too far to say that ophthalmia has more thanonce given grave cause for anxiety in every one ofthem. This has been specially the case at the Strandand the Forest Gate Schools, where steps have beentaken involving the expenditure of considerable sums

of money. Furthermore, it is practically certain thatunder present conditions they will never be safe from futureoutbreaks. Indeed, the necessity for dealing with the diseasein a radical manner must by this time be obvious to mostpeople, and it appears to me that the present is a particu-larly opportune moment for urging the claims of a centralophthalmic school. An ophthalmic school was erected twoyears and a half ago at Hanwell to receive 400 children, butfor some time past it has contained less than 100 patients.This waste of accommodation led me in J’uly last to suggestin my report to the managers that they should throw opentheir institution to other metropolitan unions. Shortlyafterwards the Local Government Board made a similarsuggestion, which the Hanwell managers, however, professthemselves unable to adopt. At the same time they arewilling to dispose of the buildings to any properly consti

tuted authority, but, so far, no answer has been received fromthe Local Government Board to the latter proposition 1From a report published by Dr. Bridges in 1890 one learnsthe significant fact that during the previous seven years not.a single parochial school remained wholly free from oph-thalmia. Tables appended to that report show the numberof children invalided by the disease on fourteen specifieddates between the years 1883 and 1889 inclusive, and a,.

calculation of some interest may be readily made from thetdata thus supplied. To obtain the following figures I havetaken the average number of children and the averagenumber of ophthalmic cases for the seven years coveredby the report, and from these have calculated the averagepercentage of ophthalmia for each school. The results.arrived at are suggestive. Hanwell heads the list with anaverage of 16 per cent. ; Norwood comes next with 9 per-cent. ; Edmonton and Sutton, 5 per cent.; Banstead-road,Leavesden, and Brentwood, 3 per cent.; Anerley and Harold-Court, 2 per cent. ; Ashford, Forest Gate, Leytonstone,Southall and Mile-end, 1 per cent.; and lastly, remaining-institutions showing less than 1 per cent. of ophthalmia.It is interesting to observe that on the last date given-by Dr. Bridges (July 6th, 1889) no less than 598 cases ofophthalmia were under treatment in the various schools.During the last two years the City of London and theparish of St. Saviour’s have sent to the Hanwell Ophthalmic.School 128 affected children, only 28 of whom had previouslybeen inmates of a pauper school. Again, a considerable numberof children suffering from ophthalmia are at this moment de-tained in the Lambeth workhouse and infirmary because themedical officer at Norwood very properly refuses to admit,such cases into the school. These facts show that amongthe fresh admissions to the London workhouses are a numberof children who have already contracted the disease outside."Granular lids," as most people know, drags its tediouscourse over a number of years, so that cases must accumulatein the infirmaries. On the other hand, to send affectedchildren to schools that have not proper accommodation’would be to court disastrous outbreaks of ophthalmia. A-central ophthalmic school would receive not only existingcases of ophthalmia from the various schools, but also allchildren thus affected on admission to the workhouses.The metropolis has upwards of 11,000 pauper children dis-tributed amongst eighteen schools belonging to differentunions. Each school has therefore to deal with its ophthalmic.cases as best it can. - Complete isolation is now admitted to,be essential for the prevention of ophthalmia, but it is clearthat in most schools such isolation is at present impossible.When an outbreak occurs the infirmary becomes quickly filledand the children overflow into the school itself. It is possible.that some at least of the widespread outbreaks recentlywitnessed would never have taken place had a systemof rigid isolation been consistently in force. Should a.

school determine to grapple efficiently with ophthalmia.the attendant expenses will necessarily be heavy. At Han-

well, for instance, upwards of :E30,000 has been spent OIl

the erection of a suitable isolation school, while at least£4000 have been expended on salaries already. The direct andindirect expenses of the recent outbreaks at Norwood, ForestGate and Edmonton must have been proportionately heavy.The certainty of incurring pecuniary burdens of this sort is

scarcely calculated to encourage action on the part of boards.of guardians ; yet it is obviously to the interest of the com-munity that such steps should be taken. Individual boards,however, would feel no hesitation in sending affected childrento a central institution to which each union contributed.

