Introductory Lecture

Abstract

I think I am right in drawing the following proportional relation between local symptoms and fever, in gastritis and in rheumatism of the stomach. In gastritis, the acuteness of the attack, the pain of the stomach, and dryness of the tongue, are in proportion to the degree of fever. In rheumatism of the stomach, the pain may be very intense, with moderate or little fever, and a moist tongue. Now this is of some value, though not without exceptions. No doubt, it is of the first importance to know real inflammation, be it primary or arising from acute rheumatism of that organ. In about twenty-four hours this becomes clear; under that time, if in high fever you find the child vomiting, with tense epigastrium, a lively expression of pain in the countenance, and continuous painful moaning, instantaneous increase of those symptoms, by a painful outcry of the child, as soon as you press with your finger upon the epigastrium; if all these are present some hours, and cease not under suitable warm poultices, it would be a fault to wait longer with energetic antiphlogistic means, and expose the child to the possibility of danger by delaying until the fever, and along with it the gastric affection, might show its real nature. Rheumatisn of the liver, having its seat in the serous envelope of this organ, causes painful moaning under the respiratory movements of the chest and diaphragm, bilious vomiting and similar diarrhoea, and is easily discoverable by carefully touching over the liver. I believe most of those cases, which it the first years of any hospital practice I have called " hepatitis," were but rheumatic affections of this organ, only a few of which had the inflammatory character. Both rheumatalgia and rheumatic inflammation of the intestines are rather common in children, even of the tender age. Rheumatism in these parts, connected with fever, can scarcely be overlooked; besides a continuous uneasiness, and painful expression of counte,nance with moaning, from time to time the pain increases so far as to cause vehement painful crying, with the usual drawing up and moving of the legs, then usually comes a sudden diarrhoea of thin serosity, a little yellowish in nurselings, above that age not unfrequently greenish. After these tumultuous evacuations the child becomes more quiet, but appears still uneasy, the belly is puffed up and tender on pressure. If the affection be inflammatory all these signs are more strongly expressed, and the expression of pain itself almost unremittingly strong. In peritoneal rheumatism the more puffed state of the belly, with exquisite tenderness all over its surface, will soon discover the seat of pain. Serous diarrhoea and most of the before-mentioned symptoms will be present. I believe in fact, that the abdominal peritoneum may merely be affected in this way, without involving the intestines. As to the question,-Whetber the seat of rheumatism be in the serous or muscular, or both envelopes of the alimentary canal? I believe that it can take place in all or any of them; but to make a distinctive diagnosis between the affection of either coat is, I think, as impossible as useless. I remember an old and respectable colleague of mine expressed strong doubts as to the possibility of diagnosticating the abdominal seats of rheumatism in a child affected with fever, because the child, he said, is so irritable, and feels so much tenderness all over its body from the fever itself, that at a moderate pressure by your hand it will show great irritability, with some expression of pain, and not bear the touch, even if there is not the least degree of pain or irritation present. Similar remarks I may be allowed to state, arise from superficiality, which may be carried with us to the grave. There is no doubt that there will be instances in which we cannot make out the seat in the first twenty-four hours, or whether it be simple rheumatism or beginning gastro-enteritis or peritonitis; but these, (in which, however, a good practitioner will know what to do,) are not frequent for him, provided that he be skilled in children's ailments. It is also of importance not to overlook, under the recent primary paroxysms, those inflammations. Now in this respect. I can assure you that a young child affected by any high paroxysm, lies downcast, depressed, heavily moaning, with half-shut eyes; and if in this state you press upon the belly, there will be expression of acute pain, by vehement outcries, only in the case of real significant pain; under other circumstances, the child in fever will scarcely notice your touch. Rheutmatism of the Aisp-joint, I very seldom saw connected with strong fever; it appears more frequently in the chronic form, and never, as I am aware, before about the sixth year, when it will be easily diagnosticated. Now, I have finished that short review of rheumatic local affections, each of which can exist merely as painfixed, or erratic, leaping from one part to the other-or pass within the first day or two into inflammation. In my next lecture, I will try to give you more exact practical directions on the rheumatic fever in its different connections with the described local affections.