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There was a history of epistaxis in three of these children. In one case the
nose bleeding heralded an acute attack of pericarditis, and was a somewhat serious
haemorrhage. Sickness, vomiting and digestive upsets are fairly common, especially
during febrile periods, and although cardiac involvement is the most spectacular
feature, the disease is too wide-spread throughout the body to leave other tissues
and organs untouched—witness the nerve irritation in chorea and the tendency to
serious exudations.
These symptoms collectively form a syndrome, which with the clinical picture of
the child outlined above, together form a silhouette sufficiently clear in most cases as
to be unequivocal even in the absence of cardiac involvement. All pains in children
are by no means rheumatic in origin, but pains fleeting from place to place, with
occasional swelling of joints, with repeated sore throats and recurrent feverish
attacks, etc., are undoubted manifestations of rheumatism.

This incidence is more or less what one might expect to find in any random
sample of 100 normal elementary school children of these ages, and no evidence was
found that any of these diseases played any part in establishing or in influencing the
course of the disease. In six out of nine cases of scarlet fever there was a history of
rheumatism prior to the scarlet fever, and cardiac involvement showed no heavier
incidence in the children who had had scarlet fever or diphtheria.
The incidence of rheumatism in children falls especially on the poorer classes.
It is rarely seen in consultant practice, and it is a negligible factor in morbidity at
preparatory and public schools, as Dr. L. R. Lempriere, school medical officer of
Haileybury, who has collected statistics from many public schools, has shown. Yet he
points out that the " nervous " type of boy is present in increasingly greater numbers
in public schools, so much so as to reduce the standard of general fitness at these
institutions. " Nervousness " in children may be the result of poor nurture or of
illness, but in the majority of cases it is for the most part inborn. Who amongst us
has not seen the parents in the child ? Already the pendulum is swinging back from the
purely environmental explanation of every departure from the normal to include the
older and broader view of inherited qualities, disposition or character, held through
the ages. Aristotle said, " Men are called healthy in virtue of the inborn capacity of
easy resistance to those unhealthy influences that may ordinarily arise—unhealthy in
virtue of a lack of that capacity." Sir Archibald Garrod (B.M.J., Nov. 26, '27,
page 967), stated a truism when he said, " It is an indisputable fact that some
individuals are far more liable than others to suffer from particular maladies."
Professor MacLean, of St. Thomas', and Dr. Hurst, of Guy's, have shown the familiar
tendency to kidney, stomach and circulatory disorders. The rheumatic diathesis was
firmly believed in up to the end of last century, and has not vet been discredited.

In twenty-three no record of family history of rheumatism was obtained. Sixtysix
showed a rheumatic incidence in one or more members, apart from the patient,
in the immediate family, and in eleven other cases the incidence was traced only in
near collaterals—grandparents, uncles and aunts. In thirty-five of these children,
the family history included both the immediate family and the collaterals. In the
majority of the adults the story of rheumatism dated back to their childhood and
their then habitat was in many instances far removed from their present homes, so