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15
to exist between London and Hornsey. London would appear,
from recent reports on the subject, to be a hotbed of juvenile
rheumatism. In Hornsey the incidence of this disease is relatively
low. What is the explanation? Three possibilities must
be considered—first, that the difference is real; second, that it
is false; third, that it is partly real and partly false.
In support of a real difference, there is a good deal to be
said. Hornsey has definite advantages in altitude, clear air,
sunshine, open spaces, good housing, and good social and economic
conditions, all of which favour robust child-life, and
therefore a low incidence of juvenile rheumatism.
In support of a false difference, there is something to be
said which concerns diagnostic standards. I have already indicated
the general range of signs and symptoms of acute rheumatic
infection in childhood. It must not, however, be assumed that
all cases show all or even a majority of these features. Cases
differ greatly in clinical character and severity. But before a
sick child is diagnosed as suffering from acute or sub-acute
rheumatism, some of these symptoms in some degree should be
present. I emphasise this point because it would appear that
acute rheumatism is frequently diagnosed in children on very
slender evidence. For example, it has become fashionable to
regard any pains in the limbs of a growing child (so-called "growing
pains") as acute or sub-acute rheumatism. Some of the
more advanced experts go further and diagnose certain debilitated
children as rheumatic without any sign or symptom other than
the debilitated state. I would urge that the only sound basis
for deciding whether a debilitated child is or is not suffering from
rheumatism is the presence or absence of the signs of
rheumatism.
In regard to the puzzling difference in incidence, therefore,
as between one district and another (e.g., Hornsey and London),
I believe that the difference may be partly real, but is largely
false, in the sense that it merely represents a difference in
standards of diagnosis.
Diminishing incidence of Juvenile Rheumatism.
Whatever may be said about differing incidence in different
districts, there is, happily, no doubt that the general prevalence
of the disease is less now than formerly. Juvenile rheumatism
is definitely a declining disease.