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aborting or cutting short an attack rather than in guiding thedisease for a stereotyped number of days to a crisis, by whichtime the patient is often poisoned by toxsemia and his heartparalysed by exhaustion. By the administration of anti-toxin we abort an attack of diphtheria, and in my judg-ment we must use every endeavour to stop an attack ofacute pneumonia. I take it that the crisis" " in pneumoniais the exact time when a sufficient amount of anti-pneumo-toxin has been formed in the blood automatically, tocounteract the toxins of pneumococci.

If we can bring about that result early in the disease bythe use of vaccines or serum we will save an enormous

amount of suffering and greatly reduce the mortality fromthe disease which is so aptly described by Osler as "the-Captain of the Men of Death."

I am, Sir, yours faithfully, -

NATHAN RAW.

A NEW GALACTAGOGUE.To the Editor of THE LANCET.

SiR,-It is well known that the food of an animal and theseason of the year modify the quantity and the quality of themilk secretion. Goats’ milk, for instance, is said to be

astringent after the animals have eaten the leaves of the oakor pine trees, and to act as a gastric sedative if the wildhellebore is made a part of the diet.

It was customary in the old days to prescribe the diet, notonly for the infant or invalid, but for the animal from whosemilk the patient was to be fed. An instance occurred in thepractice of the famous Italian physician of Milan, JeromeCardan, when about the end of the sixteenth century he wascalled to Scotland to attend Mary Queen of Scots. The Arch-

bishop of St. Andrews, John Hamilton, whose brother washeir to the throne of Scotland, never had robust health, andwas at that time suffering from some lung disease, probablyphthisis. Advantage was taken of Cardan’s presence inEdinburgh to ask him to attend on and prescribe for thearchbishop. He treated him with beef-juices made of blooderum ; chicken broths flavoured with cinnamon, wine andginger; but milk was the I I sheet anchor" in the dietary.The savant contended that milk kept the stomach open andcleared the brain, and he ordered the archbishop to drinkfrom two to four pints of ass’s milk, either all at once or inseveral doses with no greater interval than an hour. The asswas treated also. The animal was ordered to be providedwith mild herbs, such as mallow, juicy beetroots, rose

blossoms, as well as fresh corn and barley, and the motherand foal were ordered to run together freely in a meadowdaily. This prescription gives a hint to those interested inmilk feeding of consumptives to-day.The turnips given to a stall-fed cow impart a flavour to its

milk and to the cream and butter ; a similar thing occurswhen the animal is fed with new clover. Leeks, onions,garlic, and other members of this group taint the milk,their active principles being secreted by the milk gland, as inthe cases of oils of dill and aniseed. Before the days ofartificial foods physicians were careful to order milk derivedfrom one cow, the animal being specially fed, and in someparts of the country this is not now departed from.

Beans, peas, and lentils have long been held in esteem for in-creasing the milk-supply. Hippocrates recommended cabbage;Paul of Aegina the carrot, beet-root, cresses, and chicory, forthis purpose. Professor Tarnier’s favourite galactagogue wasmalt, and farmers still use the draff of the brew-house forcow feeding. Dr. Carron de la Oarriere, of Paris, speakshighly of the old-fashioned goat’s-rue, or as others call it,galega, formerly much used in medicine as a diaphoretic and,stimulant. He has observed, when this is given to thesuckling mother, the infant increases in weight and rests andsleeps better.

Our Pharmacopoeia has little to offer the medical practi-tioner or midwifery nurse in the way of milk-inducingagents. Recently, a preparation of the cotton seed has beentried with much success, increasing the mother’s milk bothin quantity and in fat and casein. The product has beenminutely described by Dr. Ballerin, of Paris. Cotton seedsare reduced to a fine powder, the oil and resinous mattersare extracted by ether and benzine, and the active principleobtained by infusing the residue, and thereby getting rid ofthe colour and the odour. The resultant liquid is con-centrated in vacuo and the blocks pulverised. This powderis free from cellulose, oil, and other indigestible products.

It has no toxic properties. The active principle, so faras milk-producing properties is concerned, is edestine.The product has been administered to domestic animals,with the result that the quantity of milk increased by30 per cent., and the fats and solids in corresponding pro-portion. The same results have followed its administrationto lying-in or suckling mothers. Several cases of this naturehave come under my personal observation. For example,a lady with her second child noticed at the fifth month thatthe breasts were becoming soft, and the milk diminishing inquantity. This cotton-seed powder produced a large acces-sion of milk, and by continuing its use she was able to go onnursing without further trouble. The following is rather asevere test. A mother who had never been able to sucklemore than four months has been able to continue for ninemonths, the baby being plump and thriving, to the greatdelight of the mother. The milk-supply has been abundantthroughout.

Bearing in mind that artificial feeding is the most potentcause of the maladies of early infancy, and the chief factorin the production of infantile mortality, the importance of areliable galactagogue can scarcely be over-estimated.

I am, Sir, yours faithfully,W. LAUZUN-BROWN.

