757 is the right path remains to be proved, and will in the very with a word of encouragement pass on to his next patient.- nature of things require about ten years to show results. Although district nurses have been here and there available- My own, in spite of war food difficulties and influenza, show and they have done splendid work under trying conditions- this year so far a reduction of 20 per cent. on the mortality yet for many cases an occasional visit from a kindly neigh- of 1914, and the more serious cases are undoubtedly bour has been all that has been possible. The civilian diminishing in the district. It is bad policy for those population has suffered severely, not so much because we- who have so far admitted failure to condemn a method have been unable to make up our minds as to the actual before a reasonable test has been made. War should causative agent of the disease, or whether one should surely have taught us not to condemn new methods before administer a dose of 10 million or 500 million dead influenza’ trial where present procedures are not equal to the under- bacilli, or even because we have been unable to provide a taking. I trust Dr. Jessel will continue and give us the definitely curative agent against the virus, but rather owing results of his increased home supervision. to the distress and misery caused by the apparent helpless- ness of the public health, Poor-law, and hospital authorities- To the Editor of THE LANCET. to do anything adequate to deal with a situation where and care an SIR,-Your issue of Nov. 16th contained an interesting nursing of acutely ill people have been urgent letter from Dr. F. E. Wynne, medical officer of health need. The of have been failure to of Wigan, on the subject of dispensary supervision in difficulties, course, great, but- pulmonary tuberculosis. Dr. Wynne maintains that con- cope with the problem has obviously been due to want of rather than sumptives in Lancashire will not, or do not, carry out organisation of beds, doctors, and nurses. The- war has that in the hands a such common-sense hygienic methods as they have been clearly demonstrated of central can overcome and the- taught to do. I have, of course, no knowledge of the authority organisation everything, medical and have county borough of Wigan, but as regards the administrative nursing professions been able to success- meet In one county as a whole I am convinced Dr. Wynne underrates fully situations of unparalleled difficulty. way, the has done It the average intelligence of Lancashire men and women. therefore, epidemic good. has proved the need for an efficient Medical It is a mistake to take dispensary supervision or any urgent State Authority. The existence of such an would have made it other single item in a comprehensive scheme and expect authority possible the death-rate from tuberculosis to be much raised or for a clear-cut line of campaign to have been immediately It would have that loivered as a consequence of its adoption. In Lancashire, in instituted. been possible for authority to have at once ordered the of 1917, no less than 256 persons died from pulmonary tuber- closing every hospital and culosis who had not been notified, 19 died before receipt of infirmary bed to all but urgent cases. In this way wards notification, and 433 within three months of notification. could have been set apart and nurses set free for the care of numbers of infLuenzal Under such con- Such a reservoir of infection, coupled with other war condi- large pneumonias. it to to tions, makes a much smaller death-rate compared with pre- ditions would have been reasonably possible attempt out Horder’s most excellent of war years most unlikely, but surely every effort to enable carry Sir Thomas principles treatment and so the a better and at persons suffering from open consumption to have a separate give patients chance, the same time to have saved families from the distress bedroom, as carried out so admirably by Dr. Jessel and the many and to look after ill other county tuberculosis officers in the county areas under misery produced by attempting acutely their charge, helps in the right direction and not in the relatives under conditions that are all against recovery. I wrong -I am, Sir, yours faithfully, am, Sir, yours faithfullv. G. LISSANT COX, Leeds, Nov. 25th, 1918. C. W. VINING, M.D. Central Tuberculosis Officer, Lancashire County Council; I Medical Adviser, Lancashire Insurance Committee. OF County Offices, Preston, Nov. 25th, 1918. PARLIAMENTARY REPRESENTATION DUBLIN UNIVERSITY. TREATMENT OF INFLUENZA. To the Editor of THE LANCET. To the Editor of THE LANCET. SIR,-I wish to remind medical graduates of Dublin that recent all who SIR,—Sir Thomas Horder’s stimulating article upon the University by legislation graduates their names have the to the franchise is treatment of influenza in your issue of Nov. 23rd will, no register right vote ; not, as heretofore, confined to holders of the doubt, have been read with interest by many of those who higher degrees. In order to a not should are in with the from the register, graduate already registered engaged dealing epidemic purely send without to the Assistant of clinical side. He rightly points out that there are no delay Registrar University Dublin : his name in reliable short cuts in the treatment of these cases, and Electors, Trinity College, (1) full; (2) his of a declaration emphasises the great importance of skilled nursing and address ; (3) the registration fee £1; (4) that he, or she, is of the and a British efficient treatment on general lines, especially in the manage- required age subject. Women have the same as men. ment of the more serious of case. He of the graduates rights type speaks at of ° the with which the Sir Robert Woods, who received wide support the last importance promptness general has announced his intention of the vacant conduct of the case is established and the thoroughness with election, contesting seat. If Dublin is to return a medical man as one which it is carried out," and goes on to add that "every University of its Members it is incumbent on medical to case of the disease treated upon sound principles is a graduates contribution to medicine." The value of register as voters at once. It is not necessary to impress on preventive the an such observations cannot be overestimated. Sir Thomas readers of THE LANCET importance of returning increased number of medical men to Parliament. Horder’s paper, however, would have been still more competent I am, Sir, yours faithfully, helpful if he could have formulated for us a work- Dublin, Nov. 25th, 1918. ROBERT J. ROWLETTE. able