Carbolic acid may be used in the strength of mx. to mxxx. to the ounce of vaseline, and mercurials or other parasiticides may be added to this ointment if found necessary.

Where expense is no consideration, as in private practice, lanolin, or lanolin and olive oil should be used instead of vaseline as the basis of these ointments, as it gives them a greater penetrative action on the scalp. For very chronic cases of ringworm, and especially for such forms as the "black-dot" ringworm, which are very resistant to treatment, Aldersmith strongly advises croton oil in children over seven years of age. This is applied to the individual hair follicles over a very small area at first, and poultices are firmly applied over the patches under treatment. After a time a boggy artificial kerion is produced, and the hairs, being loosened in their follicles, can be withdrawn very easily. The hair will usually grow again in a healthy condition, but there is some risk that a permanent baldness may result, and therefore the treatment should at first be tried over only small areas.

As the result of nearly ten years' hospital experience in Birmingham, where ringworm of the scalp is almost constantly due to the microsporon variety of fungus, I have personally had far better results from the repeated use of iodine than from any other remedy. The scales and loose hairs being removed before each painting, tincture of iodine is rubbed firmly into diseased patches with a brush. Care is taken to stop the treatment for twenty-four hours or more if much soreness results, but it is resumed again when this passes off. Sulphur ointment is afterwards rubbed in by the patient at home twice daily.

A. DOUGLAS HEATH.

ABSTRACTS.

A REVIEW OF OUR KNOWLEDGE OF THE RECENT AND REMOTE EFFECTS OF ACUTE INFECTIOUS DISEASES UPON THE CARDIO-VASCULAR SYSTEM.

THE condition of the heart and vessels is the deciding factor in the life of the body; upon it depends not only the length of life, but its working capacity. The vascular system leads the van in embryonic development, provides the tissues with the means of healthful activity, and ushers in the degenerations of old age, premature or ripe. It is, then, of the first importance to understand the exact modes of production. of cardiovascular degenerations, and the responsibility of preventing, or at any rate delaying, their appearance furnishes no light task to our profession. It is for this reason that a recent paper by Thayer (1) upon the influence of typhoid fever. upon the heart and vessels is to be welcomed. Before dealing with this paper, it may be useful to summarise our present knowledge of this subject.

We have been satisfied until recently with a list of rather indefinite causes of arteriosclerosis-old age, syphilis, gout, alcohol and kidney disease—and if to these be added overeating and muscular strain, the list as given in most text-books is about complete; but, as in nervous diseases the etiological importance of cold, damp, and worry is giving place to more exact knowledge of actual toxic factors, so with arteriosclerosis the relation of the acute infections to this condition gives to us etiological knowledge of a definite character.

The recent effects of acute infections are comparatively well known. Laennec, Louis, and Stokes in the early part of last century drew attention to the occurrence of grave myocardial changes in typhoid fever, and their work was amplified by (1) Amer. Jour. Med. Sci. March, 1904. p. 391.

the minute histological descriptions of Zenker, Hayem, Déjerine, and others. Many points have still to be cleared up, e.g.—What are the exact changes in the heart and vessels produced by infections, and what is their frequency? What is the relation of these acute changes to chronic degenerations? What is the after-history of patients who have had infectious diseases as regards their vascular system?

Valvular disease from endocarditis need not here be considered, as, with the exception of acute rheumatism and the arthritic form of scarlet fever, it is but an infrequent complication of other infections. Only eleven cases were noted in two thousand fatal cases of typhoid fever at Munich (Hölscher). Still, we occasionally see cases in which rheumatism can be excluded and in which the only possible etiological factor appears to have been one of the other acute fevers. On the other hand, acute vascular disease is a complication or sequel of nearly all acute infections; clinically it is usually observed as thrombosis with its results. Virchow regarded the thrombus formation as the primary and essential phenomenon, but within recent years, and mainly through the work of French bacteriologists (Cornil, Widal, Vaquez, etc.), we have reverted to the old ideas of John Hunter and Cruveilhier, who taught that thrombosis is in all these conditions an infective process, and is the expression of inflammation of the vessel wall.

