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46
poor. Children in better circumstances are very
seldom affected. Both rheumatism and rheumatic
heart disease are commoner in industrial than rural
areas.
There is little doubt that rheumatism in children
is a specific disease and that it is caused by microbic
infection. Although much work has been done by
Drs. Poynton and Payne and other research workers
in this country the true bacterial cause still remains
uncertain. Streptococci are commonly found on the
tonsils in these cases, and the prevailing opinion is
that they are the causal agents.
Tonsillitis is present in three out of every four
cases of acute rheumatism, and it is generally agreed
that the tonsils are the main portals of entry of the
invading organisms. Dental sepsis is seldom the
cause of acute rheumatism, although it frequently
causes rheumatism in adults. Foci of infection may
be present in other parts of the body in addition to
the tonsils (as in the intestine) although they are
difficult to locate. Dr. Reginald Miller states that
removal of the tonsils does not usually prevent recurrences
of rheumatism, but severe symptoms and
complications are less common after the operation.
Rheumatism is common in the parents, brothers
and sisters of rheumatic children. This family incidence
may be due to infection, heredity, or environment.
There is no conclusive evidence as to whether the
disease is or is not infectious. Dr. W. St. Lawrence
suggests that it may be transmitted by close contact
with the patient over long periods of time, and Dr.
G. F. Still states that " if rheumatism is due to infection
its incidence may be determined by special
frequency or closeness of exposure to infection or by
some condition in the particular children concerned,
rendering them especially susceptible to infection."
Many eminent authorities believe that heredity
has a considerable effect in causing acute rheumatism,
but further investigation is required on this question.