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Birmingham.—Thomson has noted on a map of the city (spot map) the situation of 400 cases collected in
over 4 years. A glance at it shews very clearly that the vast majority of these lived along the banks of the streams,
one of them notoriously liable to overflow and flood. But a further study of the map shews that the rheumatic
zones do not exactly coincide with the poverty areas of the city, and that there are several poor districts that are
relatively free.
l.ondon.—Dr. Jean Shrubsall of the London County School Medical Service, found in 1912 that children
suffering from rheumatic heart disease were definitely aggregated along the lines of the alluvial valleys marking the
ancient courses of rivers. Confirmation of this result by Dr. F. C. Shrubsall in 1925 is well shewn on examining
a spot map with contour line 50 feet above sea level.
(d) Rheumatism is associated with diseased tonsils.—The relationship between rheumatism and
sore throat has long been accepted. The rheumatic infection is now commonly regarded as invading
the bodj' through the tonsils.
Acute tonsillitis frequently ushers in a typical attack of rheumatism, especially when the heart
or joints rather than the brain (chorea) become affected, and acute sore throats are liable to recur
between subsequent attacks.
Dr. M. O. Raven, of Broadstairs, has stressed the fact that infectious sore throats spreading
in rheumatic wards are able to light up fresh rheumatic symptoms in some rheumatic cases, although
he has never seen a sore throat set up rheumatism in a non-rheumatic child.
Chronic tonsillitis (septic tonsils) is found more commonly in rheumatic than in normal children.
All observers testify to this fact, although naturally the statistics of different individuals vary, since
abnormality of the tonsil is determined on inspection by several factors, allowing of difference of
opinion, as—signs of inflammation of the tonsillar surface and of the superficial structures of the
throat surrounding it; general increase in size ; the appearance of the mouths of the crypts dipping
into its substance ; and especially enlargement of the lymphatic glands of the neck with which it is
connected.
As regards the permanence of tonsillar disease, " in a few cases of acute tonsillitis the tonsils
will recover completely, but such are a minority in rheumatic cases. Once a real chronic infection
of the tonsils has been established there is no evidence to show that spontaneous recovery is possible
during childhood." (Miller.) This, despite the application of paints and gargles to the surface of the
tonsils.
Of less clearly-grasped significance, and possibly a composite factor—
(e) Rheumatism is a disease of towns.-—That rheumatism is especially rife in towns is accepted
by those most interested in the problem. On the statistical evidence at present available Miller
concludes that further investigation will fully confirm the view that rheumatic disease is a disease of
towns in general, and of industrial towns in particular. This association he holds to be greater than is
accounted for by the increased general sickness rate common to towns. In support of this view
he mentions (1) the peculiar class incidence of the disease, which shuns the slums with their highest
invalidity rate ; and (2) the Birmingham findings of Thomson, whose spot maps showed lack of
coincidence between certain rheumatic areas and areas of general poverty.
Other possible associations require brief mention.
School Environment.—Rheumatism develops commonly in elementary school children, very
rarely in private day or boarding school children, but whether any of the conditions pertaining to
elementary school attendance definitely predispose to rheumatism is uncertain. Miller is disposed to
regard school attendance as a minor predisposing factor, but the evidence is slight.
Thus (1) whilst noting the insufficient arrangements made at certain schools for changing wet
boots and clothing, he justly admits that the disease is less common in the country where exposure is
greater, and amongst the poorest children who are least protected by clothing.
(2) He supposes that catarrhal epidemics are commoner in State schools, leaving their harmful
effects upon the tonsils. But even if it be allowed that such epidemic " colds " are commoner in State
schools than in private schools, and that tonsillar infection is thereby increased, the means of detection
and often of treatment are carried to such children by the school medical service through routine
examinations and clinic facilities. And in private school children such " minor maladies " frequently
go undetected and uncorrected.
(3) He noted that parents frequently blame school stress for the onset of chorea. Whilst
usually an unjust charge, he accepts the fact that cases occur in rheumatic children pressed in their
studies for competitive examinations. He surmises that playtime must often be a greater source of
fear to neurotic children than their working hours.
Heredity.— It is doubtful whether heredity is a predisposing factor. It is true that rheumatism
occurs more commonly in some families than in others. Thus Dr. R. H. Vercoe, a predecessor of mine
at Willesden, but now of Chelmsford, after making enquiries about 700 children (including 100
rheumatic cases), concluded that a history of rheumatism in near relations was two and a half times
commoner with rheumatic children than with no rheumatic children.
But the common factor may be environment and not blood ! Patients suffering from malaria
will frequently give a history of malaria amongst near relations—when the family live in a
malarious district!