It may, indeed, be said that a degree of vascularity which suffices for the effusion of lymph, should suffice also for its absorption. But the deposit on the valves is not all effused. Great part of it is de posited directly from the blood, on the roughened surface; and even the primary roughening results from irritation caused, not directly by the rheumatic poison, but by friction of the valvular surfaces— a mechanical force which, in the case of the endocardium, cannot be equalled or counterbalanced by any agency which stimulates absorption.
It is evident that the condition is one on which drugs can have no direct action; and thus is explained the inability of the salicyl com pounds to repair the damage done during an attack of rheumatic endocarditis.
The direct cause of all the objective, and most of the subjective, symptoms of endocarditis is not the rheumatic poison which causes the inflammation—it is not even the inflammation itself—it is the physical change caused by the rubbing against each other of the swollen valves. The lymph deposited during rheumatic inflamma tion of the heart differs in no respect from that thrown out during non-rheumatic inflammation. No one would expect the salicyl com pounds to remove the latter. It would be as unreasonable to expect them to remove the former. These drugs are not deobstruent, they are anti-rheumatic. They cure rheumatic fever; but they do not stimulate absorbents, or remove effused products.
The fact that the salicyl compounds are powerless to remove car diac damage is an urgent reason for getting the system under their influence, before the heart becomes involved.
But though they fail to effect a cure, it cannot be said that these compounds have no beneficial effect in cardiac inflammation. For if they have a destructive action on the rheumatic poison they cannot fail to be of some benefit. If they destroy this poison, they must by so doing curtail the duration and limit the extent of its action on the heart, and so mitigate the severity of the cardiac mischief.
But this is not the only way in which they tend to do good. Under their influence the joint inflammation subsides, and the febrile disturbance is allayed. This result is of course accompanied by diminished frequency of the heart's action as well as fall of tempera ture. The cardiac pulsations may fall from 112 to 72—a fall of 40 a minute, 2,400 an hour, or 57,600 a day. This diminished frequency of the heart's action implies decreased functional activity of the in flamed textures ; and this quieting of the heart's action is the one condition which is most desired and most difficult to attain, in the treatment of rheumatic inflammation of the heart. Were the rheu
matic process not thus cut short the rheumatic poison would continue to act for some weeks; the heart would continue to beat at the rate of 112 per minute, if not more; the inflamed valves would every day be subjected to the strain involved in their action 57,600 times more frequently—an enormous difference which could not fail to tell injuriously.
It is evident that independently of the good which must directly result to the heart from the destruction of the rheumatic poison and the consequent cessation of its action on the cardiac structures, bene fit must accrue to that organ from the diminished frequency of its own action, consequent on the arrest of the joint inflammation and accompanying fever.
The general conclusion to which we are led is, that the early and free administration of the salicyl compounds holds out the best chance both of saving the heart from the action of the rheumatic poison and of mitigating the severity of that action when it is too late to prevent it; but that these compounds are powerless to remove effused pro ducts, after the heart mischief is established.
The general treatment applicable to rheumatic inflammation of the heart is thus the same as that which is applicable to similar inflam mation of the joints. The existence of heart complication in a case of acute rheumatism is not only not a reason for omitting the salicyl com pounds, but is an additional one for giving them freely, and in large dose.
In the great majority of cases no other treatment is required. But every now and then a case occurs in which considerable benefit is got from the adoption of local measures. In pericarditis espe cially, local treatment is sometimes of much service. In the early stage of a severe attack, when pain is a prominent symptom, when the heart's action is disturbed and tumultuous, and when there is evidence of serious interference with the circulation, much good may be got by abstracting a few ounces of blood. This may be done by opening a vein, or by the application of leeches or cupping-glasses over the region of the heart. If the symptoms are urgent, venesec tion affords the most speedy relief; but to do good it must be had recourse to at an early stage. The cases are few, however, in which the desired effect may not be got from leeches.