ENDOCARDITIS.
The prevention of carditis or valvulitis in acute rheumatism is a most important element in the treatment of that disease. Absolute rest in bed as soon as the diagnosis has become established must be insisted upon; inc.1 that this will sometimes prevent the complication of endo carditis in rheumatic fever is probable, but this form of rest treatment must not be confused in the mind of the physician with another of still greater importance. This is the question of prevention of permanent valvular disease once endocarditis has become established; here absolute rest in bed for a considerable period (2 to 3 months) after the symptoms of endocanlial inflammation have disappeared certainly in a considerable percentage of cases avert permanent deformity of the valves.
When endocarditis has declared its presence, absolute rest is therefore also a vitally essential part of the treatment. In carrying out the most extreme degree of rest the greatest difficulty will be found in the evacua tion of the bowels; the ideal of the led-pan often proves a delusion, as some patients cannot use it without violent bearing-down efforts, and the physician who will obstinately insist in all cases on its use will often be responsible for serious results which might otherwise be avoided. The writer has personal experience of a physician who well knew the danger of these expiratory efforts, and who nevertheless fractured his fourth left costal cartilage in trying to relieve the bowel in the lying posture. Certainly with patients who cannot use the bed-pan there is less danger in permitting them slowly and with assistance to slide out of bed on to the night-chair. Often the difficulty of evacuating the bowel in the recumbent position on the bed-pan disappears when a smart saline has been administered along with a drug like senna, which in creases peristalsis; occasionally an enema will meet the case, provided the contents of the bowel are not firm.
Salicylate treatment cannot be accepted as a preventive in the ordinary sense of the term, and it is probably certain that it exerts no beneficial action on the inflamed membrane, and therefore cannot be regarded as a specific remedial agent in the treatment of endocarditis. But the endocardial mischief originally started by the rheumatic toxin is greatly intensified by the high fever and general vascular excitement, as well as in a reflex manner it is aggravated by the severe joint pains. These are
all relievable by the salicylate treatment, and therefore it should be continued in the presence of the usual rheumatic manifestations. The endocarditis remains after the constitutional excitement and arthritic pains have disappeared, and when the physician finds himself dealing with this alone the case is clear. Salicylates should be stopped, but if fever and pain return at any time they must be recommenced.
A good routine for the endocarditis is the free administration of Alkalies; Go grs. Bicarbonate of Potash given with a tablespoonful of fresh lemon juice may be taken 4 times a day in effervescence. Lees' plan of com bining in a mixture salicylate and bicarbonate of sodium is a good one; the former drug can be stopped in cardiac cases when the arthritic manifestations fade. Yeo recommends pure Salicin combined with Soda.
The effervescing mixture is, however, better, because the citrate of potassium formed by mixing the lemon-juice and alkali together reduces the tendency towards fibrinous deposit on the delicate valvular tissue, and this consideration compels one to avoid the use of Chloride of Calcium, which has unfortunately been recommended as a cardiac tonic in endo carditis. At a later stage the addition of Iodides to the alkali is clearly indicated.
Diet should consist of fluids--milk and soups.
Lees advocates the continuous application of the ice-bag over the heart; relief to cardiac pain and distress usually follows. but the writer believes that continuous application of cold eventually increases the vascularity of the underlying tissues, as demonstrated in the experimental researches of Rossbach, who found that ice when applied to the chest caused anxmia of the bronchial mucosa, but when long contact was kept up the opposite—a hypemmic—condition supervened. If this treat ment be selected the application of the ice-bag should be intermittent. It is a valuable agent when employed in this manner in the grave condi tion recognised as rheumatic carditis, when both the pericardium, endo cardium and possibly the entire organ are involved in the inflammatory process, especially in children.