Arch Dis Child: first published as 10.1136/adc.5.30.379 on 1 December 1930. Downloaded from http://adc.bmj.

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ABDOMINAL SYMPTOMS IN ACUTE
RHEUMATISM
BY
J. J. J. GIRALDI, M.B., Ch.B.
(From the University Centre of Cardiac Research, Bristol.)
The object of this paper is to record a few cases which have seemed interest-
ing in view of the recent literature, mainly from foreign observers, on the
subject of abdominal manifestations of acute rheumatism; at the same time
attempting to review briefly the literature on the subject.
In recent treatises on inedicine, no matter how exhaustive, there is little
note of any digestive or peritoneal symptoms in acute rheumatism. To the
older writers, however, these were well known and were made the subject
of treatises, on which much debate arose. This subject nlay be said to have
passed through three phases. The first was that in which it was well known,

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much commented upon, and no doubt exaggerated; then came a period
notable for its absence from the literature ; and recently an awakening interest
on the subject.
In 1635, BalloniusI in his work distinguishing acute rheumatism from gout,mentions digestive
symptoms as occurring in acute rheumatism, which he regarded as beneficial, especially the
diarrhoea, attributing to it the fact that ' elle dissipe les humeurs.' Boerhaave2, amongst the
innumerable forms of acute rheumatism which he described, gave prominence to digestive forms.
Too much weight need not, however, be placed on these early observations, for it is well known
that in those times every symtom-complex for which a cause could not be assigned was labelled
rheumatism.'
A treatise by Huxham3 in 1730 contained the first detailed (leseription of the abdominal
localization of symptoms. He described stomach pains with sickness and diarrhea followed by
the usual symptoms of acute rheumatism as we know it to-day.
Stoll4, in his 'Medicine Pratique,' wrote that he had observed innumerable cases of acute
rheumatism and drew far-reaching conclusions which have appeared as exaggerated to other
writers. Here we come to a period in which little record is found on this subject in the literature.
Grifoulhiere5 noted an enteric form of rheumatism in 1841. In his thesis on rheumatism,
Chomel6 described meteorism and diarrhwea as well-recognized symptoms. Trousseau7 anid Peter8
mentioned diarrhea as of common occurrence at the onset of an attack of acute rheumatism.
In 1880 appeared Lambin's9 These de Paris on the subject. He concluded that acute
rheumatism can localize itself anywhere in the digestive tract with predilection for the intestine,
the expressions thereof being colic, colic and diarrhcea, or diarrheea by itself; and that these
imay precede, follow, or alternate with other rheumatic manifestations.
Homolle'0, in his work on Medicine, devotes a chapter to the digestive complications of
rheumatic fever and considers diarrheea to be common.
Lately, Grenet5, has devoted many articles to this subject. To these, and others from
various authors, which have appeared recently, reference will be made subsequently.
In this paper it is intended to discuss the subject from three aspects;
those of a digestive group, a group simulating acute appendicitis, and lastly
a group with a peritonitic picture. It must be admitted that this division,
though practicable in many cases, is arbitrary in others.
 Arch Dis Child: first published as 10.1136/adc.5.30.379 on 1 December 1930. Downloaded from http://adc.bmj.com/ on April 15, 2020 at India:BMJ-PG Sponsored.
380 ARCHIVES OF DISEASE IN CHILDHOOD
Digestive group.-The frequency of digestive troubles in young subjects
is so pronounced as to make difficult the assessment of their rheumatic nature.
Nevertheless, cases are seen now and then in which the sequence of events
is such as to make it plausible to attribute to acute rheumatism several digestive
disturbances.
The following cases, seen recently, have appeared interesting in this respect.
