[Footnote 43: Lepine, "Note sur la determination de l'Alcalinité du Sang," _Gaz. Méd. de Paris_, 1878, 149; Conard, _Essai sur l'Alcalinité du Sang dans l'État de Sante, etc._, Thèse, Paris, 1878.] The manifestations of acute articular rheumatism other than the articular are various, and some of them, more especially those observed in the heart, may be regarded as integral elements of the disease, for they occur in a large proportion of the cases, often coincidentally with the articular affection, and may even precede it, and probably may be the sole local manifestation of acute rheumatism, although under the last-mentioned circumstances it is difficult to prove the rheumatic nature of the ailment. The cardiac affections may be divided into inflammatory and {32} non-inflammatory. The former consist of pericarditis, endocarditis, and myocarditis; the latter embrace deposition of fibrin on the valves, temporary incompetence of the mitral or tricuspid valves, and the formation of thrombi in the cavities of the heart. For practical purposes hæmic murmurs may be included in the latter group. No reliable conclusions can be drawn respecting the gross frequency of recent cardiac affections in rheumatic fever, for not only do authors differ widely on this point, but they do not all distinguish recent from old disease, nor inflammatory from non-inflammatory affections, nor hæmic from organic murmurs. Nor does it appear probable, from the published statistics, that these differences are owing to peculiarities of country or race. The gross proportion of heart disease of recent origin in acute and subacute articular rheumatism was in Fuller's[44] cases 34.3 per cent.; in Peacock's,[45] 32.7 per cent.; in Sibson's[46] (omitting his threatened or probable cases), 52.3 per cent.;[47] in 3552 St. Bartholomew's Hospital cases analyzed by Southey,[48] 29.8 per cent.; in Bouilland's cases, quoted by Fuller,[49] 5.7 per cent.; in Lebert's,[50] 23.6 per cent.; in Vogel's,[50] 50 per cent.; in Wunderlich's,[50] 26.3 per cent. I am not aware of any analysis, published in this country, of a large number of cases of rheumatism with reference to cardiac complications, but Dr. Austin Flint,[51] after quoting Sibson's percentage of cases of pericarditis, which was (63 in 326 or) 19 to the 100, remarks, "I am sure that this proportion is considerably higher than in my experience." [Footnote 44: _On Rheumatism, Rheumatic Gout, etc._, 3d ed., p. 280.] [Footnote 45: _St. Thomas's Hospital Reports_, vol. x. p. 19.] [Footnote 46: Reynolds's _Syst. of Med._, Eng. ed., vol. iv. 186.] [Footnote 47: Those familiar with the accuracy and diagnostic skill of the lamented Sibson will not hesitate to add his 13 cases of very probable endocarditis to his 170 positive cases of cardiac inflammation in 325 examples of acute rheumatism, which will raise his percentage to 56.3.] [Footnote 48: _Lib. cit._, vol. xiv. 6.] [Footnote 49: _Lib. cit._, 264.]