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.after a shorter time in the remaining six. In 11 casesthere was a very marked improvement of hearing,and Dr. Coelst claims that none was made worse ;vertigo disappeared in one case and tinnitus ceasedin three cases. Although all aurists will not agreethat Eustachian obstruction is the cause of 90 percent. of deafness, it is at any rate a fruitful sourceof this affection. If this method can be shown, on alarger number of patients and with a greater lapse oftime, to cure Eustachian strictures and to be reason-ably free from danger, a considerable advance willhave been made in the treatment of a very common.and distressing disability.

PEPTONE INJECTIONS IN THE TREATMENT

OF MIGRAINE.

THE possibility of migraine being due to protein.supersensitiveness has frequently been suggested,and cases often occur in families in which asthma,urticaria, and other diseases of this class are common,.although migraine itself is such a widespread diseasethat statistical conclusions tend to be fallacious. Inthe current number of the American Journal of theMedical Sciences, Dr. F. E. Ball, of Chicago, gives anaccount of the results of treatment in 20 cases. Thesecases were selected in so far as all of them had provedresistant to the commoner forms of treatment, suchas regulation of diet and administration of iodine.’The technique followed was to give an initial dose ofmv, of 5 per cent. solution of peptone intravenously,followed after three or four doses by further injectionsin which the dose was increased by fllv. each timeuntil a maximum of mxxv. was reached. If no benefitfollowed a series of eight to ten injections the treat-ment was discontinued and regarded as a failure.When, however, the result was favourable, the time-interval between injections was gradually lengtheneduntil the longest interval was found that securedfreedom from headache, the injections being continuedaccordingly. The result in this series was that 50 percent. of the cases were failures, seven cases (35 per cent.)were markedly improved, and three (15 per cent.)somewhat improved. When it is remembered thatcare was taken in the first place to select resistantcases these results must be considered as satisfactory.Dr. Ball was unable to discover any clinical or

aetiological signs indicating which patients might beexpected to receive benefit ; but in all the patientswho got marked relief visual disturbances whichnormally preceded the headaches continued at thetime, though the full attack failed to mature. Inthe same paper the writer considers what association,if any, there may be between migraine, asthma,hay fever, urticaria, epilepsy, and eczema, but uponcareful analysis of 1000 unselected family historieshe is unable to find figures bearing out the common- conception of a close relationship between thesediseases, with the exception always of an associationbetween hay fever and asthma.

MEDICAL PRACTITIONERS AND FELDSHERS

IN LITHUANIA.

THERE are at present in Lithuania 476 properlyregistered doctors of medicine, 276 dentists, 353feldshers, 270 midwives, 152 sisters of mercy, and8 masseur specialists. There are also, we learn fromthe Northern News Service, 48 hospitals, with 756 beds,and three sanatoriums—viz., at Varena, Birstonas, andKulatovoja. With a population estimated at about2,000,000, it will be seen that there is, approximately,one registered doctor to every 4000 persons, one dentistto every 7000, one feldsher to every 6000, and onehospital bed to every 2300. By way of comparisonit may be mentioned that in the British Isles, takingthe population as well under 50,000,000, there are about50,000 registered medical practitioners (including,of course, a proportion not in practice) and 15,000dentists now on the Dental Register. The proportionof hospital beds to the population is locally so

capricious as to make an average figure misleading.In this country we have nothing corresponding tothe " feldsher." Lithuania has, no doubt, inheritedthis form of semi-qualified practitioner from theRussian Empire of which it was formerly a part.The origin of the feldsher system is of interest. InPeter the Great’s Medical School in Moscow the mostsevere punishment for an erring student was expulsionfrom the school to serve in the ranks of the army.A less drastic punishment-reserved especially forstudents who repeatedly failed in their examinations-was to send them to serve, not in the ranks, butas barbers and blood-letters to the regiments. A littlelater a second category of military feldsher wascreated ; a number of the sons of soldiers were trainedin the arts of blood-letting and of nursing generally,and these helped to relieve the students by whom atthat time the nursing in the military hospitals wasmostly done. It was only after the emancipation ofthe serfs in 1861 and the creation of the system ofzemstvo government that a class of civilian feldsherscame into existence. Before the war they played animportant part in the Russian medical system.There were large areas where no qualified doctorwas to be found, and where the people were whollydependent on the services of the feldsher. The systemwas no doubt a far from ideal one, but it was perhapsthe best attainable under the conditions that prevailed.The feldsher’s training was far from negligible, andhis services were undoubtedly preferable to those ofthe " wise man " or " wise woman " of the village,to whom alone the peasant could otherwise haverecourse. The whole question of " feldsherism "

was described and discussed at great length by Dr.F. G. Clemow in THE LANCET 1 at the time of theInternational Medical Congress held in Moscow in1897. Whether the system still prevails in Russiawe are not in a position to state. In Lithuania, itwould seem, there are approximately three feldshersto every four registered practitioners.

THE ÆTIOLOGY OF ERYTHEMA NODOSUM.

THOUGH the evidence of the last few years seemsmainly to be in favour of regarding erythema nodosumas an expression of tuberculosis, nevertheless argumentsare still being advanced in support of the hypothesisthat it is produced by the organism or organismsresponsible for rheumatism in childhood. Of the threerheumatic affections-acute polyarthritis, choreaminor, and acute endocarditis-the first is apparentlythe one most often correlated with erythema nodosum,and in many accounts of this condition attention hasbeen drawn to the coincidence of pain or swelling inthe joints of the affected limbs. An examination ofthe relationship was therefore undertaken by Dr.Albin Landau,2 at Dr. Wallgren’s Children’s HospitalIn Gothenburg, and at this hospital in the periodTan. 1st, 1922, to Sept. lst, 1926, records were kept ofall the cases of erythema nodosum on the one hand,and of acute rheumatic polyarthritis, acute endo-;arditis, and chorea minor on the other. On therecord-sheets a special place was allotted to erythemanodosum, so that if there was a history of this;omplaint it would not be overlooked. It was foundthat among the 130 cases of erythema nodosumcreated in this period there was only one in whichhe relatives could give a history of rheumatism.Among the 136 cases of rheumatism belonging to one)r other of the three rheumatic categories mentionedabove, there were four in which a history of erythemanodosum could be obtained. In all five cases in which,he patients had suffered from both complaints thePirquet reaction was positive, and in as many as,hree of these cases there were signs of pulmonarylisease of a tuberculous character. Considering how;ommon both erythema and rheumatic affections aren childhood, the fact that there was a history of

1 Medicine Past and Present in Russia, supplement to theLANCET, August 7th, 1897.

2 Acta Pasdiatrica, 1927, vi., Fasc. 3-4.