UNTIL recently, it was believed that rheu¬ matic fever was extremely rare, or absent, in tropical climates such as that of Puerto Eico (1-3), and it was even suggested that children with rheumatic fever be sent to Puerto Rico to recover and to avoid further attacks (4). Textbooks still much in use today stress the rarity of rheumatic fever and rheumatic heart disease in the tropics (5, 6). On the other hand, a few workers in Puerto Rico thought they had evi¬ dence that rheumatic heart disease was not only present but occurred frequently, representing 17 to 32 percent of all cardiac patients seen there (7,8). More recently, a study of 3,600 consecutive autopsies from 1958 to 1961 in native-born, indigent Puerto Ricans revealed that 8.4 per¬ cent of the deaths due to cardiovascular disease were the result of rheumatic heart disease (9). Furthermore, Garcia-Palmieri and co-workers (10) reported 300 cases of acute rheumatic fever and rheumatic heart disease in patients aged 13 and over admitted to one charity hospital in San Juan, P.R., over an 8-year period and con¬ cluded that climatologic conditions are not a significant factor in the pathogenesis of this disease since it is present with "such a fre¬ quency" in this tropical area.
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