Regarded from an economic standpoint a central schoolwould be more efficient and less costly than would be possible-in any scheme initiated by a single union.Turning now to the educational aspect of the proposed

scheme it can hardly be questioned that teaching would bebetter carried out in a well-equipped central school than could,possibly be the case in scattered buildings set apart haphazardfor diseased children. At Hanwell the majority of the

patients have been found able to accomplish twenty-threehours’ schooling a week, and at the examination recently heldby Her Majesty’s inspector they obtained 90 per cent. of

passes. If local treatment be persevered with, I find thatophthalmic patients are capable of undergoing almost as

1 Since the above was written three metropolitan boards of guardianshave formally approved the scheme of central isolation for ophthalmicchildren. These boards are Lambeth, Camberwell and Bethnal green.The last has attempted, indeed, to open up direct negotiations with theHanwell managers.

106 THE CONFERENCE ON CHOLERA IN ST. PETERSBURG.

much schooling as ordinary children, and in organising any- scheme of tuition that fact should be kept in view.

The question remains as to what body is to assume thereins of government. It is to be hoped that the MetropolitanAsylums Board, which already controls numerous medicalinstitutions, will see its way to take this added responsibility,- otherwise it would be feasible to create an entirely newauthority consisting of representatives from all the unionsinterested. In whatever hands the management may ulti-mately be vested, it is, I think, of great importance that thewhole of the metropolitan schools should be in touch with the proposed institution. To secure that end it would be well- two maintain the school, not by contributions from individualunions, but directly from the Metropolitan Common PoorFund, thereby spreading the charge over the whole Londondistrict.

The adoption of a scheme for the collective treatment ofophthalmia, such as I have outlined in the above remarks, is, Iwould submit, a matter of pressing importance. Such a scheme,placed on a sufficiently broad basis, appears to offer the onlysatisfactory plan of coping with a disease that has been a’scourge in the pauper schools of London from time im-memorial. A suitable building is ready and waiting at Han-well. Should not advantage be taken of so hopeful an oppor-tunity ? It would be the conversion of a scientist’s visionunto a substantial, a praiseworthy and a salutary reality.

Welbeck-street, W.

THE CONFERENCE ON CHOLERA INST. PETERSBURG.

(FROM OUR SPECIAL CORRESPONDENT.)(Continued from p. 52.)

DR. GREBENTSCHIKOFF, continuing his statistical accountof the epidemic and of the mode of its dissemination, statedthat the first case of cholera in Russia occurred in Kaachka, a station on the Transcaspian Railway, on May 19th (31st).The channel by which the infection crossed the frontier isr--Lnknown. Many other parts of the Transcaspian and Samar- cand provinces were affected in May and June, and fromJune 6th (18th) suspicious cases began to be admitted intothe Baku hospitals. How the disease reached Baku is un-known, but there is evidence that the first patient there was.a foreign labourer, who had come from Persia through the’Transcaspian province and who stayed at a certain house inBaku which became one of the chief centres of infection in’that town, furnishing no less than forty patients in the firstweek of the epidemic. The disease raged violently in Baku,.and the panic-stricken inhabitants Red in all directions,carrying the infection with them. In the first half of June’cholera had affected most of the towns lying on the CaspianSea and had penetrated into the Caucasus. Thence ittravelled to Europe by two great routes-on the one handby the Volga and on the other by railway to the basinof the Don, the first of these being by far the quickest.’The speaker proceeded to trace the course of the epidemicby each of these routes, enumerating the "governments" orprovinces affected during each succeeding month. He"exhibited the following table, showing the area and popula-tion of the districts in which the disease was present during- each of the months from May to November. The whole ofthese immense areas was of course not actually affected bycholera. Many large districts remained free from the disease,but every "government" has been included from which areturn has been received, although only one "uyezd"(district) or even only one village in the "government " mayhave suffered from the disease. With this limitation thedisease was present:

In May over 484,000 square versts with 700,000 inhabitants.In June ,, 2,753,000 " 15,286.000 "

In July 7,271,000 " 63,466,000 "

In Augtxst 7,645,000 " " 77,895,000 "

In September 7,868,000 " ,, 87,346,000 "

In October 6,965,000 " 87,725,000 "

In November 1,662,000 " 69,787,000 "

The disease has spread mainly along the course of the rivers ;it affected the whole systems of the Volga, the Don, theDnieper, the Ural and the Obi, every part of the CentralAsiatic provinces, the systems of the Vistula and WesternDwina and finally the whole of the St. Petersburg districtand two ’’uyezds

’’ of the Olonetz governments.

