AN EPIDEMIC OF ACUTE OPHTHALMIA.

444 follows : boys, 328 ;girls, 240 ;and the Roman Catholic schools accommodated 180 children. There was no evidence of overcrowding in the schoolrooms and Dr. Peck, who frequently visited the schools, had no fault to find with the cubic space. The intercourse of the children occurred in the schoolrooms and playgrounds.’ There was a washing place in the boys’ school but it was in a separate building. Any boy requiring to use it was obliged to obtain the key from the master and consequently not one a week applied for it. This arrangement, though open to objection on some grounds, for the purpose of our present inquiry excluded the propagation of the disease at the thinking. Curzon-street, W. boys’ school either by towels or washing basins. In the girls’ school there was a washing place in the lobby and it was therefore more used. It has been mentioned that a AN EPIDEMIC OF ACUTE OPHTHALMIA. large number of those afflicted were brought together for examination. These exemplified the characteristics of the BY SIMEON SNELL, F.R.C.S. EDIN., epidemic and showed how widely spread it was. Altogether OPHTHALMIC SURGEON, ROYAL INFIRMARY, SHEFFIELD ; PROFESSOR 24 families were represented. In many instances one or OF OPHTHALMOLOGY, UNIVERSITY COLLEGE, SHEFFIELD. other of the parents attended with their children, in others the children came by themselves. The cases examined and EPIDEMICS of ophthalmia attacking large numbers have the evidence ascertained as to other members of the same at different times been recorded. These have often been con-families disclosed a total of 68 afflicted, and practically the nected with military establishments or other institutions whole of these had occurred within the previous fortnight. Some interesting information was obtained as to the numbers where people have been congregated together. The disease affected in different families. Frequently one or other of the in these epidemics has been trachoma or granular ophthalmia parents, usually the mother, had been affected as well as the and the disastrous and far-reaching effects of this dire disease children. In two families five children and the mother had have been well exemplified in many such outbreaks. Other suffered, in another six and the mother, whilst in one no less and the mother had been afflicted. The epidemics of less severity have also from time to time been than ten children in other families was noted as follows : four recorded. In 18941 I related at some length particulars of prevalence children and the mother, three children and the mother, an outbreak of ophthalmia in a good-class boarding school three children and the father, and three children alone. which affected large numbers and led to the temporary The fact that the sanitary inspector, with the help of the breaking up of the school. A well-known surgeon who was schoolmaster and school attendance officer, was able at less in after I had first on the was of outbreak called reported than 24 hours’ notice to collect this large number of afflicted opinion that the disease was trachoma. The sequel, however, families gave unmistakeable evidence of the widespread showed the correctness of my first opinion that it was a less extent of the epidemic. It appeared an inside estimate to say serious disease and that it was more of the nature of that that 200 persons must have been afflicted with the disease. as follicular conjunctivitis. described by Fuchs and others that on the day following Dr. Peck wrote me later to Those interested in the subject of epidemic ophthalmia may our examination he had comesay across nine additional cases find the account of this outbreak and the means adopted for attending other schools. The character of the disease was its eradication worth perusal. the same in all-muco-purulent or catarrhal ophthalmia. The outbreak now to be described is, so far as I am aware, The cases examined were in various stages of the disease; a rare and unusual one both from the numbers affected and some were very acute, with swollen eyelids and free disIt the character of the disease. spread very rapidly and in of flakes of muco-pus, whilst others had passed such a way that admitted of no question of its contagiousness charge this through stage and the thick discharge had ceased. In and quickly subsided when measures to combat it were this no case was the cornea On the

of preventing gangrene in a case of ligature of a wounded femoral artery. Another surgeon, L. Isnardi8 of Turin, finds that the application of an Esmarch’s bandage before changing the dressings of large wounds or burns obviates the distressing pain and bleeding otherwise unavoidable. Other developments will doubtless follow in the department of medicine and in connexion with cutaneous affections. But it remains a problem whether, and in what form, the principle may be made available for other districts than those of the limbs. In conclusion, I gratefully trace to H. Cushing’s paper the original impulse and to George Oliver’s most instructive work much of the growth of this

them

was

given

infants, 400.

