In entertaining the question of bleeding, local or general, it must be borne in mind that the acute stage, when got over, is followed by one in which there is apt to be considerable debility. If bleeding be had recourse to unnecessarily or too freely, this stage will be ren dered more marked and prolonged. The mere existence of acute peri carditis is not a reason for taking blood; such a measure is to be regarded only as the best means of allaying the urgent symptoms of the first stage of a very acute attack.
Cold, as got by the application of an ice-bag over the region of the heart, may be of benefit at this stage. It is to be prescribed only during the acute stage. In milder cases warm poultices often give relief.
After the acute stage has been subdued, there is generally, espe cially in severe cases which have required active treatment, some effusion of fluid into the pericardium. In most cases this disappears as convalescence advances and strength returns. But occasionally it is necessary to adopt measures for its removal.
Blisters repeatedly applied over the heart, and the internal admin istration of deobstruents, such as iodide of potassium, are the reme dies usually recommended. Blisters are certainly of use; but the debilitated condition of the patient and the weakened state of the cardiac muscles, which suffer more or less in acute cases, indicate the use of good food and tonics.
If these measures fail, and especially if the quantity of fluid be so great as to cause serious inconvenience, it may be necessary to have recourse to tapping. The trocar of an aspirator may be introduced into the distended sac without difficulty. The best point for its inser tion is the fifth intercostal space, to the left of the sternum, care being taken to avoid the line of the internal mammary artery. Whether or not the operation may be ultimately successful, it always affords relief for the time. But the operation is one which is rarely called for.
In endocarditis it is very questionable if local measures ever do good. If the case is very acute, and accompanied by evidence of dis tress, a few leeches may be applied. But all depletory measures should be used with extreme caution. So, too, should they be in myocarditis.
There is no especial treatment applicable to myocarditis ; it is essentially symptomatic. But, as a rule, the treatment of the acute stage is the same as that of eudocarditis. When that stage passes off, the administration of tonics is called for. In acute cases in which there is serious impairment of the vigor of the muscular walls of the heart, stimulants should be given freely.
Attention has already been drawn to the change in the cardiac walls, induced by inflammation. They become abnormally soft and weak. It is at all times of importance that the occurrence of such a change should be recognized. It is specially so in connection with the salicyl treatment; for °lie of the drawbacks to the use of salicylic acid is its depressing action on the heart, evidenced by feebleness and generally increased rapidity of its action.
In the treatment of the heart complications of acute rheumatism it is of importance that this action of salicylic acid should be borne in mind. If there is any reason to suspect the existence of inflam matory softening of the walls of the heart, salicylic acid, if given at all, should have its action on the heart watched very narrowly. If there is any evidence of the existence of myocarditis, or of feeble car diac action, it should not be given at all; for the addition to the already existing enfeeblement of such depression as salicylic acid may cause might add seriously to the patient's danger. It is not in every case that salicylic acid has an enfeebling action on the heart, but one never knows when such a case may occur. To give a remedy which may have such an action, in an ailment in which cardiac enfeeblement is the special danger which we have to deal, is a practice which one cannot commend, for it cannot fail at times to produce injurious results. Fortunately it is a prac tice which is never called for even in the interests of the joints; for we have in salicin a remedy which, as an anti-rheumatic, is as potent as salicylic acid; and which possesses over that acid the enormous advantage of having no depressing action on the heart. In all cases of recent inflammation of the heart, the muscular sub stance is liable to be affected. In all eases in which it is affected, there is produced a soft and enfeebled condition of the ventricular walls. In all such cases the administration of salicylic acid is at tended with appreciable risk.
Rest, quiet, good food, tonics, and stimulants in moderate quan tity, are the remedial agencies to which we must trust in the treat ment of this softened condition of the heart's walls.
The ailment is one which nearly always occurs in young people; at an age, that is, at which the system possesses great recuperative powers. If not fatal in the acute stage, recovery is generally perfect. Attention has already been drawn to the fact that it may cause sudden death. The risk of such an accident would be increased by the de pressing action of salicylic acid given either plain or as salicylate of soda. No such risk attends the use of salicin.
The injurious effects of the ordinary commercial salicylic acid (made from carbolic acid) are said to be due to impurities, and Pro fessor Charteris of Glasgow has indicated creasotic acid as the spe cial impurity. The natural salicylic acid, made from salicin or from oil of wintergreen, is said to be free from depressing effect. Even if that be so it has uo advantage over salicin, the most easily obtained of all the natural salicyl compounds, and one which we know to be quite safe.