From a table of the numbers of cases and deaths reportedfrom every government throughout the Empire to the

beginning of December it appeared that the Caucasus sufferedmost severely from the epidemic, the second in order of

severity being the Central Asiatic provinces, the thirdSiberia, particularly the government of Tobolsk, and finallythe country of the Don Cossacks and the following Europeangovernments : Astrakhan, Saratof, Samara, Simbirsk, Voronej,Orenburg and Tambof. Charts were shown indicating by curvesthe course of the epidemic week by week in every government,and from these it appeared that the cholera rapidly (in thecourse of two or three weeks) attained its greatest intensity,that it remained at this height for one or two weeks, and thenin a few districts gradually subsided; but more often therewas a remission lasting one or two weeks, then the curve againrose. the second rise being followed by a gradual fall. In cer-tain towns even a daily chart showed a similar double rise andremission. The means by which cholera was introduced intoa given locality have remained in the immense majority of casesunknown. In twenty-eight governments, however, infor-mation had been furnished to the Medical Department on thispoint, and the speaker proceeded to repeat in detail each ofthese cases. The general conclusion to be drawn was thatpollution of the drinking-water was in almost every case thechannel by which the disease was spread.

Professor Janson, the Professor of Statistics in the St.Petersburg Academy and author of several importantworks on economical questions, read a short but interestingpaper on the Value of Statistics. He pointed out the import-ance of recognising the first case of cholera or any otherepidemic disease. The only certain means of doing this wasby a thorough and constant system of notification and registra-tion of all diseases, more particularly of infectious diseases.He recommended the adoption of registration of deaths suchas is in use in all Western European countries. He alsodwelt on the necessity of recording all the circumstancessurrounding every case of an epidemic illness, as only in thisway can general conclusions on any particular point bearrived at.A paper was read by Dr. Tolstoi on Precautionary Measures

directed against the Dissemination of Cholera. In discussingthe question of quarantine he pointed out certain anomaliesin the quarantine laws existing in ports on the Black Sea.

The efficiency of cordons, the medical inspection of pas-sengers, the disinfection of luggage, the measures taken alongthe rivers, particularly the Volga, were all briefly reviewed.The following questions were submitted to the conference fordiscussion in committee :-(1) Quarantine regulations, cordonsand military isolation of places ; (2) "observation points ;"(3) general inspection of passengers ; and the followingadditional points-(a) the means of determining the first caseof cholera ; (b) the means of localising the infection.An important communication was read by Dr. Rozanof on

General Precautionary Measures before the appearance ofCholera. He discussed the efficieneyof the special Sanitary Com-missions and their relation to the sanitary authorities alreadyin existence. These commissions, it should be explained,were formed early in June, in accordance with a Governmentorder, in every town forming the centre of a "govern-ment" or uyezd throughout the country, with the object ofimproving the sanitary condition of the town and districtbefore the approach of the epidemic. On this subjectDr. Rozanof put the following questions to the conference :1. To what extent are special sanitary commissions necessaryin the struggle with the epidemic in view of the other

sanitary authorities already existing ? ? 2. How should suchcommissions be constituted ? ? 3. What should be their rela-tion to the Government and local authorities ? ? 4. Whatshould be the limit of their powers and what is to be thesource of their revenue ? ? 5. What should be the relationbetween the Sanitary Commissions and the Medico-StatisticalBureaux 6. What should be the organisation and the dutiesof subcommissions ? (Last summer subcommissions, con-

sisting of sanitary and police inspectors, were formed in eachquarter of the larger Russian towns to inspect and improvethe sanitary condition of every building in that particularpart of the town.) 7. What should be the number and con-stitution of the bodies of sanitary overseers, inspectors &c.,and their relation to the police’! ‘? Passing on to discussthe many questions relating to the sanitation of in-habited localities Dr. Rozanof pointed out that whereverthe sanitary condition of a town or district had been

satisfactory the cholera epidemic had either passedit by altogether or claimed but few victims. He deplored the