Case 1. H. M., male, aged 13. Admitted 6 years ago with a history of 4 days' illness with
vomiting, headache and epigastric pains. He then developed pains in the limbs; there was
cardiac enlargement; and an apical systolic bruit appeared. H.fe was discharged after four
weeks- On January 28th, 1930, he was re-admitted with abdominal pains and frequent vomiting
for one week, followed by pains in the limbs. He had now considerable cardiac enlargement,
and signs of a mitral and aortic lesion. Here, therefore, a recurrence of abdominal symptoms
was followed by a recrudescence of acute rheumatism.
Case2.-K. F., female, aged 18. Eight months ago shc suffered from sudden vomiting,
abdominal pain and diarrhoea; this attack was severe enough to cause her to seek medical
pains
advice. After a few days it subsided and in several joints app3ared, and a mitral systolic
bruit developed. Since then the patient has had several bouts of abdominal pain with no
relation vomitirg
to food,nausea was present often, sometimes, usually at an interval of two
weeks or less, som etimes accom panied by looseness of the bowels, at other times by constipationi.
search,
No cause for the abdominal pain was discovered after a thorough and in view of the
attack and the subsequent acute rheumatism, salicylates were given

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relation between the first
with success. She has had no pain for eight weeks.
Case 3. A. W., female, aged 12. In May, 1930, she was admitted with acute rheumatism.
The articular phenomena had abated somewhat on admission. There was some enlargement
of the heart with accentuated impulse, and a loud mitral systolic bruit, with accentuation of the
second sound at the pulmonary area. Four days previous to her illness she was suddenly taken
with abdominal pain, nausea and vomiting (twice), also diarrhcea. These subsided just before
the joint pains were felt. She had had' bilious attacks' before but never so severe. It is
interesting tonote that the cardiac lesion appearedtheto be of some standing. two months ago,
Case 4.-C. S., male, aged 9, was brought to out-patient department
complaining of abdominal pain and looseness of the bowels. On enquiry, it was found that he
had suffered from pains in the limbs for some time previously. He was now suffering with acute
carditis; the temperature was 99 50 and the pulse 92; complexion very pale. The heart's
impulse was diffuse but forcible, just outside the mid-clavicular line in the fourth space. There
was enlargement of the heart to right and left, with a loud systolic and faint mid-diastolic bruit
at the apax.
Cases such as these have been recorded by several authors, who regard
the digestive symptoms as part of the rheumatic infection.
In 1894 Hanot1' and Lyman12 wrote on these. The latter labelled these symptoms 'gastro-
enteric rheumatism.' He considered the different abdominal manifestations as due to the
selective action of toxins in the tissues. If the muscular layer of the stomach was involved,
there was pain due to cramp, whereas if the secretory nerves were affected there was pyrosis,
or a combination of thes3.
hyperchlorhydria, and diarrhoea,
I)ory'3 believed that digestive symptoms are found in a considerable number ofincases about
if
they are looked for. Diarrhcma he considered the most frequent symptom, occurringlasts from
33 per cent. of cases, i.e. as frequently as tonsillitis. As a rule it is prodromal and
five to ten (lays before the onset of arthritis.I)ory found it in 9 out of 26 cases.
Libman'4 in a review of the various symptoms of rheumatic fever, wrote that abdominal
symptoms occur frequently, diarrheea being the most frequent in some endemics. He quoted
'Thesis
the same proportion as Dory. Herman15 in hi-s on Extra-articular forms of Acute
Rheumatism,' stated that digestive symptoms often accompany the other manifestations.
* Poynton16 writing on acute rheumatism in childhood notes that vomiting, diarrhuca,
chilliness and prostration may occur at the onset of an attack.
