Aetiology.—Acute rheumatism is probably the reaction of the body to the presence of a haemolytic streptococcus of no particular strain, conveyed by droplet infection though being of but limited infectivity. A familial incidence is recognized. So far from an attack conferring immunity, children are liable to progressively severe recurrences. There is a close association between rheumatism and sore throats in childhood. It is largely an environmental disease, the two main factors being poverty and dampness of houses. It is a disease of the poor, but not of the very poor. The incidence increases directly with malnutrition, overcrowding, and bad housing. Maternal neglect is a factor. The inci- dence and mortality fall most on children between 5 and 14 years of age, girls being more susceptible than boys. During recent years there has been a marked decline in its incidence ; the crude annual death-rate has fallen from 67 per million in 1901 to 20-5 per million in 1940. But there are still 200,000 fresh cases of acute rheumatism each year and rheumatic heart disease accounts for 2 per cent of all deaths, and for 10 per cent of all deaths in those under 40.

Preventive Measures.—These include good housing (avoiding overcrowding and damp) ; sound feeding ; and school facilities (hygiene, ventilation, heating, drying of clothes).

Prevention of Sequelae.—
ι. Search for Cases and Accurate Diagnosis.—
Notification : In a few areas acute rheumatism is a notifiable disease, the definition for this purpose being rheumatic pains and arthritis if accompanied by a rise in temperature ; or/and
rheumatic chorea ; or/and rheumatic carditis.
Rheumatism centre : At a local hospital or at a school clinic.
This is not a treatment centre, but a cardiac consultative clinic, acting as a clearing house.
2. School Supervision.—Regularity of attendance and school curriculum modified where necessary.
3. Institutional Accommodation.—This may be a hospital for a stay of 6 weeks during the “acute phase ; a convalescent home for a period of 1 to 6 months, nearly all the time being spent in bed ; or an institutional recovery home in which a return to activity is regulated under careful supervision.
4. Education of Parents, Teachers, and the Public.


Classification and Incidence.—In every iooo insured males in 1922 there were 3 cases of subacute rheumatism and ι of acute rheumatism, 3 of sciatica, 6 of muscular rheumatism, and 10 of lumbago ; and of the diseases charac- terized by chronic joint changes, 1 of rheumatoid arthritis and 3 of osteo-arthritis. In every iooo insured women there were 2 cases of acute and 3 of subacute rheumatism, ι of sciatica, or of brachial neuritis, 7 of muscular rheumatism, and 3 of lumbago ; together with 3 of rheumatoid arthritis and 2 of osteo-arthritis. Rheumatic diseases accounted for the absence of about one-sixth of male and one-seventh of female workers. Three per cent of males and over 2 per cent of females attend their doctors each year because of rheumatism.

In 1924 it was reported that 15 per cent of total sickness and disablement was due to this group of diseases ; it is extremely costly in suffering, in loss of work time, and in cash benefits.

Prevention and Treatment.—Little has been done as yet by local authorities in regard to this group of complaints, in spite of their importance, if only as a factor in reducing output. Clinics have been established by such bodies as the British Red Cross Society at which patients can be investigated and treated.