Arterial thrombosis and arteritis is a rare occurrence in typhoid fever. Keen (1) has collected 115 cases of gangrene with enteric, but in the two thousand Munich autopsies no instance is recorded. It generally occurs in the arteries of the limbs, but occasionally has been found in the cerebral, pulmonary, and superior mesenteric arteries. Gilbert and Lion (2), Crocq (3), and others have produced an acute aortitis by injuring the vessel wall and then injecting typhoid bacilli into the circulation. Potain (4) has called attention to the production of acute aortitis, and Haushalter claims to have discovered typhoid bacilli in the walls of occluded arteries. (1) Surgical Complications and Sequels of Typhoid Fever. Philadelphia. 1898. (2) Bull. Méd. 1889-p. 1266.

(3) Arch. d. med. exper. 1894-vi., p. 583. (4) Semaine méd. 1894-xiv, p. 46.

Since my attention has been directed to this point, I have found in the two last autopsies on typhoid patients recent gelatinous and fatty sclerotic patches in the aorta and larger vessels. In influenza arterial thrombosis is commoner than in any other acute infection, and this is attributed by French writers to infective inflammation (artérite grippale). Kuskow (1) observed with great frequency degeneration, proliferation, and desquamation of the vascular endothelium in influenza Pneumonia has furnished several instances of gangrene of the extremities secondary to arterial thrombosis, and a few cases have been associated with acute rheumatism.

Venous thrombosis and phlebitis is much more common; its relative frequency in typhoid fever is familiar enough, and needs no emphasis. It appears to be almost always the result of phlebitis, but, although there is not at present sufficient information on the bacteriology of the thrombi in infective diseases, yet in some few cases they appear to have been definitely sterile; to explain these a toxic endophlebitis has been evoked, and degenerative changes of the endothelium have been described. Welch (2) has found nodules or more diffuse patches of cellular accumulations beneath the endothelium in typhoid, diphtheria, variola, and other diseases. These cells may undergo necrosis and become the starting point of thrombi. In influenza venous thrombosis is common, and the literature is already enormous. Chaudet has made it the subject of a special memoir, and Goodhart, writing in Allbutt's system, notes its frequency. French writers describe a phlébite grippale. Pneumonia ranks next to enteric and influenza in the frequency of peripheral thrombosis. It occurs generally during convalescence, and is again due to an infective phlebitis; in some cases pneumococci in large numbers have been found in the thrombus. Acute rheumatism was formerly regarded as an important cause, but is in reality a rare one, in spite of the fibrinous state of the blood. In other acute infections-dysentery, diphtheria, variola, scarlet fever, measles, tonsillitis, cholera, etc.- thrombosis, both arterial and venous, is not seldom associated.

(1) Virch. Archiv., cxxxix. p. 406.

(2) Allbutt's System of Medicine. Vol. VI., Article Thrombosis." Welch gives an authoritative account of the relation of thrombosis of infectious disease.

In the etiology of acute diseases of the vessels the part played by the infectious fevers is thus an important one. Their importance, however, must not be solely gauged by the frequency with which these conditions are observed clinically, for it is only by the complications or accidents that they are recognised. The minor degrees, especially in the aorta and larger vessels where thrombosis does not readily occur, and the cases of a sub-acute kind, may not produce any symptoms sufficiently prominent to attract notice, yet they must be far from uncommon, and undoubtedly result directly in arteriosclerosis, or at any rate add to the natural wear and tear of which this involution process is the expression.

Myocardial degeneration in acute disease.-Cowan (1), after a careful examination of the heart in seventy-three cases, concludes that it is liable to be affected in all its different elements-muscle, endothelium, connective tissue, and vessels. Alterations in the muscle cells are the most important and frequent. Granular degeneration is almost always found, and has as its results a loss of fibril bundles and a marked weakening of the power of the heart. Fatty degeneration is not rare, but is often due to previously-acting causes. Hyaline changes are found occasionally, but are rarely extensive; they probably result from the action of concentrated toxins favoured by vascular or other local conditions. When the pericardium. or endocardium is inflamed, there is grave interference with the neighbouring muscle fibres, both at once and for some time afterwards. The connective tissues are often the seat of inflammatory changes, which may be the starting point of chronic fibrous myocardial disease.

Acute diseases, then, have also a widespread effect upon the heart, important not only at the time, but also as the starting point of chronic changes which later seriously interfere with cardiac action. It is these remote chronic changes, the more insidious endarteritic changes in the aorta and other vessels following acute infections, which especially need emphasis. These have been chiefly studied in connection with typhoid fever.

(1) Journal of Path. and Bact. August, 1903, p. 87.