scheme for the handling of the many serious cases amongst the poorer classes of the community. His remarks and suggestions about aerotherapy, hydrotherapy, THE INTRAMUSCULAR ADMINISTRATION OF poultices, cradling, inhalations, Gamgee jackets, hypo- NOVARSENOBILLON. dermic and intravenous medication, to say nothing of the To the -Editor of THE LANCET. turtle soup, show that he is thinking rather of the patient SIR,-As the method which I have adopted of administering who is already surrounded by conditions which in themselves novarsenobillon intramuscularly appears to be practically tend a issue. are we to towards favourable What, however, painless, and as other practitioners may be interested, may I do with the serious cases occurring amidst surroundings be allowed to state the technique employed ? The successful which from the start are all against recovery ? And I take and comparatively painless administration of novarseno- it that these cases are in the doctors have majority. Many billon depends in the first place upon a satisfactory solvent by this time realised the hopelessness of treating cases of used for the drug. Many solvents and methods were influenzal being pneumonia under such conditions. An abundance tried at St. Thomas’s Hospital, with the result that a of fresh air has been almost unobtainable ; efficient nursing solution of guaiacol in liquid glucose proved to be the most in 19 cases out of 20 out of the and for cases- question, those satisfactory. The solution is thus prepared :- and there have been many of them-situated in houses where , Guaiacol ...... 1 part. the majority of the domestic circle have been laid aside even Liquid glucose ...... 50 parts. the elementary requirements of sick nursing have been absent. Water (recently sterilised) ...... to 100 parts. has been able to The harassed doctor do little more than pay The water and glucose are sterilised and the guaiacol is a hurried daily call, prescribe medicine, feel the pulse, and added when cold. 758 It is to be noted that the solution is prepared without the addition of any anassthetising agent, such as stovaine or novocaine. Experiments made with higher percentages of The Mar and After. both guaiacol and liquid glucose were found to be unsatisfactory. SUMMARY OF TOTAL WAR CASUALTIES. There are of in many qualities liquid glucose, varying WE last week Mr. statement to the to but the used gave Macpherson’s colour from dark brown yellow, product House of Commons the total British should be the substance, which is clear and colourless. regarding casualties, pure those of Dominion and Indian up to this 10 to 20 minims are taken and the including troops, Of solvent, Nov. 10th. This referred to land warfare. The of novarsenobillon is dissolved in it, which it Secretary powder readilythe has issued a corresponding statement even when the dose is as as 0 -75 With this Admiralty regarding does, large g. naval losses. From the outbreak of the war to Nov. llth amount of the is made. This amount is up liquid injection last there was a total of 39,766 casualties in the is of as the least bulk Royal Navy very small, which great importance, ofand the Naval Division should be into the tissues. Royal Marines, excluding Royal fluid possible injected ; in the War Office figures), but including the Royal I do not consider the addition of a local (included anaesthetising Naval Air Service to the end of last March. The for with intramuscular up figures agent necessary, injections pain also include a certain number of officers and men of the makes until several hours after the no appearance giving Mercantile Marine injured while serving on commissioned drug, and that time the effect of a local anaesthetic has by vessels. The total naval casualties are analysed as disappeared. If the injection is skilfully administered there follows :- is no pain at the time ,of administration and the insertion Naval Losses. of the needle is not felt. Officers. Men. Dead (including died from wounds and The method recommended is to take a 1 c.cm. tuberculin from other causes) ...... 2,466 ...... 30,895 or intramuscular syringe fitted with a fine intramuscular Wounded ...... 805 ...... 4,378 needle. Separating the needle from the syringe and hold- Missing ...... 15 ...... 32 Interned and prisoners of war ...... 222 ...... 953 ing it between the thumb and forefinger, it is stabbed with a movement of the wrist into the in the rapid glutei upper Total ...... 3,508 ...... 36,258 and outer of the it to enter the quadrant buttock, causing In addition to officers and men of British tissues at to the skin. The to which the these, 14,661 right angles depth merchant and vessels have lost their lives needle is inserted-usually from three-quarters up to the ships fishing hilt-can only be gauged by practice. The buttock should through enemy action, and 3295 others have been captured be carefully palpated beforehand to ascertain the bestand detained in enemy countries as prisoners of war. position for inserting the needle and the force requisite to Canadian Losses. drive the needle to the desired depth. When this has been done the syringe is fitted on to the needle, care being taken An official statement gives the total casualties to Nov. 5th that the needle is kept stationary while it is in the tissues last in the Canadian Overseas Forces as 213,268 :- and while the is down. The needle plunger being pushed Killed in action ...... 35,128 Missing ...... 842 and are then withdrawn as one, as as 154,361 syringe rapidly possible Died of wounds ...... 12,048 to prevent any solution remaining along the track of the Died of disease...... 3,409 Prisoners of war ... .. 2,860 needle. The buttock is then gently massaged for five Presumed dead ...... 4,620 Wounded...... minutes. 213,268 American Losses. Although a few patients have complained of pain lasting In an interview at General March for two or four hours this is exceptional. By this method I given Washington, Peyton the casualties the war in the U.S.A. find that patients are spared the intense pain which often gave during Army :- attends the administration of the with the solvents Killed or died of wounds 36,154 Wounded...... 179,625 drug Died of disease...... 14.811 Prisoners...... 2,163 in use. generally Deaths uncertified...... 2,204 Missing ...... 1,160 I am, Sir, yours faithfully, Indian Caswcalties. THOS. ANWYL-DAVIES, In charge of the Venereal Department, St. Thomas’s Hospital. The total number of casualties among the Indian troops up 13, Park-place, St. James’s, S.W., Nov. 23rd, 1918. to Sept. 30th last has been officially given as 101,439, viz. :- Killed. Wounded.