me as

In

addition,

day following adopted. Everyone seeing much of ophthalmic practice, examination, however, implicated. I saw a woman from the same district especially among hospital patients, is accustomed to observe suffering from the disease. It was very acute in both eyes instances of muco-purulent or catarrhal ophthalmia and is and the The cornea in one eye was was plentiful. aware also how highly contagious a disease it is. Not in- affected.discharge Her recovery was, however, excellent. In all the frequently several members in a family will be afflicted. A cases both eyes, so far as I could learn, were affected. The case coming under observation leads to inquiry as to others but Koch-Weeks bacillus was found with the being affected and to instructions being given for preventing attempts to obtain cultures failed. Thismicroscope failure with the extension of the disease. It is very rare, however, for I understand, is not infrequent even when the the affection to spread in a community to such numbers as cultures, bacillus is detected with the microscope. The specimens was the case in the outbreak which I am about to describe. for examination were taken from the woman just referred to On May 5th of the present year I received a communica- in whom the disease was in the acute stage and was typical tion from Dr. H. Peck, medical officer of health to the Chesterfield rural district sanitary authority, informing me that a serious outbreak of contagious ophthalmia had occurred at Staveley, one of the townships of his district, and desiring me to consult with him as to the nature of the epidemic and the steps to be taken to eradicate it. On the day following we accordingly met at Staveley. A large number of cases were gathered together in one of the schoolrooms for examination. Before, however, referring to these it will be well to give some particulars of the outbreak and of the sanitary aspects of the district. Staveley is a township with about 12,000 inhabitants and Dr. Peck informed me that the district was a very healthy one. The first case of ophthalmia occurred about three months before our visit and since that time others had appeared in the same district and later in other parts. Recently the number affected and the absentees thereby of children from school had rapidly increased. The sanitary inspector had, therefore, specially reported the matter to Dr. Peck on May 5th. Those mostly affected were children, but the epidemic implicated people of all ages, amongst whom was a female teacher. The Staveley elementary schools are national schools and the number of children attending ’

8

1

Ibid., June 22nd, 1904. Brit. Med. Jour., Nov. 17th, 1894.

of the outbreak. The investigation at Staveley thus clearly established the nature of the disease, its extremely contagious character, and the widespread prevalence of the epidemic. It will have been noticed that the great bulk of those afflicted were children of school age. They were, whilst the disease was acute, physically unfit for school and had been usually kept at home by their parents. It did not appear therefore absolutely necessary for the present to close the schools and I reported to the sanitary authority that if other measures were at once adopted it was to be hoped that the epidemic would cease without resort to such a procedure. It was pointed out that many of the cases examined were in a very acutely contagious condition and all the others were more or less so and that it was necessary to recognise how very contagious the disease was. The smallest particle of the discharge reaching a healthy eye would speedily affect it. Many of the cases were fortunately making a good recovery but it was necessary to bear in mind that in others sight might be endangered and that therefore the need for treatment should not be forgotten. The following suggestions were made : 1. That a notice should be issued by the medical officer of health setting forth the contagiousness of the disease and the necessity for separation, as much as possible, -of the affected from the healthy

445 children. The importance should be urged of the use having hardly doubled in 65 years. During the period from Linen used for the 1840-1901 the cancer mortality has increased nearly five,of separate towels, handkerchiefs, &c. children’s eyes should be destroyed. Parents before and fold-viz., from 177 per 1,000,000 living to 842. In all after giving attention to the children’s eyes should be modern civilised communities a similar tendency is noticecareful to wash their own hands. It was better for the able, especially as regards cancer, the incidence of the children to wash with running water at the tap than malady doubling in frequency in periods of from 20 to 30 The disease might be spread by others years. This tendency seems to be of comparatively recent from basins. water which one affected had previously origin. At any rate, cancer is a disease of great antiquity the same using used. 2. Any child suffering from the disease should and is known to have existed from the most remote times be kept from school and not allowed to return until all of which we have any record. The "Papyrus Ebers,"which discharge from the eyes had ceased. 3. The necessity for is believed to have been written about 1550 B.C., contains a treatment should be pointed out to the parents and they short section on malignant and other tumours, from which it should be advised to apply to a medical man as soon as the may be inferred that the cardinal features of these maladies disease commenced. Speedy treatment would not only avert were then well recognised. In the works of Hippocratesthe disease and its danger but would also shorten its dura- who is supposed to have flourished during the latter part of tion and tend to prevent the spread of it. 4. The importance the fifth century B.C.-malignant and other tumours are of

preventing the children using the towels in the schools impressed upon the schoolmaster and this would doubt-

was

less be carried out. With the greatest promptitude after our consultation Dr. Peck issued a printed notice which admirably expressed the salient points. It ran as follows :ACUTE COKTAHIOUS OPHTHALMIA. This disease being prevalent in Staveley, parents and guardians are advised to take particular care that any one of their children who is affected shall not be allowed to use the same towel as other children. The principal symptoms are, a dislike to look at light, redness of the eyes, and a discharge from the eyelids. Every case should be seen by a medical man, as there is danger of loss of sight. Children suffering from the complaint must not attend school. HERBERT PECK, M.D. (Signed) Medical Officer of Health.