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ABDOMIINAL SYAIPTONS IN ACUTFE RHEUMATISAI 381
On looking through the records of the last hundred cases of acute
rheumatism admitted to this hospital, it was found that digestive symptoms
were rarely noted. In a few cases there were vague isolated symptoms, such
as abdominal pain during the attack. These, of course, might have been due
to other causes, such as an enlarged and painful liver, pericarditis, or an arthritis
of the hip joint, or even salicylate medication. No purpose would be served
by laying stress on past records, taken by those who were unaware of the signific-
aiice of such symptoms, and might fail to inquire for them or neglect to report
them even if mentioned. Also, parents and patients alike tend to regard such
symptoms as ' bilious attacks,' unworthy of the notice of the doctor. On
the other hand, there is no doubt that, if enquiry is made, such symptoms will
be found to be of not rare occurrence, as is shown by the fact that the five
cases recorded above were all seen within a period of six months.
It would obviously lead to adverse criticism to state that a digestive upset
in a rheumatic subject is in most or all cases due to the rheumatic infection;
it is only when the sequence of events is such that a digestive outburst precedes
an attack of acute rheumatism, that it is logical to presume that the two
phenomena are related.

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If such is the case, it would be unprofitable to state figures as to their fre-
quency until a considerable number of cases have been seen and carefully
inquired into. It is as a prodromal phase that these symptoms must be
regarded and sought for; once the arthritic and cardiac phenomena are mani-
fest we must not expect to find them.
The importance of these alimentary tract symptoms lies in relation to the
pathogenesis of the disease. It might lead to a search in the intestinal wall
for information which has been unsuccessfully sought for in the tonsils and
elsewhere.
Pseudo-appendicular group.-In this group the possible rheumatic origin
of appendicitis requires discussion.
Case 5.-B. T., female, aged 8. Admitted January 26th, 1930, after being ill for four days
with abdominal pain and sickness; the pain was at first generalized but became more pronounced
in the right iliac fossa on the day of admission. She vomited three times on this day; bowels
opened two days before admission and not since. On examination: temperature, 100-2°
pulse 138; respirations 30. Tongue furred, fauces clear. The abdomen moved freely on respira-
tion. There was tenderness and rigidity, localized to the right lower quadrant of the abdomen.
Rectal examination revealed tenderness on right side. The appandix was removed; on
section, save for some slight (edema, it showed nothing gross. There was no evidence of tuber-
culosis, etc. On January 30th the child complained of pain in the left wrist; the wrist was
slightly red and tumid. On the next day the right wrist was similarly affected. A systolic
bruit appeared in the mitral area on February 1st. For two weeks after this the child ran a
temperature of 1000 to 101°, with a frequent pulse. The wound discharged for a few weeks after
operation, though at the time of the operation there was nothing to suggest this possibility.
On discharge, seven weeks after admission, there was some cardiac enlargement and a mitral
systolic bruit.
This case lends itself to some comment. It did not appear to us that the
condition of the appendix was sufficient to account for the general disturbance.
Is this, however, a case of appendicitis and, if so, are we justified in regarding
it as a case of rheumatic appendicitis?-or is the diagnosis of appendicitis
 Arch Dis Child: first published as 10.1136/adc.5.30.379 on 1 December 1930. Downloaded from http://adc.bmj.com/ on April 15, 2020 at India:BMJ-PG Sponsored.
382 ARCHIVES OF DISEASE IN CHILDHOOD
untenable in view of the findings, and should the symptoms be regarded as a
severe form of the previous group with special predilection for the right iliac
fossa ?
The aetiological relationship between appendicitis and acute rheumatism
was one of frequent comment by older writers, and in the literature of the latter
part of the last century there is frequent allusion to their connection.
Sir James Grant" in 1893, and Burney Yeo1'8 in 1894, recorded clinical accounts of cases
of appendicitis which they attributed to rheumatism. Haig" also reported several cases of
perityphlitis which he regarded as rheumatic and gouty in origin, and treated successfully with
salicylates. He believed that the action of uric acid on the fibrous tissue of the appendix caused
appendicitis, a belief which has not been supported by further experience.
Of all English writers Sutherland20 seems most convinced of the rheumatic origin of appendi-
citis. He pointed out that in many cases of appendicitis there was a well-marked family history
of acute rheumatism. Also the usual manifestations of rheumatism, such as arthritis, endocardi-
tis, tonsillitis, etc., are not uncommon in patients with appendicitis. He recorded six cases all
indicative of this association.
