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last condition, affecting the folds of the lining membrane
which form the valves of the heart, results frequently
in permanent damage to these valves, i.e., valvular
disease of the heart (organic heart disease).
(4) Nervous.—Rheumatic infection of the nervous system
manifests itself in chorea, the condition commonly
known as "St. Vitus Dance," which, like acute
articular rheumatism, may be accompanied by rheumatic
carditis.
(5) Cutaneous.—Occasionally in the course of rheumatic
infection there appears on the skin of the trunk a
peculiar erythema, believed to be an expression of the
rheumatic poison, and, lastly, but very rarely, there
may appear small lumps or nodules under the skin in
the region of joints and tendons. These are known as
" rheumatic nodules."
Sub-Acute forms of Juvenile Rheumatism.
It must be remembered that rheumatic infection in childhood
does not always manifest itself as an acute illness. The
onset may be insidious—the child may gradually lose weight,
become pale and languid, soft in flesh, unlit for food, sleep badly,
become "nervous" and complain of vague pain and stiffness
of limbs and body. In the course of such an illness the heart
may be involved, resulting in permanent damage to its valves.
From this short summary of signs and symptoms it will be
readily understood that juvenile rheumatism (unlike rheumatism
of middle and later life) is a "specific infection," that is to say,
a disease caused by a specific organism.
Unequal distribution of Juvenile Rheumatism.
One of the most puzzling features of juvenile rheumatism
is the extraordinary difference in its prevalence in adjoining
districts. In one district it is so common as to be a menace to
child life, while in a neighbouring district it may not be causing
special anxiety.
For example, in the course of an inquiry into juvenile rheumatism
in Bristol and Bath and the counties of Gloucester and
Somerset, it was found that in the city of Bristol the incidence
was five times as high as in the surrounding counties or in Bath
City. A similar or even more striking difference would appear