These notices were posted in different parts of the district and distributed by means of the scholars of the seven schools within three miles of the affected area. The warning given to, and the distribution of 1500 of these handbills by, the scholars no doubt aided very materially in limiting the spread of the epidemic. A zone was formed beyond which it was thought the disease was not likely to extend. It is satisfactory to note that the means adopted were successful and that the epidemic was soon at an end. Fresh cases arose but with less frequency. On June 6th, a month after our visit, the schoolmaster wrote saying that the attendance officer had not heard of any fresh cases and that he himself had only noticed two cases recently. Dr. Peck informs me that he saw two cases on June 7th which were then subsiding. Since that date he has neither seen nor heard of any others. I feel that much is due to Dr. Peck for recognising the seriousness of the epidemic and for the promptitude with which he aided in the adoption of measures for its eradication. Sheffield. __________________

THE PREVALENCE OF CANCER AND ITS INCREASE. BY W. ROGER WILLIAMS, F.R.C.S. ENG.

referred to. In the somewhat detailed enumeration of the various maladies prone to occur at the different periods of life which is embodied in the "Aphorisms"" no mention is, how-’ever, made of cancer. From this omission and from the comparative paucity of the references to cancer in the Hippocratic writings I conclude that this affection must then have been comparatively rare. We have but little trustworthy information as to the prevalence of cancer in England during the Middle Ages and at earlier periods, yet it is probable that it was then of much less frequent The exceptionally welloccurrence than in recent times. kept registers of Market Deeping (Lincolnshire) during the years 1711 to 1723, in a total of 387 deaths, show only two from cancer (one male and one female). STATISTICAL SUMMARY. In the very earliest years of registration, before the enumerating machinery had been perfected, the data elicited may have left something to be desired. We will therefore commence our study with the year 1840 when the national statistics, under the able guidance of William Farr, had already acquired well-deserved reputation for reliability. In that year 2786 persons died from malignant disease in England and Wales, the proportion being 1 in 5646 of the total population, 1 in 129 of the total mortality, or 177 In 1901 the deaths due to this per 1,000,000 living. cause numbered 27,487 being 1 in 1186 of the total population, 1 in 20 of the total mortality, or 842 per 1,000,000 living. In this respect the position occupied by malignant disease is unique, for no other malady can show such a great increase. Whatever the etiological factors of cancer may be it is thus evident that they are not constant in action and if capable of exacerbation in some circumstances they may be amenable to diminution in others. In further illustration of this subject I have compiled the following table which shows the decennial increments of increase during the long succession of years.

IT is stated that as the result of its investigation into this matter the Imperial Cancer Research Fund has come to the conclusion that the data upon which the mortality statistics are based indicate that there has been no real increase of cancer. As I believe this conclusion is entirely erroneous I now propose to challenge it with a direct negative and in support of this position I beg to submit the following evidence which, after weighing the subject in all its bearings, seems to me to be absolutely conclusive.

PRELIMINARY REVIEW. organic evolution some types of diseaselike species-have diminished and become extinct, while others have increased and become more prevalent. In comparatively recent times plague, typhus fever, leprosy, malaria, scurvy, and dysentery have almost or quite disappeared from our country ; small-pox and other zymotic diseases have greatly diminished ; while phthisis and other tuberculous affections are decidedly on the wane. On the other hand, a small group of maladies, of which cancer is the chief, have steadily increased, and this in spite of progressive diminution in the general deathOf the other members of this group insanity, rate. suicide, alcoholism, and diabetes are the chief ; while to these may be added diseases of the circulatory system, premature births, and congenital deformities. Coincidently with these changes the population has slowly increased, In the

course

of

THE REALITY OF THE INCREASE. With these figures before us, and all that they imply, there can be no doubt as to the reality of the increase in the cancer mortality. Yet this has been called in question. The earliest objectors ascribed the registered augmentation to mere increase of population ; but the futility of this quibble is demonstrated by the fact that while the population has barely doubled (1850-1900) the cancer mortality has trebled. Next, the attempt was made to explain the increase as due to the average age of the population having advanced and the consequent liability of greater numbers. To this the answer is, that the saving life in modern times has mainly been confined to the pre-cancerous years of existence, the death-rates of males over 35 and of females over 45 having remained almost stationary, while the numbers attaining old age has decreased. Hence, only an infinitesimal fraction of the increased cancer mortality can