Beverley Robinson2' and BrazilJ2 also w rote in. support of the view. Finney and Hamburger23
reported three interesting cases as examples of the relationship between the two diseases. Moffet
anid Rodgers24 described two cases of rheumatic fever simulating appendicitis; in these cases
Ino operationi was performed anid salicylates were used with good results. They apparently

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regarded the abdominal symptoms as part of the rheumatic inifection and not as a genuine
appendicitis. Grrenet25 has during the last few years described several cases demonstrating the
simulation of appendicitis bv rheumatism. He is conivinced that acute rheumatism may be
ushered in by a pseudo-appeindicular syndrome.
Other cases have been reporte(d by Dory'3, Chauffard25, and Bezancon and Weil27.
As experimental evidence we have the -work of Poyntoni an(d Paine28. They were able to
produce pathological lesions in the appendix by injection with their diplococcus. These lesions
resembled those found in appendicitis in man and were obviously blood-borne. They point out
that the occurrence of multiple arthritis, coincident with or shortly after an attack of appendicitis,
may be metastatic or pynmic. This usually follow s a mild attack as, if the attack is severe,
perforation or recovery after operation ensues.
We are confronted with two explanations for these cases that appendicitis
miay be caused by acute rheumatism, or that rheumatism may cause symptoms
simulating an appendicular inflammation.
The frequent incidence of acute rheumatism on the faucial tonsils and the
anatomical similarity between these and the vermiform appendix appears
to lend support to the former view. Bland Sutton , writing on the anatomy
of the appendix, emphasizes its richness in lymphoid tissue and regards it as
the abdominal tonsil. It is not irrational, therefore, to suppose that it may
become involved in a disease which so frequently invades the faucial tonsil.
It is admitted that in many cases of appendicitis the theory of local causa-
tion does not seem to apply as far as any positive evidence exists; it seems only
rational to inquire whether constitutional agencies may not be concerned in
the production of such cases, and that. an attack by a constitutional disease may
pave the way for a subsequent infection. Tripier and Paviot30 urged that in
appendicitis a general infectious origin should be more frequently recognized.
Kelly and Hurdon3' in their monumental work on appendicitis discuss the
subject and come to the conclusion that clinical evidence is in favour of an
intimate relation between appendicitis and acute rheumatism, and that animal
experiments and clinical experience support the view of a general infection as
 Arch Dis Child: first published as 10.1136/adc.5.30.379 on 1 December 1930. Downloaded from http://adc.bmj.com/ on April 15, 2020 at India:BMJ-PG Sponsored.
AB])OiIJNAT, SYAMP'TONS IN ,&CUTE RHEUMATISM 83
1`.3
a frequent exciting cause in appendicitis. Nothnagel32 noted that it is con-
ceivable that some cases of appendicitis begin as a rheumatic inflammation and
subsequently become infected with other micro-organisms. Against this view
we have the experience of many authorities. Edwards33 collected considerable
information by personal communication and sums up against the relationship
between the two diseases in question. Poynton34 also came to the same con-
clusion. Morris35 does not attach any influence to rheumatism as a cause of
appendicitis. The probability of coincidences between two diseases of common
occurrence must not be lost sight of.
That the arthritis following appendicitis is pyemic in origin is possible
in some cases, but this view will not hold in those cases where multiple arthritis
and evidences of a cardiac lesion develop, which subsequently become chronic
and present all the features of a rheumatic infection of the heart.
It has also been alleged that involvement of the hip joint by acute
rheumatism may simulate appendicitis. In some of the recorded cases, those
of Moffett and Rodgers24 for example, the hip joint was involved, but this
possibility is excluded in all the other cases, where no involvement of the hip
joint was noted. But perhaps most significant of all is the fact that though

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many cases of so-called appendicitis are recorded, in only a few was operation
resorted to and in none of these was there found in the appendix a lesion sufficient
to justify surgical interference, certainly nothing resembling the experimental
lesions produced by Poynton and Paine28 in animals.