FUNGI FOUND IN TROPICAL BRONCHO-MYCOSIS.

To the Edito’l’ of THE LANCET.SIR,-In my letter on this subject I pointed out an error

that Dr. A. C. E. Castellani had made in describingendomyces albicans as liquefying gelatin. The only organismof that name is E. albicans (Vuillemin) described in 1898(Comptes Rend1ls de l’Acccdeucie des Sciences), and again byGoedelst and Vuillemin (" Les Champignons Parasites," 1902,p. 38), when they distinctly state : "La gelatine n’est jamaisliquenee."

" Dr. Castellani remarks that anyhow there are anumber of organisms concerned in thrush, and that some ofthem liquefy gelatin. That seems beside the point, while heneglects the species described by M. Vuillemin, a distin-guished French mycologist of world-wide reputation.

In apology for my venturing to express an opinion at all,I may point out that in his original communication Dr.Castellani (1) admits he has no evidence that his saccharo-myces is a saccharomyces ; and (2) offers no evidence thathis endomyces are endomyces. (3) Finally it appearsprobable there are still two slips in the fermentation table-for instance, one organism ferments (A.G.) raffinose, but nodisaccharid, and another ferments raffinose and saccharose,but not levulose. These are abnormal and in need ofconfirmation.-I am, Sir, yours faithfully,

ROBERT CRAIK, M.D. Glasg.

THE BED ISOLATION OF CASES OFINFECTIOUS DISEASE.To the Editor of THE LANCET.

SIR,—In the course of such unfavourable comments as

have hitherto been made on the plan of ’’ bed isolation" indealing with infectious diseases-which, by-the-bye, have,so far as I know, only issued from those who have not

given it a trial-the responsibility for its origin has beenpretty definitely allotted to myself. I shall be glad thereforeif you will be good enough to allow me to make some refer-ence to the encouraging results reported by Dr. C. Rundleand Dr. A. H. G. Burton, in their excellent paper inTHE LANCET of March 16th. There is just one pointwith which the authors are doubtless quite familiar, butwhich is not perhaps emphasised sufficiently by them toarrest the attention of those who have not read the originalpapers on the subject. I mean the paramount necessity ofthe routine cleansing (with a view to minimise possibleaerial dissemination, as well as to effect other ends) of themouth and throat, if not the nose, in all cases. At Mortlake

every patient used on admission to be given a separate sprayproducer and a new tooth-brush. The tooth-brush was usedat least twice a day, and the atomiser, with an oily disin-fectant, every four hours at first.Of course (in the case of small hospitals especially) there are

many contingent advantages in the ado ption of the methodof bed-isolation, but, as I have tried to point out, in arecently published volume of essays, it is a method that

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depends on principles that should be always applied in

dealing with cases of infectious disease, whether kept at homeor sent to hospital. The use of symbolic barriers, like thered cord, or material barriers, like the glass partition, has inprivate practice an analogue in the fetish of the wet sheet.In all these cases attention is directed to a non-essential

symbol, and the success or non-spccess of the barrier andcubicle systems depends not on the barrier or wall so much ason the incidental attention paid to hands and articles.The method of " bed isolation," then, is nothing more than

the carrying-out of the principles of asepsis and antisepsis inthe case of certain diseases. The details are to be modified,if necessary, as we gain knowledge of the differences in themode of transference of the different viruses. But certain

principles are suitable for application in all cases, and shouldbe applied whether the patient is at home or in hospital,in a special ward or in a " mixed " one.

I am, Sir, yours faithfully,F. G. CROOKSHANK.

CAVITATION OF THE LUNGS IN YOUNGINFANTS.

To the Editor of THE LANCET.

SIR,—The instances of haemoptysis occurring in younginfants referred to by Mr. P. Carruthers Watt and Sir R.Douglas Powell in the issues of THE LANCET for Jan. 27th andFeb. 3rd of this year are of some interest from the standpointof the presence of cavitation due to tubercle in the early monthsof life. I have seen a large cavity in the lower lobe of theleft lung crossed by a fibrous band at the age of 5 months.Death was due to tuberculous meningitis. In another case,of a child, aged 8 months, a cavity of the size of a walnut waspresent in the upper lobe of the left lung.

Interesting though this cavitation is at so early an age,whether complicated or not by hoemoptysis, there seems tome to be a danger that its presence should be taken as

evidence of the not uncommon occurrence of phthisicalcavities of chronic character in children. Such cavities are,’ ‘’in my experience, of great rarity in childhood. Needless tosay, I speak especially, not of the early months, but of theearly years of life. The cavities above referred to occurringin infants, like tuberculous cavities occurring later in thelungs of older children, were acute or subacute in character dueto the rapid breaking down of caseous broncho-pneumonia.Although well known, it is a fact which is deserving of

emphasis in these days of examination of school children,that chronic cavities in the lungs of children are almost

invariably bronchiectatic in nature. It may be interesting toadd that considerable degree of dilatation of the bronchialtubes may be present under the age of one year. In a child