In Mesopotamia ...... 14,742 ...... 30.589 SECURITY OF TENURE FOR MEDICAL OFFICERS In France...... 6,900 ...... 16,380 OF HEALTH AND INSPECTORS OF THE CASUALTY LIST. NUISANCES. The following medical officers appear among the casualties To the Editor of THE LANCET. announceda since our last issue :- SiR,-As the time is approaching when, I think, an appli- Killed. cation might be made to the Local Government Board for Capt.C R. Clark, R.A.M.C., attached Hussars. the issue of the Order referred to in the enclosed letters, I Died of Wounds. send you copies of the letters for publication. Lieut.-Col.I P. S. O’Reilly, C.M.G., R.A.M.C., qualified in I am, Sir, yours faithfully, Ireland in 1899, and joined R.A.M.C. shortly afterwards. Nov. 23rd, 1918. PHILIP MAGNUS. He took part in the South African War, and at the time. [ENCLOSURES.] of his death was senior medical officer at the Royal Local Government Board, Whitehall, S.W. 1, Arsenal, Woolwich. 30ch December. 1915. Died. My DEAR MAGNUS,—In accordance with the decision of my pre- Capt.Ca M. W. Miles, R.A.M.C., qualified in London in 1917, decessor, which was contained in his letter to you of February last, my and thereupon joined up. He died in England of Department have prepared an Order giving security of tenure to whole- influenza. time medical officers of health and inspectors of nuisances in the future. pneumonia following CCa E. D. was a student at Aberdeen I entirely agree with the decision at which Mr. Samuel arrived, and Capt. Keane, R.A.M.C., am strongly in favour of security of tenure for these officers, but I University and qualified in 1901. He held appointments must confess that my own feeling is that the present is hardly the at the County Asylum, at Uhalmers’ Hospital, and at the most appropriate time for the issue of such an Order, in view of the Dispensary, Banff, and was in practice at Kensington fact that so many of our best men have given up local work for service at the time of joining the R.A.M.C. with the Army or Navy, and that the conditions are now quite MajorMa W. S. MacDonell, Canadian A.M.C. abnormal. Ca M. S. K. R. I.M.S. Perhaps you would kindly let me know what your views are and Capt. Rao, , whether in the circumstances you would see any objection to the issue MajorMeMa G. G. Anderson, R.A.M.C. nf the Order bainty further postponed.—Yours sincerely Surgeon-Lieut.Su J. F. Howell, R.N. (Sgd.) WALTER H. LONG. SurSurgeon Sub-Lieut. J. D. Gear, R.N.V.R. Local Government Board, Whitehall, S.W.1, Wounded. 7th January. 1916. Capt. J. J. B. Edmond, R.A.M.C., attached K.R.R.C. MY DEAR MAGNUS,-Many thanks for your letters with respect to the tenure of office of medical officers of health and of Capt. G. Robinson, R.A.M.C. inspectors LieLieut. H. Devonshire nuisances. I felt sure you would agree that there were good grounds Cal W. Ross, R.A.M.C., attd. Regiment. for postponing the intended change. CaCapt. A. W. Raymond, M.C., R.A.M.C., attd. Rifle Brigade. I see no objection at all to your publishing our correspondence. Ca.]Capt. Santokh Singh, I.M.S. Yours sincerely, CaCapt. W. G. MacKenzie, M.C., R.A.M.C. (Sgd.) WALTER H. Lmm. P, now not Wounded. I am very grateful to you for your most valuable and friendly Previo2csly Reported Wounded, Reported coöperation.—W. H. L. Ca.]Capt. W. G. Shakespeare, R.A.M.C.