The very acute cases which come under observation during the first two or three days of the illness are also the ones in which the heart is apt to be affected from the commencement. In such cases the joint and heart affection are often contemporaneous, though, for reasons already given, the symptoms of the heart trouble are more slowly developed.
In subacute cases the symptoms are developed less rapidly, and the evidence of the heart affection is more likely to be delayed a few days; but so also is the period at which treatment commences, for such cases are generally ailing for at least three or four days before they come under notice. In acute eases the heart affection is devel oped so soon and so quickly, that there is not much time to get the prophylactic action of the salicyl componnds. Subacute cases come under notice at so comparatively late a period that there is not much opportunity to do so. So that whatever prophylactic properties we may accord to the salicyl compounds ou theoretic grounds, there re mains the difficulty that in actual practice this result is not readily got. We know that it may be got ; but in no given ease can we be sure of having got it. With such a possibility before us, however, and with spell a tremendous issue at stake, it is impossible to exag gerate the importance of the early and free administration of the salicyl compounds in all cases of acute and subacute rheumatism ; for we never know when we may be dealing with a case in which prophylaxis is attainable. The bare possibility of such a result is worth striving for. But promptitude and decision are requisite to success. Thirty grains should be given every hour till the tempera ture is normal and pain gone. A delay of a few hours in commencing treatment, or the administration of the drug in insufficient close, may make all the difference between perfect recovery and recovery with a damaged heart—a calamity which in some cases is scarcely prefera ble to death, so hard may be the conditions under which life is car ried on.
Do the salicyl compounds have a curative action in rheumatic in flammation of the heart ? Regarding such inflammation as identical in nature and pathology with rheumatic inflammation of the joints, and recognizing the dis tinctly curative effects of the salicyl compounds in this, it might, not without reason, be expected that they should have the same action in rheumatic inflammation about the heart. Experience, however,
has shown that such is not the case, and that under the salicyl treat ment, as under all other, rheumatic endocarditis (to which we shall still confine our attention) is apt to leave some trace behind.
Attention has already been drawn to one obstacle which intervenes to make the treatment and cure of inflammation of the heart specially difficult—the impossibility of giving rest to the inflamed textures. This is an obstacle which no treatment can overcome. It is an im portant factor in keeping up the mischief originated by the rheumatic poison, and affords an adequate explanation of the fact that the treat ment which rapidly allays acute rheumatic inflammation of a joint may fail to have a like action in similar inflammation of the heart. In both rest is essential to quick recovery. In the one it is easily got; in the other it is unattainable.
But it is not enough to explain why the aihnent should be so little amenable to treatment during its acute stage. We have also to ex plain why the endocardial mischief is so apt to be lasting.
Pericarditis may be perfectly recovered from, the effused products may be absorbed, and the membrane restored to its natural state. So too may myocarditis. But in endocarditis the signs are apt to per sist after all inflammatory mischief has ceased. It is a pathological fact that when once a certain amount of change has taken place on the endocardial surface the damage is apt to be permanent. The endocardium is the only structure habitually affected by the rheuma tic poison of which this can be said; it is also the only structure in the heart which has no analogue, anatomical or physiological, in the joints. The fibrous and muscular textures of the heart and joints have a like structure and function. So have the pericardial and syno vial membranes. The endocardium alone is unrepresented in the locomotor apparatus. It stands alone, too, in its pathology. Its scanty vascularity and low vital activity make it insusceptible to acute general inflammation. Such inflammation is, therefore, un known in connection with it. The same circumstances intervene to prevent the absorption of products effused on its valvular portion dur ing an attack of rheumatic endocarditis. To the absorption of such products a certain degree of vascularity is necessary; such vascular-' itv does not exist in the endocardium.