aged six months I have seen half of the lower lobe of alung affected with broncho-pneumonia thickly studded withdilated bronchial tubes, some measuring a quarter of an inchacross. Broncho - pneumonia, especially apparently the

broncho-pneumonia of measles, is the main cause of dilatationof the bronchial tubes in children.The frequent reference in medical papers to the widespread

infection of children with tubercle tempts a further remark thatthese references not uncommonly appear to manifest confusionas to what is meant by infection by tuberculosis. Some writersappear to assume that frequent infection of children withtuberculosis proves the frequency of chronic pulmonary tuber-culosis. In children tuberculosis of the lungs is acute orsubacute. During childhood the lungs appear to exhibit littleor no power to prevent the rapid spread of infection withinthem, and death occurs before many months have passed.

I am, Sir, yours faithfully,THEODORE FISHER.

THE MEDICAL PROFESSION AND THENATIONAL INSURANCE ACT.

To the Editor of THE LANCET.SiR,-In November last year you published a letter of

mine in which I proved from the figures of my own practicethat contract work paid for by premium per head and salarywas much more lucrative than ordinary private work paid forby fees per visit. The publication of my discovery made butslight impression at the time, and apparently it failed toconvince many of your readers that what was a particulartruth as regards my practice was, indeed, a general truth of

all practices. My contention then and now is that paymentby premium gives better returns than payment for work done,and that in view of the falling sickness-rate the premiummethod is the only means by which our incomes can be main-tained. I also tried to show that premiums can be adjustedto clients of all grades of income and of all degrees ofill-health. Throughout the controversy on the Act nothing-has been more astonishing than the wide differences inthe estimates made by various correspondents as to the

equivalents of the two methods. Scarcely any twowriters have agreed as to what premium per (Japitawould be equivalent to a given fee per visit, and thisis the very key of the whole position. It is practicallyagreed that if the Act would give us half-a. crown a visit orits equivalent premium we should be content. I think weare unanimous on that point, and it is about the only pointon which there is complete agreement. The disagreementhas arisen through the erroneous methods employed to findthe equivalent in premium to this fee of half-a-crown per visit.Estimates have varied from 25s. to 6s., the latter figure beingthe sum offered us under the Act. In my November letter I

thought that 8s. 6d., the premium paid by the Post Office,should be the amount paid under the Act, and wet knowthat the Association has now fixed its demand on that sum.All this confusion of opinion has arisen from the absence ofstatistics. Actually the only trustworthy and useful figuresbefore us are the returns of the societies, which give us thenumber of members and the total sick days paid for

by them. But these returns do not give us the numberof visits paid by the doctors attending, nor do they giveus any idea as to the number of visits each sickmember received. Sick days have the vaguest relation tosick visits. Practically no one keeps a record of the workhe does for his clubs. Another difficulty in accepting thevarious estimates as equivalents arises through the know-ledge that sickness-rates vary in different districts, atdifferent times of the year, in different years, in differentindustries, in the two sexes, and at different ages. Not

only does the sickness-rate vary, but so also does thepersonality of the doctor who makes the visits. So that

every attempt to solve the difficulty has but added to theconfusion-so far. Clearly the truth lies in this, that anyestimate must depend on and vary with the personalequation-no two estimates could be exactly alike, becausewhat I may call the "visiting habits " of no two doctors arealike. An average must be struck. That is what theAssociation has done. Is it high enough ? 7 Every generalpractitioner can put it to the test, in a way I will presentlydemonstrate.

I have within the last 24 hours lighted on an idea whichto me seems likely to help us to solve this problem of

equivalents. As I have said already, the equivalent arrivedat will differ, slightly it may be, perhaps only fractionally,in every two practices. But every medical man wouldlike to know what premium per head would give him thesame return of income as his present visiting fees do. He isat a loss in his search for truth in all the maze of conflictingviews that confront him at meetings and in the journalsweek by week. My plan will enable him to get very close tothe mathematical truth. He will be able in half an hour tofind how near to the average 8s. 6d. struck by the Associationcomes his own way of doing his work while charging for itat the rate of 2s. 6d. per visit.

Every practice contains so many clients at any givenmoment. A client is a person who either is now, has been,or may be a patient. What we want to know first of all ishow much each client pays in the year to the doctor of hischoice. Now here I must point out that no town doctorwhatever, and very few country doctors, know how manyclients they have, and herein is the root of many fallaciousestimates. A client may never actually be a patient at all.For instance, an old client of mine was found dead in hisback yard-he had never had a bottle of medicine in hislife. If he had been a private client this practicewould have derived nothing from him-there are suchcases in every practice no doubt-but as a matterof fact this man as club client had been paying 6s. a

year for 40 years to the practice. If, again, this man had livedin a town, and had not been a member of a club, no doctorwould necessarily have known whose client he was. I makethis illustration to show that very few doctors can really besure how many clients they possess, and also to demonstratethe probability that there are thousands of people walking