For this reason very acute cases are more often seen in private than in hospital practice, and hospital statistics are to be regarded as giving to acute rheumatism a milder aspect and shorter duration than would be got from similar statistics taken from private practice. For the same reason Dr. Peacock's statistics probably under- rather than over-state the mean duration of all cases of acute rheumatism.
Such are the statements of the best authorities. All agree in ascrib ing to acute rheumatism a mean duration of several weeks. And this coincides with the experience of every practitioner. No one who saw much of the disease before the days of the salicyl treatment, can fail to recall, on the one hand, cases in which the patient, to the delight of himself and attendants, got over the attack in one or two weeks ; and, on the other hand, cases which dragged on their weary and painful course for six or eight weeks and even more.
The duration of the disease is determined by the duration of pain, its most prominent and characteristic feature. Pain, of course, is only one symptom, but it is that which is most characteristic, which is most complained of, which continues so long as the rheumatic poison exercises its action on the joints, and without which rhemna tism cannot be said to exist in the joints. The temperature may de cline, the pulse may fall, the perspirations may cease; but so long as pain remains in any of the joints, the patient is not convalescent, and may have a re-accession of all his symptoms.
Nowadays we have in the thermometer a delicate means of deter mining the duration of the febrile symptoms which are an essential characteristic of acute rheumatism. It is found that the objective evidence thus got, accords very closely with the subjective evidence derived from the patient's feelings on which our fathers relied. The temperature falls and rises with the decrease and increase of pain and swelling in the joints, but rarely comes permanently to the nor mal standard till the joint pain disappears. The cases in which the joint pains persist after the normal temperature has been reached, are those in which the chronic form of the disease follows in the wake of the acute, and in which this sequence of events imparts to the attack an unusually prolonged duration, if we calculate this by the duration of the pain alone. This grafting of the chronic on to the
acute form explains the long duration of those cases in which acute rheumatism is said to have lasted for several months. Such cases commenced as acute rheumatism, gradually passed into subacute, and still more gradually into the chronic form. So insensible are the gradations by which the one form runs into the other, that with the thermometer it is difficult, and without it impossible, to say ex actly when acute becomes subacute, and subacute chronic. It is seldom, however, that a case remains acute for more than three weeks. It may be acute for that time, subacute for three or four weeks more, then gradually and without cessation of pain pass into the chronic form, and so remain for many weeks—the whole duration of the ail ment being several months. It is one attack all through ; but it is not acute rheumatism during its whole course.
The chronic course of such cases may be interrupted and varied by subacute exacerbations of longer or shorter duration; serving to show that the chronic form of the disease owns the same causation as the acute and subacute forms which precede and follow it. These very prolonged cases are exceptional. Generally the febrile symp toms and the pain decline and disappear about the same time.
The authorities and statements which have been quoted existed and were made before 1876, the year in which the salicyl compounds were introduced for the treatment of acute rheumatism. When we come to consider the duration of the malady under this treatment, it will be seen how vast are its benefits. For whereas this duration was formerly calculated by weeks it is now estimated by clays. Taking pain as the index of its continuance, it will be found that when the salicyl treatment is properly applied the disease lasts as many hours as it formerly did days, or as many days as it formerly did mouths. For in many cases the pain is now more effectually and surely relieved in one day than it formerly was iu one month. The temperature, too, falls to the normal very soon after the pain is abolished.