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A. P. Thomson, of Birmingham, has been unable to confirm the view that rheumatism is
hereditary. In his series of cases the incidence of true rheumatism in close relations was 25 per cent.,
and he believes that the " inclusion of complaints of pain loosely and not truly " described as rheumatism
have in the past falsified statistical studies. It will be well in the present state of knowledge
to go no further than agreement with Miller—that perhaps a hereditary influence aids and abets the
environmental influence.
Direct Contagion.—All the evidence points against the importance of this factor (Miller).
When more than one case occurs in a dwelling the common factor of environment is present without
postulating infection. Conditions of great poverty, destitution, underfeeding, overcrowding, excessive
dirtiness do not seem to have an influence specifically towards rheumatic infection.
The Gravity of Rheumatism.
It may be said at once that rheumatism is one of the great disabling and killing diseases of
this country, comparable in its malignity to tuberculosis and cancer.
The significance of this fact has been but slowly grasped by medical and public opinion alike,
and Miller is justified in complaining that " until quite recently the rheumatic infection has received
less attention from the public health point of view than any other disease so prevalent and so harmful."
For one reason, rheumatism is not notifiable. For another, its name is primarily and popularly
associated with a spectacular affection of joints, always (with very rare exceptions) completely
recovered from, and not occurring in all cases of rheumatism. But rheumatism disables and kills
by its effects on the heart, and so insidiously may its poison operate that many a patient is found to
have advanced and incurable " heart disease " (rheumatic) without having experienced any symptoms
of rheumatism sufficient to drive him to seek medical advice.
The mortality returns of the Registrar-General show that in 1925 in England and Wales
64,000 persons died of heart disease, 52,000 died of cancer, 40,000 died of tuberculosis.
Statistical Relationship of Heart Disease and Rheumatism.
What proportion of this great annual total of 64,000 deaths from heart disease—one-seventh
of the total death-rate of the country—can be fairly attributed to rheumatism ? The history of the
case when available is frequently characteristic, and so too are the signs revealed by an examination
of the patient during life. Moreover, the effects of the rheumatic poison upon the muscular substance
and lining membranes of the heart are in most cases so characteristic, both on naked eye and microscopic
examination, that a trained pathologist can usually confirm the diagnosis made during life by
an xamination of this organ.
Dr. A. P. Thomson, on analysing 240 cases of heart disease at the Birmingham General Hospital, which
he presumes to be a fairly representative sample of the general population, found that roughly 60 per cent, were
very probably attributable to rheumatic infection.
Dr. G. A. Allan, in Glasgow, analysing 320 cases, found 46 per cent, to be certainly due to the rheumatic
infection and a further 13 per cent., although there was no definite history, there was a very great probability that
a proportion of them were also due to the same cause.
Allan thus finds it " reasonable to conclude that abou' 50 per cent, of the total mortality of heart
disease, as recorded by the Registrar-General, is due to rheumatic infection " or approximately 30,000
cases per annum. And at present the death rate from heart disease from year to year is stationary.
Now it is not only the vast aggregate of deaths from rheumatism that claims attention. These
deaths are nearly all premature deaths preceded often by a lengthy period of great distress.
" They present a mortality which cuts off life when it is sweetest and most valuable, the disease which
infects in childhood, which spoils the productive power of early manhood, and which often causes a decade or more
of invalidity before it kills."-—(Sir George Newman.)
The post-mortem examination of patients under forty years of age who have died of heart
disease almost always shows the lesions to be rheumatic in type.
Frequently those awaiting their end must be in hospitals for very long periods. Home nursing
is difficult, for " the majority of cases occur in working class people, and it should be emphasized that
cardiac breakdowns are apt to occur at times in their lives when it is particularly desirable that they
should be able to discharge their manifold duties efficiently ; in women who have become mothers,
for instance, and again in men who have become responsible for the support of homes.
It would be difficult to exaggerate the anxiety, distress and the deterioration of a family unit
that may result from the crippling of a parent by the advance of rheumatic heart diseases."
What are the causes of the other half—the non-rheumatic half—of this great mass of fatal heart
disease ?
The larger proportion of this other great army of 30,000 die from degenerations of the heart
substance inexorably accompanying old age, or afflicting those whose organs are prematurely worn
out by over work or unwise over-indulgence in food and drink or other unhealthy modes of life.
Many of the remainder have contracted syphilis, and the uncured infection, choosing a proportion
of cases to fasten upon the heart and blood-vessels rather than the brain or other tissues, slays
.them in middle life.
Others (usually in childhood) die from the inefficiency of a malformation of the heart (congenital
heart disease) present at birth, and of which the cause is unknown.