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II. Contributory Factors.—But if the natural history of the disease demands the hypothesis
of one specific organism as invariably causative, it is equally true that certain environmental
conditions are so consistently present that their evaluation in predisposing to infection is of the
first importance. Dr. Reginald Miller writes of " the multiplicity of the factors at work and the
comparative lack of precise information available about them. Certain impressions have been
accepted which are probably quite correct, but they are backed by little in the way of quotable statistics
or definite evidence."
Recent work has done much to fortify these earlier impressions, based upon the uncorrelated
fruits of the prolonged clinical experience of shrewd observers. The following general conclusions,
taken from Miller's " Report on the environmental and other predisposing causes of rheumatic
infection" (1926), are thus stated:—
" The disease in England is essentially one of children of the artisan class, living in damp
rooms in an industrial town, attending an elementary school, and suffering from tonsillar sepsis."
(a) Rheumatism a disease of childhood.—School medical officers are agreed that the incidence
of heart disease is much greater among the group of children approaching leaving age than
it is among those who have newly entered school at the age of five. Sir George Newman, reporting
in 1925, is satisfied that a very substantial amount of the heart disease which proves mortal at premature
ages is due to rheumatism contracted or first manifested during school life.
Dr. Carey Coombs, who has given much attention to the subject, estimates that about twothirds
of the cases of rheumatic heart disease in Bristol begin between the ages of five and fifteen.
Dr. A. P. Thomson considers the evidence is very strong that it is during the years of elementary
school life that the foundations of most of the cases of permanent cardiac damage are laid. He
observes that it is not without significance that the total rejections on account of heart disease of
young adult lives by insurance companies in the State of New York—2 per cent, of the proposals—
is not much greater than among the leaving group of school children in the same area.
(b) Rheumatism is a class disease.—This disease is unique in that not being infectious it is
practically limited to the poorer classes, affecting rather the children of the skilled artisan than of the
destitute. Thus, quoting from Miller's report, Hutchison from a very long experience of children's
diseases affirmed in 1925, " rheumatism was certainly not specially a disease of the slum child, but
he entirely agreed . . . that it was a disease of hospital and not of consulting practice and he
could count on the fingers of one hand the cases of acute rheumatic carditis that he had seen in consultation
in thirty-five years."
Thomson, from large experience in Birmingham, wrote in 1926 : " It is almost unknown in
the great public schools, or in the better-class private preparatory schools, and yet curiously enough,
it is more frequent among the children of the decent poor than it is among the squalid."
Coates and Thomas from investigations in Bath, wrote in 1925 : " In practically every instance
the parents of the affected children were in steady work in receipt of a steady income, and generally
belonged to the skilled artisan section of society."
The causes of this peculiar class incidence are uncertain. If they were known, " a key position
in the fight against the disease would have been gained " (Miller). It is possible that it is connected
with the factor next to be mentioned, damp housing. Are the slum-dwellers protected by their
overcrowding, living together in one room used also as a kitchen ? (Miller). Dr. K. D. Williamson
has suggested that the probable reason is that the delicate rheumatic children of the very poor die
early.
(c) Rheumatism is associated with damp housing.—The traditional connection between rheumatism
and dampness is confirmed by recent investigations. Miller concludes that it is the state
of the home that matters, rather than the proximity of the house to water, the subsoil, or the altitude
of the site, except in so far as these contribute to the dampness of the fabric.
At London, Bristol, and Bath it was found that nearly two-thirds of the rheumatic cases studied
for this purpose came from damp rooms. In a total of two hundred cases, care was taken to ascertain
the condition of the rooms actually occupied by the patient when first diagnosed as suffering from
rheumatism, and most of these were actually inspected. For certain reasons this proportion may
be taken as a minimum. These are : that the self-respecting poor often dislike admitting that their
rooms are damp ; that others accept a definite degree of dampness as normal; and that certain cases
of choreic or post-scarlatinal rheumatism doubtfully or definitely not associated with dampness
are included.

The influence of site, subsoil, proximity to water, altitude probably operates only indirectly by rendering
the interior of the home damp.