It must be admitted that our case described above was probably not
appendicitis at all, but a simulation of appendicitis by the rheumatic infection.
It is safe to conclude that in some instances acuite rheumatisnm may give rise
to abdominal symptoms simulating appendicitis, but that at present there is
iio warrant for the use of the term rheumatic appendicitis.
Peritoneal group.-In the following case a suspicion of rheumatic peritonitis
arises.
Case 6. . B., male, aged 9. Admitte(d June 16lth, 1929), with a history of frequeent vomiting
and acute abdominal pain for the last 30 hours. The temperature w%as 99 8' and the pulse 132,
of poor volume. On examination, the tongue was furred; the abdomen moved little on respira-
tion ; there was generalized guarding and tenderness. Rectal examination revealed tenderness.
Peritonitis was diagnosed and the abdomen was opened. The appendix was normal in appearance
and there was free fluid in the peritoneal cavity. There was no evidence of tuberculosis in
peritoneum or glands. Appendicectomy was performed. No lesion was found in the appendix
on section. The temperature and pulse-rate remained raised after the exploration. Ten days
later the temperature rose to 103°, multiple arthritis ensued, and a mitral systolic bruit was
discovered. The condition subsided under treatment with salicylate. Recently this child
has been seen with some cardiac enlargement and an apical systolic bruit.
Cases such as this are not unknown.
Tricot36 described a case with a similar onset which, oII operation, showed some clear serous
fluid in the peritoneum, and a few days later polyarthritis, with a mitral systolic murmur,
appeared. This case had two subsequent relapses of polyarthritis. both accompanied by abdominal
symptoms which were relieved by salicylate.
* Since writing this, my friend, Dr. H. D. Pyke, has brought to my notice a somewhat similar
case, of a patient with chronic cardiac rheumatism who had a severe abdominal crisis and oln
exploration nothing but some serous fluid in the peritoneum was found.
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384 APtCHIVES OF DISEASE IN CHILDHOOD
Garrod37 has said that though many recorded cases of rheumatic peritonitis are openl to
question, there are a few which seem hardly to admit of any other interpretation than that the
peritoneal inflammation formed an integral part of an attack of rheumatic fever. He recorded
three cases previously described by Fuller38, Marmonnier39 fils and Blachez40. These three
cases agreed in that in all of them there were grave pulmonary lesions. An autopsy was per-
formed in Fuller's case, which showed bands of recent lymph together with turbid serum in the
peritoneal cavity.
Garrod37 gave several references to relevant literature, such as that of Chauffard'6,
Desplets41, Andral42, Morin43, etc. Grenet has lately described two cases of this type. Pilod
and Meersmann44, and Bernard45 describe cases of young soldiers with severe abdominal pain,
fever, and fleeting arthritis. At operation nothing but a congested peritoneum was found. One
of Pilod and Meersmann's cases later developed pericarditis and aortic incompetence. Costedoat46
describes another case and points out the difficulty of diagnosis and the possible fixation of
virus in the abdominal wall.
Worms47 has observed three cases of this nature, all of them submitted to operation, in one
of which there was free fluid in the peritoneal cavity. He gives a brief account of several cases
reported by some of the authors already mentioned, and interprets them, in view of the operation
findings of exudation and congestion, as a primary infection of the peritoneum.
Quite recently Auvray48 observed a case of a child presenting signs of peritoneal inflammation.
Operation revealed serous fluid in the peritoneum. Bacteriological examination of this fluid
proved negative. Blood culture was also negative. Ten days later the child developed arthritis
and pericarditis which responded to salicylate medication. Howard49 in Pepper's ' System of

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Practical Medicine' says that he has but once met with a case of acute peritonitis as a com-
plication of acute rheumatism.
Bauer50, in iemssen's ' yclopedia of the Practice of Medicine ' says that rheumatic
peritonitis is undouibtedly an exceedingly rare complication of acute rheumatic fever.
In their article on peritoniitis in the ' Dictionnaire Encyclopedique des Sciences Medicales,'
the authors5' poinit out that all degrees of rheumatic inflamination of the peritoneum may occur,
from simple hyperxmia with very little exudation to fibrinous purulent or hbemorrhagic
exudation.
Allchin and Andrewc s5 in their article on peritonitis regar(d the association of peritonitis
with acute rheumatic fever as an extremely rare occurrence.
Our case described above, which we regard as an example of a peritoneal
reaction to an infection, needs little comment. The abdominal symptoms were
such as to make urgent operation justifiable and yet exploration revealed but
serous fluid in the peritoneal cavity. In view of the subsequent outburst of
acute rheumatism it is very tempting to ascribe this serous peritonitis to acute
rheumatism. This view, as already mentioned, has been adopted by others
who have met with similar cases.
It has been taught and accepted that the peritoneum is almost, if perhaps
not quite, invulnerable to invasion by the rheumatic virus. This immunity
of the peritoneum is an inexplicable anomaly in view of the proclivity of the
other serous membranes. But, it may well be that this immunity is more
apparent than real. The peritoneal cavity, owing to its capacity, may hold
an appreciable amount of exudate without its presence being revealed or easily
ascertained. In two recent cases of acute rheumatism we have convinced our-
selves of the presence of fluid in the peritoneal cavity. These have been very
severe examples of the disease in young subjects. In both of these there was
t * A localised peritoniitis of the subdiaphragmatic region has been described, amongst others,
by Rolly53, Coombs54, Poynton", and Paul55. Paul gives a full account of such a case and brings
forward postmortem and histological evidence of the rheumatic nature of the condition,
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ABDOMINAL SY,MPTONS IN ACUTER RHEUAfATTSM\1 385

some tenderness over the abdomen, not an uncommon finding in these cases
with a massive dose of infection. It is true that such tenderness may be due
to a pericarditis, an enlarged liver, or even to the usual attendant constipation,
but the presence of a peritoneal reaction mav well be worth considering. It
has been tentatively suggested by some that a peritonitis during the course of
acute rheumatism may be due to some local lung or pleural lesion whence in-
fection through the diaphragm may take place. This is possible but not
probable. The spread of infection is, as would b)e expected from the lymphatic
anatomy of this region, in the opposite direction. Rarely does a virulent and
even long standing empyema give rise to general peritonitis. Furthermore,
in many cases of so-called rheumatic peritonitis, there has been no demonstrable
pulmonary lesion either clinically or post mortem.
It may be Qoncluded that an acute peritonitis, one which assumes import-
ance in view of the difficulties it presents in differentia]ldiagnosis, at the onset
of an attack of acute rheumatism, is a rare phenomenon; one of the rarest
manifestations of this disease. On the other hand, it is urged that the fre-
quency of a peritoneal reaction with evidence of exudation, during the course
of a severe attack of acute rheumatism, has been underestimated and is wcrthy

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of future consideration.
Conclusions.
The following conclusions are submitted:
1. Digestive symptoms precede the onset of acute rheunmatism imiore
often than is at present realized.
2. There is, so far, no warrant for the use of the term rheumatic appen-
dicitis, but in some cases acute rheumatism appears to give rise to symp-
toms simulating an acute appendicular inflammation.
3. Acute peritonitis at the onset of an attack of acute rheumatisml is a
very rare phenomenon; but there is not infrequently, in acute cases,
evidence of invasion of the peritoneum by the rheumatic virus.
4. These abdominal manifestations of acute rheumatism are of importance
chiefly by reason of the help that they may afford to a study of the pathogenesis
of that infection.

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